0:00

Next case is a 31 year old man who presented

0:04

with chest pain and elevated troponins that had no

0:07

concerning ECG changes.

0:09

So relatively low risk.

0:11

And so the thought here is this is probably not

0:15

coronary related chest pain.

0:18

So they went straight to cardiac MRI to evaluate

0:21

for myocarditis and I wanted to show this case

0:24

to just show you, you know, how to work

0:26

through the differential diagnosis, uh,

0:29

in patients with chest pain.

0:31

So here we see two chamber looking very good.

0:35

Four chamber also very good.

0:37

This is a young man, so really don't expect there

0:41

to be a lot of issues in terms of his

0:44

function or volumes.

0:47

We'll go to the short axis next

0:50

and working down, everything's contracting normally.

0:53

Thickening well, no regional wall motion abnormalities

0:57

that we've seen so far.

0:58

Getting down here towards the apex, same thing.

1:01

The heart seems to really be

1:03

functioning just like it should.

1:07

Uh, and so then we go to LG images next

1:12

and taking you down from base to apex.

1:16

As we get far apically here, there's one finding

1:19

that shows up and it's kind of right here.

1:23

You can see there's a little bit

1:25

of late gadolinium enhancement here in kind of this apical

1:28

inferior or on the border of the inferior

1:30

and lateral segments.

1:32

Kind of just one slice through there.

1:34

And there also may be possibly some pericardial thickening

1:39

and enhancement in that region as well.

1:40

Kind of oftentimes difficult to identify that.

1:44

I'm gonna look on the four chamber now

1:46

to see if I can cross-reference any of that

1:50

working my way down.

1:51

And sure enough, here in that same area we see a focus

1:56

of Lake Galine enhancement.

1:57

What I want you to notice, and I think

1:59

it's displayed really nicely on this view, is

2:03

that there's clearly endocardial border left here.

2:07

And I think we can probably see that here as well.

2:11

You know, this is certainly more of a sub epi

2:13

or mid myocardial process with maybe some

2:16

bleeding up towards the endocardium.

2:19

This is not the same thing as a sub endocardial

2:22

focus of LGE.

2:23

So you know,

2:25

already we're thinking this is probably less likely

2:28

to be vascular and sounds like maybe the team

2:31

is right on the money with thinking about this

2:33

as more of a myocarditis.

2:35

Here's our T two maps.

2:37

Uh, and you can see in this, this is the most apical.

2:40

So basement apex, some of these areas

2:42

of bright orange here are corresponded to that area

2:46

of lake enhancement.

2:49

So that is showing

2:50

that there's some edema here quantitatively right

2:52

in that region as well.

2:53

We kind of see that sort of mid

2:56

to apical, infra lateral segment

2:58

And inferior segment have elevated T twos in this region.

3:02

So taken all together,

3:04

we have a troponin elevation in a young man, uh, that's

3:07

otherwise low risk for coronary disease.

3:09

We have LGE that's in a nonvascular pattern

3:12

and we have elevated T twos in these regions.

3:15

This is consistent with acute myocarditis.

3:18

You know, I won't go into Lake Louise

3:21

criteria here necessarily.

3:22

That's part of a, a different type of cardiac

3:24

and marked topic, but that's kind of

3:26

what we're using when we think about acute myocarditis.

3:28

The presence of some type of, you know, enhancement

3:31

or scar looking injury.

3:33

Uh, and then the presence of edema

3:36

to diagnose acute myocarditis.

3:38

So this is one of the main differential diagnoses

3:40

that we have in acute chest pain that we can sort

3:43

of tease out with cardiac MRI.