0:00

Okay case three.

0:04

Here we have a 50 year old man.

0:07

Who presents with acute chest pain?

0:10

an elevated troponin

0:13

and an elevated CPK

0:17

he has

0:18

St. Elevations and multiple

0:21

ECG leads

0:24

and I'm showing you two images from his cardiac MRI.

0:30

And the two images are shown.

0:33

As a stir image or a short towel

0:36

and version recovery image on the left.

0:39

and a 10 minute post contrast inversion

0:42

recovery image on

0:45

the right in which normal myocardium

0:48

Is made to be black or the version time

0:51

to select Imaging?

0:55

Is 300 milliseconds which at

0:58

1.5 Tesla generally is the time at which normal.

1:01

Myocardium is made black.

1:05

These are vertical long axis also referred to

1:08

as two chamber of use. Please have a look at these and

1:11

see if you can identify any abnormalities.

1:17

Okay.

1:24

There are abnormalities on both of the

1:27

images.

1:28

Point them out here this isn't

1:31

abnormal area of increased T2

1:34

signal on stir and increased

1:37

T2 signal this is the mid

1:40

ventricular sub-appocardial

1:44

anterior segment and this is the basal.

1:48

sub-appocardial inferior segment

1:53

these are abnormal because of

1:57

increased water content or increased edema

2:01

the image on the right which we also refer to

2:04

as a late catalinian enhancement image shows

2:07

abnormalities in exactly the same location. There's a

2:10

bright spot.

2:11

Where we saw bright spot on the stir Imaging the

2:14

mid ventricular anterior segment and likewise

2:17

in the sub epipartial.

2:20

Basal inferior segment. Now these

2:23

abnormal Foci are abnormal for

2:26

different reasons on the left. It's because we

2:29

have edema on the right. It's because we have abnormally

2:32

expanded extracellular space which

2:35

is where gadolinian goes.

2:38

And this is a classic appearance.

2:43

For what some of you may have already diagnosed is myocarditis.

2:47

This is viral. Myocarditis. Some of

2:50

you who are doing cardiac MRI.

2:53

May have come across cases of post

2:56

MRA vaccine. Sorry Mr.

2:59

MRNA vaccine.

3:03

Associated myocarditis and it looks exactly the same

3:06

or it can look very similar to viral myocarditis.

3:10

Um, and we we have seen a number of

3:13

cases at our institutions. In fact have recently published

3:17

a small case series on the post.

3:21

Vaccine Associated myocarditis. It

3:24

looks just like this. But in this case, it's viral model

3:27

for Davis. Here are a few pearls about viral.

3:30

Myocarditis has a

3:33

highly variable presentation.

3:35

and it includes

3:38

The presentation of acute coronary syndrome so people can be in quite severe

3:42

distress. They can also come in in heart failure

3:45

or they can present with a rhythmia.

3:48

Sometimes they'll have symptoms of upper respiratory tract infections

3:51

or enteritis.

3:53

At CMR, we see what we just saw which

3:56

is a edema and Lake Catalina

3:59

enhancement patterns involve the sub-epocardium and

4:02

the mid wall.

4:04

And tend not to involve the sub-indocardium which

4:07

is where we see myocardial infarction.

4:10

Incidentally if the lateral wall

4:13

is involved in viral. Myocarditis is usually

4:16

horrible virus b19 itself Limited.

4:20

If the septum is involved and it's usually either human

4:23

herpes virus 6 in

4:26

isolation or combined with parvovirus b19

4:29

and septal involvement generally

4:32

portends are worse

4:35

prognosis.

4:36

That's useful to know but in general these

4:39

patients will be followed clinically anyway.