0:00

Okay, so our next case here is a 68 year old man

0:05

who had a known circumflex chronic total occlusion.

0:09

And this exam was to evaluate for ischemia

0:14

and then also any evidence of myocardial infarction

0:17

and viability assessment.

0:19

So, uh, again doing a freeze frame here

0:22

of our profusion images.

0:25

So stress is across the top, rust across the bottom base

0:29

mid apex.

0:31

And what we see here pretty nicely laid out

0:35

is that it's stress.

0:36

We have the base, a sub endocardial area

0:39

of hypoperfusion really involving the kind of anterolateral,

0:43

infra, lateral, inferior and infra septal segments.

0:47

In the mid, we kind of see it involving more the infra,

0:49

lateral inferior in some of these septal segments

0:52

apex we almost see it looks to me if I scroll in

0:55

and out here, almost looks circumferential at the apex.

0:59

And we may see as I'm going down here to the rest images,

1:03

you may see a little bit of that area

1:05

of hypoperfusion here at rest as well.

1:07

So you kind of wonder if this is gonna be more

1:10

artifact in part of tissue.

1:11

But the rest images in these other regions

1:15

look fairly normal.

1:16

There is a little focus here

1:19

of southern endocardial hypoperfusion that kind

1:23

of corresponds to the infra lateral segment,

1:25

but certainly not the extent

1:26

that we're seeing on these images.

1:29

And then same at rest, we kind of have sort of

1:33

maybe that persist here in the inferior segment,

1:37

but pretty actually normal mid myocardial segment here.

1:41

So off the bat, you know, we're kind

1:44

of thinking there's at least some degree of ischemia

1:47

and then we need to check the LG image to see

1:49

If any of these areas that have hypoperfusion stress

1:52

and rest correspond to areas of infarction.

1:56

So just gonna pull up the LG images next.

2:00

And going now from base to apex, we can see

2:05

that there probably is a small infarct tear in the

2:08

basal infra lateral segment.

2:10

Certainly not involving most of this portion

2:14

of the myocardium

2:16

that we saw hypoperfusion in on the perfusion images.

2:20

And then as we get down a little bit more aply,

2:23

we do see some, what looks like circumferential areas

2:26

of lake galine enhancement here at the apex

2:29

that are consistent with vascular injury.

2:32

So makes me think that we were correct in sort of saying

2:36

that the apical segments are probably infarct.

2:40

See if our long access views can help us out here.

2:43

Indeed they can.

2:45

There was also, you know, this one area

2:48

of infarct in the circ territory,

2:50

but most of what we saw would've been

2:52

consistent with ischemia.

2:54

So we know we have some ischemia

2:56

with a background myocardial infarction

2:58

that's useful information for them

3:00

because now they know they have some targets

3:02

that they could potentially intervene upon

3:05

to perhaps avoid further myocardial damage.

3:08

So the other thing that I wanna show in this case is I just

3:11

wanna look at these areas that were ischemic

3:13

to see if there are regional wall motion abnormalities

3:16

associated with them.

3:18

And I'm working through here

3:22

and certainly as we're getting out here in these areas that

3:27

were kind of involved in this area,

3:31

I think the infarct was a little higher up here

3:33

sort of in this location.

3:34

But we can see even areas infra lateral segment

3:37

where we saw, definitely saw some ischemia, kind

3:40

of these septal segments here where we saw some ischemia.

3:43

You can see areas of hypoperfusion

3:46

that don't really correspond to areas of infarction.

3:48

And so this would be consistent with hibernating myocardium.

3:52

So we have ischemia in this one case.

3:55

We have areas of infarction, we have areas of ischemia

3:58

and some of the areas of ischemia are associated

4:00

with hibernating myocardium.

4:01

So nice example of how this kind

4:03

of all plays out on a tissue characterization

4:05

and functional level.