Dr. Juan Lopez-Mattei discusses the efficacy of multimodality cardiac imaging in diagnosing and identifying cardiomyopathies.
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All right. Welcome back. Everyone were looking forward now to the second half of our program today. We are joined now by Dr Juan Lopez from M. D. Anderson Cancer Center. Again, as I mentioned earlier, he eyes an associate professor there and co directs the cardiac radiology service. And so we're very fortunate to have him join us. We were just discussing earlier that we were all all three of us were looking forward to meeting together in person. This year. Azzawi were planning this symposium, you know, in the beginning part of 2020. But we'll have to delay that until next year. But looking forward to your talking Thank you for joining us. Absolutely. Absolutely. Thank you. Andi, I'm really glad toe join you. You guys are a great group. I heard so many good things about you and, um, you know, and I'm happy to really join you. Here are whether it's not as nice as what you guys usually have. But it's getting nicer now, thankfully. So let's just get started. So I'm just gonna talk to you about beyond echocardiography the roll off. Multiple I t cardiac imaging. Uh, CMR and Cardiac City. What is relevant. Toe heart failure, practice and general cardiology practice. See if I can advance the slide. Uh, okay. No, I don't have any disclosures. So why cardiac, Marie or cardiac magnetic resonance in cardio myopathy assessment. So basically, I think this I love this slide on bond. This is I feel that this slide explained very well why, um you know, Carrie camera is important in cardio myopathy, And one of the most important things is the robust volume quantification, which will produce into robust left ventricular ejection fraction, quantification and based. Basically, the way it works is that when you are acquiring an image, basically, you, uh you are gonna acquire the short access stacks of short access off the left ventricle on basically in diastolic and insistently, and you have the area. Plus, we know how thick the slices are on your going to get a very accurate volume on this is you know, it's not like echo where you kind off. You know, you have some sort off geometric assumptions here. There's no geometric assumption. You basically what you measure is what you get on. This is important because when you look at comparisons between echocardiogram I mean, if you look at this, uh, left side panel here where the graphs are and you compare the echo, which are the white Bart's, this this is will be the standard deviation off the measurements off mass volumes on ejection fraction. And you compare that with cardiac emery and the CCF means that and and the end means that thesis was this was a study where the cardiac Emory where was done in normal patients, and this was in patients with clinical heart failure on Basically, when you look at this, you see how the variability it's less in L v mass in volumes on in injection fraction. So, um, this is ah, very objective evidence that the variability off measurements is very narrow on its less prone to error. And this is another table that I like because I feel that it really illustrate the robust way in how Carnegie Emery ejection fraction variability IHS less than eco. And just look at this election fraction. So let's say we have a clinical trial and part of the clinical trial, which it doesn't make that much sense. But part of this political clinical trial is that you need toe measure at least changed in 3% in ejection fraction. And you're thinking about which morality I'm gonna use to prove that. And when you look at echo basically toe uh, toe, be able to prove a nab salute changing 3% you will need a sample size off 100 patients. But with Emery, you only will need a 15 patients to prove absolute changed in 3% which represent our percent of reduction sample size 85% which is very remarkable. So that's Onley something for for you to ponder How accurate is for the ejection fraction quantification. And this is just an illustrative example showing. Basically, this was a patient with a 37 year old woman with lymphoma that was undergoing chemotherapy with and recycling Onda. Basically, the echo looked like this. And then, you know that we got a ejection fraction of 40% and it didn't really sound, you know, right, because when I look at the echo, even, you know, visually kind of looks better than what it measures attack. That point contrast was not given, so we decided to do a cardio Gaymard because there were some discussions about interrupting her treatment, Onda Emery proved that there was an ejection. Fraction of 54% on the volumes were normal. So we left this patient continue treatment, and she did well and there was no further reductions. So I think it's important to understand that, you know, this tool is really accurate. And now part I will say that a pillar off cardiac memory is the delay enhancement. And for cardio myopathy assessment, basically, you know, is one of the best noninvasive tool that you can have toe assess and look for the ideology on. Uh, this is just illustrating how it works. The late enhancement with Carolinian. So basically, you inject contrast, you wait 10 to 15 minutes, and then you start imaging and in a normal myocardial, you're going to see that the contrast is not going to accumulate between the mile side. You're gonna just see a dark or a black mile kardian. But if you have an acute infarction, you're gonna have a rupture in cell membrane, integrity and the gallery, and it's gonna penetrate. Or if you have a scar already, If the patient developed a scar either by a nen fact or myocarditis, the contrast is going to accumulate between the mile sites and then you're going to see the delay enhancement off the scar. Eso in amyloid is different. The reason why there's enhancement and we're gonna talk about a little bit later about it. But I think that it's important to understand that this is the pillar of cardiac Emory In cardio myopathy assessments. One of the pillars you have ejection fraction quantification and then leg value enhancement are the two most important pillars. And if you look at hyper enhancement patterns, which is the important thing, basically you can, you know, asses. You know, we categorize the cardio myopathy is as ischemic and non ischemic on the hyper enhancement parents. You can also terrorized ischemic and non ischemic on ischemic cardiomyopathy. Eventually, that ischemic cardiomyopathy or, ah, history of M I they're gonna have some and a cardio in far which meaning that is in the south end of cardio. Any extends a little bit more inward or trans mural. If you have the whole segment die because there was an inclusion and it just was not river secularized, timely fashion, you're gonna have ah bright segment there and then the notice giving our multiple. There's different patterns you have made wall, which can be seen in, uh, idiopathic dilated cardiomyopathy or myocarditis. You have enhancement at the RV insertion points, and you can see that input. My hypertension hypertrophic cardiomyopathy, aan den. You have the mid mural ones that you can see in sarcoidosis. Myocarditis understand Fabry disease Onda the epic cardio ones. Basically there there's another differential diagnosis associated with it. And, more important, the amyloid you're gonna have. You could have sub and a cardio pattern or trance mural. And you know what is important. And this is something that we were discussing earlier with A. J and Rajiv. And is that because you see that there's a differential diagnosis tied to the delay enhancement a parent. So it's very critical for us to know what is your question In regards to the patient? Where are the clinical? Um, accuse That way the clinical accuse that we need from you is important. So when you're referring, the test for your writing for a carriage Emery is very important for us to know. What is your differential? Not just not right cardiomyopathy, but just think about you know what my patient. Have you know what? What? What is the differential diagnosis or what? What are the things that I feel clinically especially have, and that's gonna help us better do our job and will be better for us to help you and get the right diagnosis. So this is a very good example. Um, basically, on a large animal model off delay enhancement. And this is a very early paper by raking from Duke. And basically, if you look at the at the left hand side off the different images, you're going to see the pathological specimen. And here is the emery. The black and gray is the Emory. Um um, image. And you can see that for every spot off scar, you know, the alignment off the basically, if you put one over the other, you're gonna have a very nice overlay off what you see in Emory with what you see in pathology. So this is the really the best non invasive assessment off scar that you can do with Carnegie Marie on. I think this really illustrates that. So this'll is one of the earlier studies that was done to assess for ischemic cardiomyopathy, uh, in cardiac Emery. And basically they had a group where they did calf in all on all had carried memory and basically they were able to separate the ones that had the typical, um, some end of Korea trance mural or ischemic enhancement from the ones that had negative calf. So patient that had a positive coronary angio for ischemic cardiomyopathy. They had a they definitely had significantly more this different enhancement, parent. Now you have to understand that there other theologies that can cause some and a cardio enhancement. But the key will be the corner distribution. Like if you have a central soup and a car, your pattern that is patchy and it doesn't follow a coronary distribution, then likely this is non ischemic. But this is one of the earlier studies showing that really cardigan Marie is useful to identify. Uh, ischemic cardiomyopathy. This is a little bit more off. I mean, not reason a little bit all but but interesting study that they use cardiac emery as a gatekeeper toe calf in one arm and in the other arm it was just usual care, which will be patient with a heart feeling in certain ideology, that just just straight captain versus just go toe Marie and then decide if we should catch them or not based on the enhancement pattern. And when they did the comparison off the two techniques. Basically, the numbers favor were very favorable for Cardigan Marie, where you had a higher sensitivity. Hire a comparable specificity on a little bit of a higher negative predictive value. Onda hire a diagnostic accuracy, and it's just because when you do a cath, you basically you either say ischemic or not ischemic. But when you do on Emery, you're able to really differentiate at that point Now. Certainly the biopsy has a big role, you know, in your practice. But this is just illustrating how useful cardiac emery is just compared with traditional calf. And you know that in most center they don't really dio, you know, biopsy. Or of course, in a robust heart failure program. That will be the case, but But it's interesting toe. I think it really contributes to the practice to do an Emory in your patient because you're gonna know earlier what is going on. And and again, there are some cardio myopathy is there are patchy. So maybe when you get when you try to attend Biopsy. You know, if there's a disease processes more in the epic cardio or or outward not in the septum. Uh, inter ventricular septum. Then you could miss potentially miss the the diagnosis. And Emory, you just acquire the images and you look at them has been pattern. And I think that that that will definitely be helpful in in a lot of cases. And this is just a illustrative case off what is an ischemic cardiomyopathy from our practice. And basically, the apex is, uh, this kinetic and you can see some real Muslim abnormalities in the Septimus Well on may be a pickle lateral, and here you can see this skinny Asia as well in the apex. But when you look at this, you you will. Some people will say, just looking at the foreign to chamber. Certainly we don't have the three chamber, which will show an abnormality, But sometimes Takatsu Takasu like presentations could just be l a deletion. But in this case, you can see enhancement like a trance Mueller infarction in the intercept. Um, on in the apex, you can see some end of cardio, and then France mural Apex on another interesting thing. I mean, for those that are emerging aficionados, you can see the in the apex. There's a little bit thing. Either you see that the apex a story in the appendage in the left atrial appendage, there's a little thing either that was seen with, you know, didn't enhance. With contrast, patient also had a small left, a trail trump. A So one of the advantage of card game are is that you can identify pathology that you were not expecting because you is within the field of view and you can have a protocol where you can look at the appendage as well. And you know, also look at that. So another important thing for non ischemic cardiomyopathy will be that presence off LG is prognostic. So if you have laid down in enhancement present in a non ischemic cardiomyopathy, basically these patients don't do that well, So the combined endpoint of cardiovascular mortality in this meta analysis shows that definitely when there is presence of LG, the book of the data shows that there's a higher cardiovascular events on da combined endpoint off ventricular tacky, tacky, arrhythmic event in no ischemic cardiomyopathy the more scar they have by Emory, the more events with accurate NIA. So it's important to understand that, you know, Carnegie Marie can definitely help re stratify your patient. There's this concept that is called imaging fana typing, which, uh, and this is an example of This is a great slide from from my friend Salerno, where basically you have chronic and my acute myocarditis and hypertrophic cardiomyopathy on their These are different parameters that we use. Eso. I have bean talking only about legal in enhancement, but there's native or pretty one off native T one, which is a new image acquisition that you're able to measure the T one directly. I know that you've heard about T one and T two weighted images, especially in the brain memory T one and T two images. But we do the same thing in the heart, and basically you're able to measure the T one and high tea. One. Values are correlated with fibrosis, so when you have a high tea one value, you have fibrosis and you're able to also look at that in the patients currently with the current techniques on the extra sir, volume is basically were able to quantify how much space are between my oocytes on the larger the space, the more fibrosis. So that's another, uh, surrogate off fibrosis. So E. C. V. NT one are very clinically relevant, and we're gonna talk about them, uh, in a bit more details soon. So in using these parameters t one values and T two values and also t one and t two weighted images. And I think this is a good example here, but let's talk about the leg loose criteria. So the Lake Louis criteria is the car car. Nick Emery diagnostic criteria for myocarditis. And it's very stringent, like you if you have to really have either mockery evidence of myocardial. No, not either Sorry evidence of myocardial oedema on. None is giving myocardial injury, so you have to You need to have both, and there's some supportive criteria. But really, these are the most important, too. And if you don't have both, there's no Margaritis, you know, by Emory, at least. So basically, when you talk about T two mapping or T two weighted images, T to mapping is when you're able to directly measure in a map that you acquire in an image that you acquire. You're able to measure the value off T two on the T two. Weighted imaging is just either It's bright or darker, and it depends on if you're acquiring in a T one on a T toe weighted, uh, imaging acquisition. So the tea t t two and t one weighted It's more like, not measuring directly. It's just visually saying, Oh looks brighter. So that has high signal in T one or has high signal in t two. And these are the the for a lot of for most of the time in radiology. This waas, the one that was used mostly. But now we're starting to use more the direct measurement of the T one and T two. So Markarian Latina. When you when you have high high values of T two or high signal in t two, then that's evidence of myocardial oedema. And when you have a non scheming myocardial injury, when you have high values of T one or the extra volume fraction or you have presence off late gallon enhancement that will support non scheming material injury and these are the most stringent criteria. I think that you have to be really strange and not one but both. And let's just see this case because I think it's gonna help. Uh, this case is gonna help us apply what we just discussed. This is a 60 years old woman with myeloma on presented with chest pain with a negative, uh, invasive coronary angiogram on high sensitivity troponin of thousands. Okay, so it's pretty remarkable. You can see that. Basically, there's some global hypo. I don't see any regional ITI in the fourth chamber or in the tree chamber. It looks pretty global to me. Then when you look at the leg Ari enhancement images, you can see that there's a you know, this is trance mural enhancement, but interesting. It's first a little bit the sub and a cardio. So you see a bit of dark here and you see, mostly break here and you see also meet mural enhancement here and a little bit here in the lateral wall. So thesis, not ischemic injury of the myocardial. And then looking at the T two measurements The measurement in t two. I think that normal values are usually I would say, uh, below the mid fifties and here you have 64 which is significantly high. So you have my evidence of myocardial oedema and evidence of non ischemic injury. So this patient indeed have myocarditis proven by biopsy, so But it's important to understand that with an emery you can actually diagnose some accurate Jesus. Well, another thing that I wanted to really, uh, you know, emphasize is that cargo camera is very sensitive and specific to diagnose cardiac amyloidosis. Now, you really cannot tell if it's ctr or a L when you do the Emory because Emory is gonna tell you. Oh, this space, I mean, you're gonna look at the images, and they're going to suggest you that this is a malloy. But for the tt r n a l to be able to differentiate, you could certainly, you know, do a P Y p or a pirate phosphate scanning, you know, to see if there's uptake, then on it's really update using the spec technique, which is really the most accurate because the planner acquisition is not good. Eso the because the specter technique allows you toe look at the uptake off the mile kardian with the image correction from the city images. But the planner. You know, it doesn't really allow you to do that so that we could be a next step. If you happen to do an m r. I on a patient has something like Pattern. Then you know, we could do a P Y. P. And also you can do biopsy. You know you can. There's multiple things that you can look at the central free like changed all that. But but Keurig Amara really is very accurate in identify cardiac amyloidosis. And you can see that in this study when looking at this model that they had the Multivariate the only one that really pan out toe be significant. What's the enhancement pattern on? They found a negative predictive value of 90% using memory on also the prognosis waas. Worse if you had presence off off enhancement pattern off amyloidosis. So this is just a earlier small study, but it really was very useful. And this has been confirmed by multiple studies, one off them. Basically, when you look at patients that are you have suspicion of cardiac amyloidosis, any enhancement, any any presence of enhancement, they're gonna really do poorly in regards to survival. Andi, If it's defused enhancement, basically, if that If. If there's diffuse enhancement and it's present, they're going to really do poorly as well. And looking at a composite of heart failure, freedom of heart failure, admissions, transplant of death. Basically, if you don't have enhancement, the patient is going to do great on. If you don't have diffuse enhancement, the patient's gonna do great. So it's not on Lee presence of enhancement. But how diffused, or what is the extent off involvement in cardiac amyloidosis on the prognostic capabilities off presence of La Guardia Enhancement carrying amyloidosis? I think they're pretty much well established in this meta analysis. They show that patients all cause mortality was higher if there was presence off late Galileo enhancement or in this case, will be that, you know, patients did well when they had negative legal enhancement. So presence off the enhancement pattern is prognostic as well. So it's not only your diagnosing the patient, but you also are prognosticating what is gonna happen in the future. And this is just an example off case of cardio Camilla, uh, two cases you can see this sub global. So I mean mid mural and south and a cardio enhancement, and this is more a big transmit. There's a more trance morality here, and the more enhancement. Sometimes you're gonna find this situation where there's not much contrast in the cavity on, ah, lot off. More contrast in the mockery in. And sometimes that happens because there's so much space within the Maya cardio, I mean within the mile sides that the the leader is gonna accumulate favorably within the mile cardio. And then you think that, Oh, there's something wrong with these images, but but But it's not. It's just that there's more space to accommodate in the contrast in the mockery, Um, and these are patients are really advanced. And part of how the enhancement pattern occurs in cardiac amyloidosis is that you know you can see Healthy Mile sites here and the Galilean stays out. But if you have any infiltration, you have the amulet protein infiltrating. There's more space between mild side, and the contrast accumulates, and that's why you see the enhancement. It's not that it's scar. It's more that is infiltration of the protein that creates spaces that the gallery in accumulates on. Basically, there's the E. C V, which is the extra several board infraction which in these patients tend to be high because there's more space between my outsides and it's prognostic. This market has been prognostic as well. On this is one study that showed that not only the CCTV that waas the higher the S e v the worst the survival, but also the t one. If the t one without contrast you If you have high tea one you're gonna do worse as well where? Survival. So these parameters are important to so not only the lega enhancement, but the TV one and TV also are prognostic even nominate on changing years. Basically, this is, uh, how you using an Emory technique. Carnegie Marie technique named the t two star quantifying the material iron Basically how in the UK by guiding that and selecting patient with thalassemia that had, uh, t to values that were abnormal if they did kill Asian therapy, this pay the mortality decreased significantly. So I mean, this is remarkable, like, you know, I mean, this was like a 70 like a 70% reduction in the death rate from iron overload. This is really remarkable. And you know how hard a camera using cardigan Marie really changed the natural history of this patient by you Understanding. I mean, because the iron overload creates a lot of mortality by ventricular arrhythmias are failure, Andi and you know, and you see the memory really helps. So if you have a patient that you're suspecting iron overload I mean, you have to do Ah, Carnegie Marie and get that into start. And this is an example off. Basically, these are the normal values, like in the heart. It's more than 20 milliseconds and deliver its more than 10 milliseconds. And you can see how you know in this case in the septum, basically, the values were reduced was like 11 0. R. 10 in the heart. That's abnormal. So it's important and you have that diagnosis and this is you don't need to give contrast to use the Tito start. You can do it without contracts. So if you have a patient in stage renal disease or patient with significant kidney problem, you can do at Emory without contrast with a T to start and you answer your question there and let me talk a little bit about the Euro CMR registry, which was a pretty large registry, 11,000 patients. And they're just describing how, uh, Marie had an impact on patient management and basically 16.4% off completely new diagnosis that we're not suspected before. So you saw the patient you ordered Emery, and you find 60% of the case you're gonna find something that you were not even expecting. So which is good? Onda And in some instances, it led to changing medications like a 20%. Let the cardigan Marie really findings, uh, drove the changing medication. There were some interventions also that were done. Uh, I mean, not very high, but there were some changes. Is 12 on the impact on patient management, new diagnosis on Earth, Their ability consequence 62% which is pretty high. I think on then when you did. And then how How many tests were order after Emory, basically 12% where transparency, choreography and there were minimal off T or city. So Emery really stands by itself in many, uh, situations. This is a classic. I like to say this like a classic study, cause I think it's really valuable. Um, we're basically thistles. Just looking at how memory diagnosis change. You know how often change and how often it led to changes in management or new diagnosis. Uh, and basically, uh, pre CMR diagnosis and possibly, um, our diagnosis. And if you look at this figure, you know, there were some changes about, for example, cardiomyopathy, every known ideology, you know, there were some that were classified most. There were some that were a gastronomic scheming. And then there were others as well. So left anti Trump speech eleventy Trump's and then after a merino 11 record trouble. So this is pretty remarkable. And you can see how changes in in this practice that WAAS using memory there was 35% changing management and 13% of new diagnosis, and 17% of the patients had both, which is important, so 65% has significant clinical impact. So I think you know, it's a really useful tool that is gonna really change the way you practice because you're gonna have more informations upstream. You see the patient, you know, Let's say you got an echo. You look at it E f slow. Let me assess better let me do an Emory, and perhaps you can have you know important clinical impact. This is a very interesting story, Andi. It's just basically done by a couple of friends of mine. I think she attention. Oh, and on Demand and Maxine Foreigner on Group. And it was very interesting the way they did it, because they compare patients with pre transplantation cardigan Marie on patient without Pre Transplantation Cardigan Marie and some of the findings that they saw. What's that? Pre transplantation and the myocardial biopsy patients that you know had pre transplant memory. It really lead toe more biopsies, which which is interesting and what's statistically significant and likely because you found more things than you wanted toe figure out more, which is which, which often is the case in memory. Um, on the other thing that they found that I found really interesting is that errors in identifying the diagnosis off cardiomyopathy in patients with clinical diagnosis of non ischemic cardiomyopathy is the one that had memory had less errors, that the one that didn't have memory and that waas significant. So I think it's important to understand that this technique is here toe act. It's not here to substitute on. It's not here to substitute Echo on or, you know, or biopsy or you know it. Really? I think it really helps on this is in our center. We basically on this, our patients are different, right? Our patients, I mean, M D Anderson Cancer Center. You want to be, you know, a little bit more conservative on, basically, you know what we found? And this is still, you know, we're submitting this on. Basically, we found in 60% of the patients 110. We found that there were 121 events off clinical impact. 46% was changes in diagnosis. And then when there was changing diagnosis and change in management, we documented it and we were in some patients. And in this patient, sometimes you want to be less invasive for three other reasons. So we prevented by us in 21%. Um, changes in medications, 12% prevent the cornea enduring 9% and other things as well. So, in a cancer center, it definitely has a clinical impact as well. Um, on board and let's talk a little bit about C. T. Because I think I feel very strongly about cts. Well, it really helps. And this is just a meta analysis. Um, where it show It showed that for ischemic cardiomyopathy. Basically, um, it's very specific and sensitive on also, if there's ah, coronary, um, abnormality or our current starts in one of 50% is also sensitive and specific. So it's a very good technique also to assess for, uh, ischemic cardiomyopathy or non ischemic on. This is an interesting case where this is a patient that has, you know, the classical Takatsu pattern, but you have to rule out a c a d. You know, it's important to rule CED, but you can see the optical ballooning here and here. But you really need to know the coronary anatomy. And, you know, in this case, basically, let me see if I can I'm able toe show you Look at the Esso Look at the l. A. D. Look at the left menace here And then if you follow the l a the l a d let me show you left main, And then look how the a D goes towards the apex and the lady is wide open. So this patient, all the corn eyes were normal. So this patient indeed have Takasu bond. You could do that just by doing a coronary CT. Now, sometimes it's a challenge. Toe rate control this patient, so you have to keep in mind that you have tow control the heart rate. But it's a great technique to do that as well, and not only using cornerback city but costume score. So if you have a calcium score of zero, has a high negative negative predictive value, excluding ischemic cardiomyopathy. So this is as easy as you seeing the patient. Okay, F slow. Let me see if the patient has an old chest city or whatever. If you don't see any costume there or if you are, patient happens to have a costume scoring zero. Likely, it's not a scheming carry on my own, but it's not. It's chemical amount, but it's not a skinny. So it's also important to understand that this is also very valuable, especially in my practice. We have cancer patient. We have a lot of scans chest cities on. Sometimes when I see that the F is slow, I look at the previous imaging. Let's say they got a chef imaging. I don't see any costume. Likely this patient don't have an ischemic cardiomyopathy, but you still have to the work. But I think it really helps also in c t. One of the things that really helps for a heart failure. Practice is elbow for elbow assessment, and you can see the image, the inflow and outflow cannula you can assess, because if in echo, you have limitations, right? Sometimes the image quality is not great. And you have some questions. But I think that city is very valuable in a household of practice specifically for patients that, you know have Elva, that you cannot do. Ana Marie, you cannot really You want to do something on invasive and you know you want to see what's going on. So I think that for Elvis, Assessment City has definitely a place a swell. So I mean, this is all that I have for you in regards toe imaging. I'm very excited to be here. And I look forward for your questions and thank you for the invitation. All right. Thank you so much. That was a wonderful talk. Um, you know, it's great to hear your perspective on cardiac memory. You know, we were talking earlier in the morning just about, um, When When we should be considering Emery. Um, in terms of work up for cardiomyopathy. Um, one of the questions that came up, you know, can you elaborate a little bit more on LG scar patterns? But, you know, ischemic versus non ischemic on. Because sometimes we do see those that air sort of red as, uh what looks like it's a coronary distribution. And then sometimes I have normal angiograms, you know? Is it possible for them to have these kind of patterns? When, When It's in fact, the non ischemic type picture? Well, you know, No, thank you for that question. You know, I think that there's an entity that we have to be aware of it. And it's called the Minnow Ca. You know, the M I with normal coronary arteries. Uh, on basically in some patients, you're gonna see some end of cardio infections, but the corner is there gonna be clean on, you know, And I think that's something that you know. You have to really? You know, after excluding multiple other things on if you see something the cardio infarction in a coronary distribution. But the coronary angiogram is normal. Then you still are able to capture that patient. And the patient had a name, I But it was just probably anabolic in nature, or it was, you know, open close and then recognized. So So I think that for the LG for the presence of L G uh, in a sub industrial distribution, I think that memory is very specific for to identify that this is indeed, uh, am I now? There could be some industrial components. Like if you have some patients have transmittal components like Sarko, it could have transmitted component, But it's not gonna be in a corner of distribution, so that will, you know, make you think Well, what the septum. Why the septum has enhancement, but not the apex or what happened. Or, you know, it doesn't make sense with a coronary distribution. So that could be another thing, like sarcoidosis. Or you know so and often, you know, cardigan Marie often will lead in certain diagnosis, tome or imaging. Like if you have an Emory that suggests are coy, you should do a pet to see if those areas off enhancement light up. If they light up, I mean in the appropriate distribution, then it's likely circled, right? Yeah. In the case presentation that you presented, it was exactly that we used both Marie and F d g pet to confirm. Was there enhancement with the F d G pet in the same distribution Where the scar was that we saw on memory? Um, I've another question for you. So what you spoke about this earlier? Kind of looking at patients undergoing chemotherapy. He gave that case where, you know, the ejection fraction on Echo is being read it about 40. But then with m r I, it was closer to 50. Plus, um, what's your what's your sort of threshold for using Emery Thio? Get that inaccurate E f assessment. Of course, Sometimes the echo is limited. We have to use eco contrast to get a better assessment, that kind of thing. But if we're seeing, you know, a drop in ejection fraction by echo, um, do you sort of default memory or what? When when should we be using Emery Mawr? As we do surveillance of these chemo patients. So, you know, right now I have a manuscript that, you know it's ready to be submitted. You know, when you start getting tired of it. That's a good sign. So and what we really found once that you know, in some patients we're echo identify an ejection fraction of 30% you know, And they really had, you know, mostly breast cancer patients that were receiving a recycling or accepting. You know, if Echo identified that the drug and it's a you know, very reasonable drop. Like, you know, you look at it and it's not like borderline or whatever, but it's like a 30% then Emory in that scenario, off a patient receiving entre cycling on the F dropping doesn't have a big role there, you know, because dropped an echo identify. So in those patients we didn't saw significant, either changing diagnosis are changing management on. And I think that's true. Like if you really see a legit drop off ejection fraction in a patient receiving and recycling, I mean that likely Sandra cycling toxicity, you know, however, if there's a confounding factor or something else in a clinical picture is not making sense, then I will just emery for sure. But if he's a, you know clearly that drop and it's when patients receiving entre cycling, then to me. That's not really you know, not not. E guess maybe when it comes up to decisions about whether or not to, you know, take a pause and treatment or treatment. Um, those kinds of scenarios where maybe we need, um or we need to know what? What? The true ejection fraction is perhaps e mean in the grain songs in the borderline. Songs like, you know, you have for 45% and you're like, I'm not sure if you know, maybe the guy that read a drink, their coffee or whatever. Something like that, you know? And you really need to prove the oncologist and the people you know, this ejection fraction is normal. We really, you know, because it's important. I mean, uh, treatment interruptions really affect patients adversely, right? Absolutely right. And our goal, as you know cardiologists, is to ensure that they get through their treatment. That's what we always tell the hematologist oncologist is that our goal on our side is not to stop treatment. It's to make sure that we can continue with the treatment that you Scribd. We're just here to assist to make sure we could do that in a in a safe away as possible is faras cardiac toxicity. Yeah,
