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Today we're honored to welcome Dr. Kate Hanneman, for a lecture on case

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review of cardiac manifestations of COVID 19 and COVID 19 vaccination.

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Dr. Kate Hanneman completed medical school and diagnostic radiology residency

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at the University of Toronto, a cardiovascular imaging fellowship at Stanford

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University, and a master's in public health and epidemiology at Harvard

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University. She was appointed as an associate professor at the University

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of Toronto, and as a clinician scientist at the Toronto General Hospital

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Research Institute. She leads an active research program focused on improving

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health outcomes for patients with cardiomyopathies using cardiac imaging.

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At the end of the lecture, join Dr. Hanneman in a Q&A session

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where she will address any questions you may have on today's topic.

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There will also be a short Q&A after each case, so please use

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the Q&A feature to submit your question. Any additional questions will be

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answered at the end of the lecture. With that being said,

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we are ready to begin today's lecture. Dr. Hanneman, please take it from

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here. Wonderful. Thank you so much for the invitation to be here today

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and thank you all for joining. As mentioned, we're gonna go through a

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couple of cases at the beginning, and then we'll have a bit of

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a review to summarize some of the findings. But I'm happy to address

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any questions about the cases, each specific case afterwards while it's

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loaded and up. So with that, we're gonna jump right in to a

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case. We're gonna start with a couple of cases, patients who presented with

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suspected myocarditis after COVID 19 vaccination. All of these are anonymized,

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and I'll kind of give you non identifying data so you can understand

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the demographics before each one. So our first case was a young male,

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a young adult male. At our center, we don't scan pediatric patients,

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so all of the patients that we'll present today are 17 years of

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age or older. This is a young male patient who presented with acute onset

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of chest pain and had a troponin elevation and came for cardiac MRI. We're

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going to start with our sinuses at V images here on the left. I

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have our four chamber view and I'm going to play it for you.

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And you can see here, if you read cardiac MRI, you can perhaps see that

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the left ventricle global function is impaired. So when we quantified that

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ventricular ejection fraction was 50%, so mildly impaired, there's no obvious

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valvular abnormality and the right ventricle is near the lower limits of

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normal for function as well. Here I'm going to show you the short

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axis mini SSFP clip. And as we go through, you want to look

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for regional wall motion abnormalities as well as assessment of function.

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And of course, this is a stack that we quantified

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on our post processing software. And I'm just going to go back to

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the base and draw your attention to the basal to mid inferolateral wall.

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And perhaps you can start to see here that that area of myocardium is

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thickened and it's actually hypokinetic. So not only is there a global impairment

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of function, but we also have a regional wall motion abnormality. And so

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one of the key strengths of MRI is of course the ability to

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do tissue characterization. So I'm going to start with our T2 weighted imaging.

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Here's a black blood T2 weighted sequence. And this allows us to look

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for edema in the myocardium. And I'm going to pull up a T2 mapping image.

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And we're going to go back and I'm going to show you how

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there is an abnormality that becomes much more conspicuous when we window.

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And we can see here that the myocardium remote area of abnormality in

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the septum is isointense to skeletal muscle. But at that basal to mid inferolateral

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wall, we have this area of high signal intensity that we can see

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visually on our black blood T2 weighted image. This is telling us that

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there is increased water and fluid in that area of myocardium. And here

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on a corresponding T2 map, this is a parametric mapping sequence, we can

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see visually that there is higher values, and again, very important to look

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at your color lookup scale. I'm showing you here

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that the scale is ranging from zero milliseconds, dark navy, all the way

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to 120 milliseconds, light yellow to white. And so areas that are more

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orange and yellow are higher on T2 mapping values. And that's telling us

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again, that there is edema here. One of the things that we're going to reiterate

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today and go over again in the slides is there's two key MRI features

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that we want to look for when we're thinking about acute myocarditis. One

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is a T2 based criteria. If we're thinking about applying the revised Lake

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Louise criteria, and you can actually meet the T2 based criteria in more

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than one way, you only need to meet one of the potential ways

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to meet a T2 criteria. And so here we have both a regional

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hyper intensity on T2 weighted imaging, which would qualify. We also have

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high T2 mapping values. And so again, both of these are telling us

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that there is edema. The next criteria that we would want to look

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for is a T1 based abnormality. And traditionally, I'm going to pull up

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now our late Gilman Hanst image, our sequence rather, this is a short

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axis stacks for kind of looking at a corresponding image here on the

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left. This is a post contrast sequence. And really, in the past,

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this is kind of the workhorse for tissue characterization, not just

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in myocarditis, but another cardiomyopathy. And this tells us there is an

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abnormal area of myocardium that is held on to a retained contrast.

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And here this is at again, at that sub epicardial inferolateral wall.

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You can also see that the pericardium is abnormal and enhancing overlying

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that area of myocardium. So this is a patient who had myopericarditis after

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vaccination. And now we have met not only our T2 based criteria, but also

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our T1 based criteria. The other way that we can potentially meet the

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T1 based criteria that's required to make a diagnosis of acute myocarditis

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using the revised Lake Louise criteria is with mapping. Here I'm showing

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you a native T1 map. So this is a non contrast sequence.

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And of course, we can actually quantify these values. They were elevated

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above our normal reference range. But I also think it's important to look

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at the maps as well. Remember that this is not just a quantitative

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technique. It's an image just like this.