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Okay, so this is our first Ischemia evaluation

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case of the day.

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And, and this is a 50 year old man

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with a known chronic total occlusion

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of the LAD who's undergoing cardiac MR for both evaluation

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of ischemia and any evidence of infarction.

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And so I'm just gonna start by showing you, uh,

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still image of the perfusion portions of the exam.

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You're more than welcome to review the case and go through

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and see how when you actually watch the contrast come in,

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how you can kind of pick this up.

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But I think it's instructive here to just show, you know,

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when I stop kind of at a maximal enhancement side

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of the myocardium, what we can see here

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of note stress is across the top RUS is across the bottom

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first columns base, second columns mid third columns apex.

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But what we can see here at stress is

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that we get maybe a little bit of

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sub endocardial hyperperfusion here in the

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basal anter infra septum.

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Don't really see that here at rest.

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Definitely have a profusion defect here

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in the anterior infra septum in the mid,

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which is not present at rest.

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And then circumferential here in the apex area

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of hypoperfusion, which is not present at rest.

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So when we're looking at this, we're thinking, okay,

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this is looking like LAD territory

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and it looks like right now

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that there's a reversible perfusion defect.

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What we have to look at next is gonna be the LG images.

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So I'll pull those up next

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and there is gonna be no

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LGE in this territory.

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And I will tell you that there are no areas

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of regional wall motion abnormality in these locations.

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And so what we would expect qualitatively is

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that this is consistent with ischemia in the LAD territory.

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I'm just gonna show you the quantitative

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perfusion findings in this patient.

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So here we've got, uh, stress map where we can see

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that particularly starting to impact the mid antra septal

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and infra septal regions.

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We have a little bit lower stress

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flows than we would expect, but globally it looks okay.

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At rest we see kind of relatively normal flows throughout.

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And then when we do our myocardial perfusion reserve,

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which is the stress flow divided by the rest flow,

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can actually see in some of these areas

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where we saw hypoperfusion, definitely

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that mid anterior segment and mid anter septal segments

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and then mid anterior lateral

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and kind of apical anterior kind

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of throughout here we see evidence that there is decreased

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Flow. So again, this is

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quantitative perfusion evidence

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of ischemia, the LAD territory.