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So our next case is a 44 year old man

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who had multiple cardiovascular risk factors

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and presented to the emergency

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department with acute chest pain.

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He was found to have a STEMI

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and then went to cardiac catheterization

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and was found to have a hundred percent LAD occlusion

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and then underwent stenting of the LAD.

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And then he got, while he was still an inpatient four

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or five days later, they wanted

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to do a quote viability study and assess for complications.

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And so I wanna show this case

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and I'm gonna show the follow-up to show why it's hard

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to assess for viability at such a short time point

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after an acute injury.

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So just looking here at our standard approach, you can see

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probably a little bit of hypokinesis there in the anterior

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mid to apical anterior segments.

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Four chamber actually doesn't look too bad in this case.

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Here's our three chamber, again, some

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of the septal segments towards the mid

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and apical regions are a little bit hypokinetic.

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Moving to our short axis views

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so far, things are moving pretty well.

1:21

Now we're starting to get into the mid region here

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and I, I think you know, this is

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where we're gonna start seeing some relative hypo

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or kinesis here of the anterior segment.

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Anterior septal also seems

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to be a little hypokinetic as we scroll through.

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Everything else appears to be relative or well preserved.

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Similar pattern here as we move on down towards the apex

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here in the apex, you know, we're starting

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to get a little bit more circumferential involvement.

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Again, often the LAD applies sort of the true apex is one

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of these more wraparound type LEDs.

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So not surprising that we're seeing more

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so circumferential involvement here.

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Then if I go to LGE, so you know, this is a person

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who had a hundred percent LID occlusion that was

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reperfused just a couple days before this exam.

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And so as I'm

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Working down from base to apex,

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we see definitely LGE in the kind of

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basal anterior segment.

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And what I want you

2:32

to notice about this LGE in this particular case, you know,

2:36

there's a lot of what looks like enhancement,

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but it's very hazy.

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You know, if you contrast that to some of the true infarcts

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that we've seen on viability cases

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or some of these big territorial infarcts,

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this is quite hazy actually.

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Not a ton of enhancement in terms of intensity.

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But the extent here would be, for example, here in the,

2:59

in the septum, this looks like a hundred percent extent

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of transmural here.

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The whole wall thickness has some

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of this hazy enhancement if you compare it say

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to this portion of myocardium, which is normal.

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So the question in this case is do you call that non-viable?

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Is that what we are sort of stuck with in this case?

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You know, as I'm working back up towards the base here,

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same thing, a lot

3:23

of this looks really transmural in these

3:25

areas that were involved.

3:27

They were hypokinetic.

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And as we get down in the apex, you know, kind

3:30

of similar story, almost full thickness

3:32

enhancement in most of these segments.

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But very sort of like hazy.

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And then of course this was an acute injury, so we wanted

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to look at the T two.

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And uh, not surprisingly in this case,

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particularly in the apex, we see a lot of edema.

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Remember 60 is our cutoff

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and then kind of in the other portions of the LAD territory.

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So basal anterior segment here, anter septal segments

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and the basal mid.

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And in this true apex there is, you know, elevated

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or borderline elevated T two.

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So this is all going with acute myocardial injury.

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So what we sort of said to the referers in this case is,

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you know, we don't feel confident, you know,

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discussing viability on this particular study

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because it's so acute

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and we really think if you wanna understand viability,

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he needs to be brought back,

4:18

the patient needs to be brought back.

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And so they did bring him back three months later

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and I'm gonna show you those

4:23

Examples. Now, the first thing

4:24

that I'm gonna do, I'm just gonna kind

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of skip right through to sort of the functional

4:29

Assessment and, and

4:31

This updated study,

4:34

and we'll work our way through here,

4:39

still feels like maybe there's a little bit of

4:43

relative hypokinesis, but

4:44

that function has almost entirely recovered, which starts

4:48

to make us think that, you know,

4:49

the Walsh abnormalities that we saw

4:52

On Our original study probably were related

4:56

to some degree of myocardial stunning,

4:57

pretty good story for that.

4:59

And so there has been probably some

5:02

functional recovery of those segments.

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If we go now to the LGE, you know, this is

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Just three months later.

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And really even if I, you know, kind of try to really window

5:12

and level it pretty aggressively, the vast majority

5:17

of that hazy LGE that we talked about, you know,

5:21

on the original case has pretty much completely resolved.

5:25

Interestingly, he does have a couple little dots

5:27

of LGE here and there.

5:29

I think maybe we can see these better on a few

5:32

of the long axis views.

5:34

But really the LGE has almost entirely,

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or maybe has entirely resolved even at the apex,

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which we thought was, you know, kind of the most at risk.

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There's one little focus of LGE down here at the apex,

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Which again, you know, may be a,

5:51

just a embolic infarct from his stenting procedure.

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So this is kind of what happens, you know,

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how infarcts can evolve from that acute finding

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where it looks like it could be pretty extensive now

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to a much more, you know,

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looks like really a really successful reperfusion

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with not much residual damage at all.

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And so I think that's an important lesson in terms of,

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you know, you've gotta be realistic with your referers about

6:17

if it's a really acute injury,

6:19

I can't make a good assessment of viability.

6:21

We really need to give it, you know, at least a few weeks,

6:24

if not more, up to a month, two months, three months,

6:26

to really start to understand what's

6:28

gonna be viable and what's not.

6:29

What is enhancement from the acute phase, the edema phase

6:33

of the injury versus what is true scar.

6:35

That's really what we're trying to tease out.