0:00

Next case is a 58 year old woman who presented

0:04

to the emergency department with chest pain.

0:07

She didn't have any past medical history,

0:09

but her ECG findings were

0:11

concerning enough to take her to cath.

0:12

I'm gonna not tell you what the cath showed

0:14

until we see the case here a little bit.

0:17

So I'll show you first the cene as usual.

0:21

So our two chamber view, I think

0:23

hopefully at this point you're getting

0:25

comfortable looking at these.

0:27

And I think if I freeze it around this frame, one

0:29

of the things that's pretty clear here in the anterior

0:33

and apical inferior segments, there's definitely thinning

0:35

and hypokinesis relative to these basal segments.

0:38

So already on this two chamber view, we're sort

0:42

of suspicious that there's something going on here.

0:47

And then we can also see on this four chamber view here in

0:50

kind of the apical

0:52

and mid for septal segments here we can see similar

0:56

findings, some of this thinning

0:57

and wall motion hypokinesis here,

1:00

and then three chamber, kind of an incidental finding.

1:04

If you look at the aortic valve right here,

1:06

this person has aortic insufficiency, which you can see kind

1:09

of coming back across ATUs.

1:12

But then focusing now again on the myocardium,

1:14

you can see again sort of this relative thinning involving

1:18

septum apex and kind of infra lateral segments of the heart.

1:22

So kind of this apical region is looking not super happy.

1:28

We now move down the short axis images from base to apex

1:34

where we see some myocardium here, basal

1:39

function here, everything's really

1:41

contracting vigorously thickening well looking okay,

1:44

but then one

1:45

or two slices later, as we start to kind of get into the mid

1:51

region, you start to see thinning

1:54

and hypokinesis here of the anterior segment.

1:57

A little bit of anterior septal,

1:58

really this anterior lateral segment as well.

2:02

And then as we start to get down to the true apex,

2:06

it's very thin circumferentially, so

2:10

certainly thinning

2:11

and pretty much kinesis of these apical segments,

2:13

which is similar to what we saw

2:16

on the long axis use.

2:20

So now if we go

2:21

and we look at our findings on LGE imaging, again,

2:26

this is a person with chest pain

2:27

and we've just had a calf going from base to apex,

2:32

not a ton of LGE here, even in areas where we saw a lot

2:36

of thinning and wall motion abnormalities in the

2:38

mid to apical segments.

2:39

But what you do start to see as you kind

2:42

of get down here towards the true apex here is

2:45

where we really start to see LGE

2:48

and a kind of vascular distribution.

2:50

So maybe the first site here that we see is kind of lateral

2:54

aspect of the apex.

2:55

There's sub, sub endocardial, transmural, LGE,

2:58

similarly here in the more inferior aspect of the true apex.

3:02

And then if we get out here to the far apex, it looks like

3:06

probably transmural.

3:08

So we'll take a look at our long axis views.

3:10

I think the three chamber may be a good view

3:13

to take a look at here.

3:15

This is, I'm clicking through the three chamber.

3:17

You start to see again as we get into the apex here,

3:22

this is gonna be kind of lateral aspect of the apex,

3:26

our inferior and infra lateral aspect of the apex.

3:29

You see transmural, LGE here, probably some transmural,

3:32

LGE kind of more circumferentially at the apex.

3:36

As I click through these three chamber slices,

3:40

look at a similar view here on the four chamber.

3:43

And on some of these views you can see the whole apex has

3:47

completely got LGE, kind of transmural, LGE.

3:52

And then a few areas maybe that have a little bit

3:55

of less transmural, LGE, so not the entirety of

3:59

The segments that were Hypokinetic.

4:01

You know, again, just as a summary, you know,

4:04

we really see hypokinesis involving a lot of

4:06

what looks like LED territory, these anterior segments.

4:10

But the LGE is primarily focused down

4:13

And the apex itself, you know,

4:15

from a cardiac MR standpoint, I think what we would say is,

4:18

you know, there appears to be apical myocardial infarction.

4:22

That is, you know, depending on the chronicity

4:25

of the finding and the presentation, you know, is transmural

4:28

with low likelihood of functional recovery.

4:30

Now this was more of an acute finding

4:33

or you know, kind of when we're doing the MR Subacute.

4:35

So it's a little viability,

4:36

still a little bit challenging when they're

4:38

still kind of subacute.

4:40

What this actually turned out to be on cath,

4:42

this was the case of spontaneous coronary artery dissection.

4:45

So the patient came in with chest pain.

4:47

50 year old women are tend to be predisposed

4:50

to spontaneous coronary artery dissection or scad.

4:53

That's kind of the vernacular.

4:55

And so it was a pretty long segment distal LAD

4:59

or mid to distal LAD.

5:00

And so it's probably that's what's causing a lot

5:02

of this wall motion abnormality is maybe more of a ischemia

5:06

or even sort of a stunning, uh,

5:08

appearance of the myocardium.

5:10

And then unfortunately,

5:12

probably did have true myocardial infarction of the apex.

5:14

So this is a case of SCAD and this woman.