0:00

Our next case is a 64 year old man with a history

0:03

of LAD stent who was found prior to this study

0:07

to have inducible, non-sustained ventricular tachycardia

0:10

during a recent stress test.

0:12

So this exam was to evaluate for any scar in the myocardium

0:17

and viability of the myocardium.

0:20

So again, starting in our usual approach,

0:22

we are looking first at the two chamber

0:27

and not a ton to say on this one.

0:29

It looks like to me there may be a little bit of thinning

0:33

relative, at least to the rest of the myocardium here

0:36

towards the apex, kind of the anterior segment of the apex

0:39

and all the way around.

0:40

I mean, we know that he is had an LED

0:43

territory infarction at some point,

0:44

so perhaps this is gonna end up being residual from

0:47

his LED infarction.

0:48

The other thing, and I think this will show a little bit

0:51

more nicely on the short XS images,

0:52

I think he's overall has a little bit of

0:55

left ventricular hypertrophy,

0:57

which sometimes can make our lives easier

1:00

'cause there's just more, at least in terms

1:01

of viability imaging, there's more

1:02

myocardium to sort of look at.

1:04

So there's the two chamber view,

1:08

four chamber view here.

1:11

Again, not much to add, but always important to look at.

1:17

And same on three chamber.

1:18

Overall, this person's function looks pretty good

1:22

and I, I do think that there's gonna be some left

1:24

ventricular hypertrophy when we look on the short axis.

1:29

So now I'm gonna move our way down from base to apex

1:40

and there is gonna be circumferential hypertrophy.

1:44

I won't measure here since this is a

1:48

schemic cardiomyopathy talk,

1:50

but it's important to at least recognize this

1:53

and comment on it when appropriate.

1:55

You know, it can be related to many things,

1:57

including chronic hypertension,

1:59

hypertrophic cardiomyopathy, amyloidosis.

2:01

So all things to at least note here,

2:05

even on patients where the exam is not indicated,

2:10

a little arrhythmia in this patient.

2:11

So the image quality is not as pristine

2:14

as maybe we would hope,

2:15

but this is kind of like what happens in real life.

2:18

So starting to get into

2:22

some interesting findings.

2:24

I think here I'm gonna start to draw your attention to sort

2:28

of this region, the basal to mid

2:31

anterolateral segment here.

2:34

And as I scroll through the cynic lip,

2:39

you'll probably see it looks a little bit relative

2:43

to the rest of the myocardium,

2:45

maybe a little bit thin there,

2:47

or at least something is different about the wall motion,

2:49

maybe a little hypokinesis in that region.

2:53

And scrolling through, again, a little bit

2:56

of gating artifact here in this patient

2:58

Who, who may have had some arrhythmia,

3:02

this is gonna be a little bit better quality example.

3:04

And I think you can see if you contrast that kind

3:07

of anterolateral segment relative to

3:11

the other segments of the myocardium,

3:13

which are contracting quite vigorously, that looks

3:16

a little bit hypokinetic

3:18

or maybe even a kinetic in that segment.

3:23

More of the same here.

3:28

And now we're down into the apex, which relative to the rest

3:32

of the myocardium may look a little bit than like we

3:34

saw in the long axis.

3:37

So now go moving to LGE imaging.

3:41

So we're gonna start with the short axis here.

3:44

And almost immediately as we get into the first kind

3:47

of true basal slice here, we see that there's gonna be some

3:52

late gata limb enhancement involving

3:54

that anterolateral segment.

3:56

And here it gets quite intense relative to maybe

4:00

what we would see in more

4:02

of an non-ischemic cardiomyopathy or something like that.

4:04

There is a lot of contrast that's been taken up here

4:07

and it's definitely in a sub endocardial distribution.

4:10

I cannot identify any endocardium below this area

4:14

of Lake Catalan enhancement.

4:16

And as we keep clicking down, clicking through kind of in

4:19

that area where we saw, you know,

4:21

questionable wall motion abnormality

4:23

and thinning, we're definitely making out some late

4:26

Catalan enhancement in this region.

4:29

And more of the same as we move down.

4:31

Notice we kind of don't have any as we get

4:34

to the true apex in that particular region.

4:37

So here I'm kind of scrolling up

4:38

and down through that region.

4:41

And then as we get down into the apex though, we start

4:44

to see some inferior sub endocardial,

4:47

late gado limb enhancement

4:48

that becomes nearly circumferential at the apex.

4:51

So this is probably related

4:55

to his old LAD territory infarction with sort

4:58

of like a wraparound LAD anatomy

5:01

that you know is supplying kind

5:02

of the inferior aspect of the apex.

5:05

But this is gonna be actually most likely a circ territory

5:10

myocardial infarction here.

5:12

And I, I really want to use the long axis in this case

5:16

to try to understand the morality of this

5:19

because it's a little challenging I think in the setting

5:22

of hypertrophy here to know kind of like

5:24

what the true myocardial thickness is.

5:27

So let's see if the four chamber is

5:29

gonna cut right through here.

5:30

So I'm gonna pull the four chamber next

5:33

and see if we can get a better idea of what

5:37

the mural extent is here.

5:38

And I think we probably can, this is probably the best view

5:42

that's kind of cutting right through it.

5:44

And you can see this is probably normal myocardial thickness

5:46

here, and this is maybe normal myocardial thickness here.

5:50

And so here is kind of our infarcted region

5:53

and it's actually less extensive than I think it looks

5:56

Like on the short axis.

5:57

So this is again, why a long axis view can be very helpful.

6:01

This I would probably put at 50%,

6:04

or probably in my kind of world, I just use that 50% cutoff

6:08

and say, you know, less than 50%.

6:10

And I would say this has a high likelihood

6:12

of functional recovery.

6:15

So again, here's what it looks like on short axis

6:18

when we get thinned out a little bit.

6:20

Sometimes, especially in a hyper sort of area of LVH,

6:24

you can get a little bit of where's the blood pull stop

6:27

and the enhancement start.

6:29

And that's why I think those long axis views can be quite

6:33

helpful and kind of give you a little bit more myocardium

6:37

to look at to see, okay, what's actual normal thickness

6:40

in this patient versus areas of enhancement.

6:45

So circumflex territory, myocardial infarction

6:48

with viability.