0:01

This next case is an 83 year old female with dyspnea on exertion

0:06

who ended up getting an echocardiogram that showed normal left ventricular

0:09

function but really large atrial. And she eventually got sent to a cardiac

0:14

MRI to look for an infiltrated cardiomyopathy as an explanation for her

0:19

heart failure symptoms. So what we see on this initial set of static

0:23

images on the cardiac MRI is that this patient has really,

0:27

really dilated atrial, out of proportion to the left ventricular and right

0:30

ventricular dilation. This is a pattern highly suggestive of restrictive

0:35

cardiomyopathy. And certainly we know from her history, that fits her clinical

0:40

diagnosis as well. So when we look at cine images of this same

0:44

patient, we see that there's preserved left and right ventricular systolic

0:49

function. The left ventricle here, there's a little bit of blurring at end

0:52

systole. But I would say it's normal to low normal systolic function.

0:57

And then you see it, there's both mitral and tricuspid regurgitation based

1:01

on these regurgitant jets through the valves. And then you see that these

1:06

atrial are massively dilated. And that there's also

1:10

blood swirling in the atrial. And whenever you see this blood swirling on

1:15

cardiac MRI, that really tells you that it's just not moving very fast.

1:20

So there's a lot of stasis. If the blood starts swirling,

1:24

that means that there's basically saturation of the blood that's happening

1:27

because it's moving so slowly through the image.

1:30

And so anytime you see that, you know that this patient has poor

1:33

function in whatever chamber it's that you're looking at. This patient also

1:37

had atrial fibrillation that accounts for some of the fuzziness. And one

1:41

way you can often tell if there's atrial fibrillation on cardiac MRI is

1:45

you don't see that nice atrial kick. You should see a little squeeze

1:49

of the left atrium right before systole. And in this case,

1:51

you really just don't see that. It's sort of just static,

1:55

the left atrial wall throughout the cardiac cycle.

1:58

Now when we go to the short axis cine images, I'll just show

2:02

a representative slice, you're gonna find that the left ventricular function

2:07

here actually looks pretty good. And right ventricular function as well.

2:11

I think if you had only this image, you might not really say

2:15

there's a whole lot wrong with this patient. And this is again really

2:18

typical of restrictive cardiomyopathy. You have preserved left ventricular

2:21

function with really abnormal atrial morphologically. Now when we move on

2:27

to the late gadolinium enhancement images, what we're really looking for

2:31

here is some sort of enhancement that might explain why this patient has

2:34

a restrictive cardiomyopathy. And remember, restrictive cardiomyopathies

2:37

are caused by increased stiffness of the ventricles. And that stiffness

2:42

leads to the atrial having to work harder to push blood into the

2:45

ventricles. So although the ventricles have normal systolic function, they

2:49

squeeze fine. They don't relax normally. So the diastolic function is abnormal.

2:53

And so we're looking for diseases that could be causing that diastolic dysfunction.

2:59

And unfortunately in this case, we really didn't find anything. You see

3:02

that there's really no late enhancement in the ventricles on this view,

3:06

the four chamber view. And then if we go to a two chamber

3:09

view, similar, nice dark uniform nulling of the myocardium. And then finally

3:16

when we go to the stack of short axis views, you can see

3:19

that again, there's really nice uniform nulling of the myocardium, no late

3:24

gadolinium enhancement identified that would explain the restrictive cardiomyopathy.

3:27

Now in some later cases, we're gonna go through other etiologies that can

3:31

explain restrictive cardiomyopathy and show their enhancement pattern. But

3:34

in this case, if you were reading this, you would have to say

3:37

this is a patient who has restrictive cardiomyopathy features,

3:41

but with no late gadolinium enhancement to suggest any scarring or infiltrated

3:45

disease to explain her restrictive cardiomyopathy.