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This case is a 78 year old woman with a history

0:04

of non-ischemic cardiomyopathy and heart failure.

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And it actually looks like she's a kind

0:09

of dilated cardiomyopathy phenotype.

0:12

And so they wanted to do an evaluation to look both

0:14

for signs of ischemia in case there is an ischemic component

0:17

to her underlying cardiomyopathy.

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And also look for other signs related

0:22

to her cardiomyopathy enhancement, any patterns of disease

0:25

that may be diagnostic.

0:27

So, uh, again, showing you the profusion images first,

0:30

stress across the top, rest across the bottom,

0:32

and then base mid and apex here.

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And so what I want you

0:37

to notice about these exams is the stress

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and rest images look almost identical

0:43

in this particular case.

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And particularly pay attention to some areas here, like

0:48

as I kind of go through time, you notice

0:52

that maybe there's a little bit of hypoperfusion here

0:57

in the septum and maybe even lateral,

0:59

almost circumferentially here,

1:00

but it kind of does the exact same thing at rest.

1:05

And that's true for all of our slices.

1:09

You know what looks like hypoperfusion here in the septum

1:12

Also, we see it at rest.

1:14

Same thing in the septum here in the apex. Same here.

1:18

And so one thing that you have to sort

1:21

of do first is you do a quality check.

1:23

And so we talked about the splenic switch off sign.

1:26

So here's actually the spleen right here, spleen right here.

1:30

And you can notice it's stress.

1:32

The spleen is dark at rest, the spleen is bright.

1:36

So you know, we feel like the adenosine

1:38

had an appropriate response.

1:40

The patient had a response

1:41

to the adenosine, her heart rate went up.

1:43

So we don't think that this is a sort

1:44

of a image acquisition issue.

1:46

This wasn't a quality issue.

1:48

So we're kind of left, you know, mass profusion defects.

1:52

So we're thinking either this is a big infarct,

1:55

which we'll look on LGE or this is an artifact.

1:58

And so let's look at LGE next.

2:00

And by artifact I mean dark rim artifact.

2:02

This is kind of classic dark rim artifact.

2:05

And just to tell you, that's what we kind

2:07

of thought it was initially.

2:09

So here we're looking now at our LGE images, again,

2:13

you notice that the myocardium is really thin

2:15

and an LV is dilated.

2:17

So kind of classic dilated cardiomyopathy.

2:19

Look, no LGE here.

2:21

Certainly nothing that looks like infarct

2:24

or something that would cause circumferential fusion defect.

2:28

So we were pretty comfortable with the idea qualitatively

2:31

that this was gonna be dark grim artifact.

2:33

But as I'd mentioned, we do more quantitative profusion now.

2:37

And I'm just gonna pull up, uh, side by side here the

2:42

results of the quantitative profusion evaluation to show you

2:46

how this can perhaps be helpful.

2:49

So from left to right,

2:52

I have the flow at stress, the flows at rest,

2:57

and then the myocardial perfusion reserve.

3:00

And what we thought was quite interesting here, this,

3:03

the flows at stress were pretty low

3:07

while the flows at rest were pretty normal overall.

3:10

So when you do that division, which you can appreciate,

3:12

you know, myocardial perfusion reserve is

3:15

stress flow divided by rest flow.

3:17

And you can see almost all of these are less than two.

3:20

And the global overall perfusion reserve

3:23

is quite a bit less than two.

3:25

And so given the fact

3:26

that we had a good physiologic response,

3:28

we ended up calling this likely microvascular disease

3:31

or three vessel disease and this person

3:33

because the quantitative perfusion was so abnormal

3:37

and we had no other reason to believe this is the case.

3:39

So I think this is just a nice example of

3:41

where quantitative profusion can help you work through some

3:44

of those artifacts or or questions that may come up.

3:47

And it sort of makes us wonder, you know,

3:49

we've been doing qualitative for years.

3:50

How many of these cases have we actually may be under called

3:53

where quantitative mabo now will get us to the right answer.