0:00

For this next case, this is another, uh,

0:03

example of a follow-up.

0:04

This is, uh, a follow-up of the patient

0:06

that we saw earlier in the course

0:09

who had the coronary artery aneurysms

0:11

and had an LAD infarction.

0:13

And now this is a follow-up about seven years later from

0:17

that initial event.

0:18

So the patient's now 36

0:21

and he had a known LAD infarction seven years ago.

0:25

And I'm showing this case we're gonna start a string

0:28

of various complications related to myocardial infarction

0:31

that I want to make sure to highlight.

0:34

So here, working through our normal algorithm,

0:36

the two chamber view, you can kind of see here as I scroll

0:41

into kind of peak systole where the base

0:45

and the basal segments are sort

0:47

of maximally contracted here.

0:49

What you can start to appreciate is

0:50

how thinned out this apex has gotten here.

0:54

And if I play it through now as a syn A,

0:57

it's actually would be appropriate

0:59

to call this apex diskinetic notice.

1:01

It's moving kind of opposite to the rest

1:04

of the myocardium when the rest

1:05

of the myocardium is contracting.

1:06

This is sort of being pushed outward.

1:10

Similar correlate here on the four chamber view

1:14

and also the three chamber view.

1:17

So thinning and

1:18

what looks like aneurysmal dilation of the apex.

1:22

I'll just quickly go through the rest

1:25

of the short axis stack here.

1:29

So the base and mid are actually functioning reasonably

1:32

well, but then we get into sort

1:37

of these areas of infarcted tissue.

1:42

Most of the myocardium thickening nicely.

1:44

The septum obviously is not really moving quite as well

1:48

and is reasonably thinned out.

1:51

Some of what we're seeing here.

1:52

When you see this area of low intensity

1:54

and the septum, sometimes that,

1:57

and especially in chronic infarction, that can be a sign

1:59

that there's some fat in the myocardium

2:02

that has what's called an India ink artifact associated

2:05

with it, which makes a black line around it.

2:07

You know, keep in mind these are post contrast images,

2:09

the way that we do them on these short XI nase.

2:11

So some of it can be related to areas of chronic no reflow

2:16

phenomenon like we discussed earlier.

2:20

And we see more of that here with thinning

2:24

and hypokinesis now towards the apex and the septal

2:28

and inferior segments and more of the same.

2:34

One thing when you see chronic changes like this

2:36

that it's always good to start to look for on the syn images

2:40

and then continue to look carefully at on LGE is,

2:43

is there any evidence of, you know, thrombus here?

2:47

And we will see some cases or at least a case of thrombus,

2:50

but it's always important to look when you have this degree

2:52

of wall motion abnormality.

2:54

It's a good place for thrombus to sort of set in form.

2:59

So here we see the LGE images correlating to this

3:04

as I work my way down from base to apex here,

3:07

working my way down.

3:09

We see areas of LGE.

3:11

There's a little artifact here on this image,

3:13

but LGE involving the septal segments, transmural,

3:17

they're quite thinned out.

3:19

So kind of non-viable myocardium in this area.

3:24

And again, looking for any evidence of thrombus,

3:27

I think this is gonna be an artifact, kind

3:29

of probably a spatial, a-list artifact

3:31

or a rap artifact in this particular case.

3:33

But we'll interrogate that more carefully.

3:37

Some of these other studies here, the two chamber view,

3:40

again showing nicely the infarcted regions here in the apex.

3:44

Non-viable infarct here involving

3:48

the inferior aspect of the heart.

3:49

So really the whole apex is involved.

3:52

And then a nice example of kind

3:54

of these aneurysmal segments here.

3:56

So this is an example of a true aneurysm.

4:00

We will take a look at a case of a pseudo aneurysm as well,

4:03

but a true aneurysm is really where there's no neck.

4:05

It's, it's kind of related to just the fact

4:08

that this tissue is not functioning or completely scarred

4:12

and now is kind of dyskinetic and, and bow outward just

4:16

because there's no contraction occurring.

4:18

It's bow outward. A lot

4:19

of times we see true aneurysms at the apex like this,

4:22

but they can be anywhere where there's been, uh,

4:26

previous myocardial infarction,

4:27

but they're kind of distinguished by this more bulbous look

4:30

and they'll be distinct from pseudo aneurysm,

4:32

which we'll see in a little bit note here, this is an area

4:35

of low intensity kind of within that area

4:38

of aneurysm right up against the wall.

4:40

This would be one site where we would be concerned perhaps

4:44

that this is a thrombus.

4:45

I didn't really see it on any other views

4:47

that we could definitely identify,

4:50

but this would be one where you would kind

4:52

of perhaps raise the possibility

4:54

of a thrombus in this location.