Cardiac MR: 2 Perspectives Cardiologist vs. Radiologist

In this episode, we discuss Cardiac MR with a Cardiologist (Dr. Marcotte) and a Radiologist (Dr. Jokerst). We cover various topics starting with the basics of what Cardiac MRI is used for, important sequences, 1.5T 3T comparison, what pathologies are better evaluated on MR vs other modalities, the purpose of Contrast, and all the ways CMR help with treatment and better outcomes for the patient. Thanks for joining us here in Zone 3.

Show Notes

In this episode of the Zone3 podcast, hosts Robert and Reggie sit down with Dr. Jokerst and Dr.
Marcotte, a radiologist, and a cardiologist to discuss cardiac MRIs.

Early in the episode, Dr. Jokerst and Dr. Marcotte introduce themselves, discuss their
collaboration, and what makes them work well together. They also cover some of the differences
between MRI, echocardiograms, and CT scans.

The doctors also discuss common pathologies and risk factors. Dr. Jokerst explains the tools he
uses to differentiate imaging and diagnosis. They also cover the advancement of computer
technology and its effect on imaging.

The episode wraps up with a conversation about physics and educational materials for
technologists. They also highlight the collaboration between radiology and cardiology. Both Dr.
Jokerst and Marcotte also share what inspires them in their work.

00:53 - Dr. Jokerst and Dr. Marcotte dive into their background.
4:40 - Robert and Reggie talk with the guests about imaging for
17:36 - Dr. Marcotte discusses when a cardiac MRI may be necessary.
28:17 - Robert and Reggie ask the doctors a hypothetical question about which machine they'd
pick for their department.
42:08- Robert and Reggie as their guests about common pathologies.
1:19:41 The doctors discuss history and physics and educational materials.
1:26:03 - Collaboration and building communication across disciplines.
1:29:59 - Robert and Reggie ask the doctors about the most satisfying experiences in their field.

Links:
Learn more about the Society for Cardiovascular Magnetic Resonance
Learn more about the Journal of Cardiovascular Magnetic Resonance

Tags:
radiology, CT, MRI, medical, hospital, doctor, radiologist, cardiologist

Creators & Guests

Producer

Katie Lincoln

What is Zone 3 Podcast?

Zone 3 is a podcast that discusses everything MRI. Tune in to hear about the latest advances, optimization techniques, and more! Hosted by Robert and Reggie who are both MRI Technologists. They have an entertaining rapport as they tackle topics like MR safety, imaging protocols, upcoming technology, and so much more.

You can tune into Zone 3 Podcast on YouTube or listen to it on your Podcast RSS Feed! Thanks for Stopping by Zone 3.

00:00:47:13 - 00:01:04:09
Robert
Zone three podcast. Robert here. I got Reggie with them. Right, guys. Oh, lucky enough to be joined by the cardiac guys. We've got Dr. Jokers closer to the camera here, and we've got Dr. Mark. We got a radiologist and a cardiologist. And today we're discussing cardiac MRI's.

00:01:04:10 - 00:01:07:09
Reggie
Right. Really special guest today. Appreciate you guys come and visit us.

00:01:07:09 - 00:01:08:00
Dr. Jokerst (Radiologist)
Thanks for having us.

00:01:08:00 - 00:01:13:15
Robert
Wow. Yeah. We're lucky enough to be joined by some of the best in the industry. So today.

00:01:15:10 - 00:01:17:18
Reggie
Very modest. Very well, I like that.

00:01:18:14 - 00:01:23:03
Robert
So if you were Dr. Doctors, just kind of describe your background, you know, some of your hobbies, maybe.

00:01:23:03 - 00:01:24:10
Reggie
I'm sorry about yourself for sure.

00:01:24:10 - 00:01:46:22
Dr. Jokerst (Radiologist)
Sure. So, you know, I'm from the Midwest, originally a little town about an hour south of Saint Louis. Yeah. I grew up, spent a lot of time outdoors, did all my training in Saint Louis, went to medical school there, you know, residency and diagnostic radiology, fellowship in cardiothoracic imaging at Eric. Can I mention an institution? Sure. Here at Washington University there in Saint Louis, yes.

00:01:48:00 - 00:02:08:21
Dr. Jokerst (Radiologist)
Yeah. And you know, I came out to Arizona, got gosh, it's been about seven years ago, 2013 when I came out here. So I've been an attending now for about seven years, you know, and do cardiothoracic imaging. And, you know, we have gotten more and more interested in kind of the physics and technical aspects of MRI, but.

00:02:09:08 - 00:02:10:02
Reggie
Wow, nice.

00:02:10:08 - 00:02:13:06
Dr. Jokerst (Radiologist)
So that's a little bit about me. Anything else you guys want to know?

00:02:13:06 - 00:02:16:08
Robert
Oh, we're lucky to have you in Arizona for sure. Yeah. You're in the same hospital.

00:02:16:22 - 00:02:17:16
Dr. Jokerst (Radiologist)
I miss in the winter.

00:02:17:16 - 00:02:26:04
Reggie
Yeah. So you're probably one of the first reds that I witness actually jump on the scanner and like, really knew what you were Monaro. And then I just click, click, click, click, click, I.

00:02:26:05 - 00:02:27:17
Dr. Jokerst (Radiologist)
Say that's you know I was.

00:02:27:17 - 00:02:28:06
Reggie
Really in your.

00:02:28:06 - 00:02:29:00
Robert
Like house.

00:02:29:00 - 00:02:32:10
Reggie
Yeah, yeah, yeah. It's just like Hollywood right now.

00:02:32:14 - 00:02:41:03
Dr. Jokerst (Radiologist)
Scanning and doing surgery and all that kind of stuff. But yeah, my fellowship, you emphasize that a lot. I'm glad I did because it's helpful.

00:02:41:07 - 00:02:52:22
Reggie
Oh, for sure. I know it helps us out a lot too, that you can actually break down where to go to make some of the changes that you're requesting are some of the things that you know you want us to do for yourself. I mean, I really appreciate that. Oh, that's nice.

00:02:52:23 - 00:02:53:10
Dr. Jokerst (Radiologist)
You're sweet.

00:02:53:13 - 00:02:59:11
Robert
And we also really appreciate Dr. Marka. Yes. So, Dr. Marcotte, if you would, tell us about yourself, your background.

00:02:59:11 - 00:03:25:18
Dr. Marcotte(Cardiologist)
I am possibly Barakat. I'm originally from Montreal, did my med school at University of Montreal, and then the residency McGill University and then fellowships at the University of Toronto. Oh, nice. I'm special. I'm a cardiologist who specialize in congenital heart defects, which is people born with heart defects, nice little babies and unfortunate and noninvasive imaging. And I've focused on imaging that doesn't require X-rays.

00:03:26:00 - 00:03:44:22
Dr. Marcotte(Cardiologist)
So I start with ultrasound, and then I saw some of the limitations of ultrasound and became interested in MRI and then learned about that. And they've used it ever since. I've been doing MRI for about 20 years and I really enjoy it. I think it's a great complement to to to my practice. I think it can bring a lot to the table.

00:03:45:06 - 00:03:45:16
Reggie
All right.

00:03:45:23 - 00:03:46:09
Dr. Marcotte(Cardiologist)
Glad to be.

00:03:46:09 - 00:03:54:13
Dr. Jokerst (Radiologist)
Here. And Francois has brought a lot to the table. I got to say, reading cases with him has been one of the highlights of the last few years. So it's a real pleasure.

00:03:54:13 - 00:03:56:07
Reggie
Has it made you step your game up a little bit? Absolutely.

00:03:57:02 - 00:04:01:06
Dr. Jokerst (Radiologist)
When he was coming, I was like reading books and trying to like, you know, because I didn't want to.

00:04:01:12 - 00:04:03:00
Reggie
Read your.

00:04:03:00 - 00:04:04:00
Dr. Jokerst (Radiologist)
Back, look backwards.

00:04:04:00 - 00:04:24:23
Dr. Marcotte(Cardiologist)
Yoko I think I think our collaboration exemplifies the importance of collaboration and the fact that we, we, we each have our strengths. You know, for me, there's stuff that I feel less comfortable reading, like, you know, chronic aortic syndromes or stuff that's in the lungs or mediastinum and stuff like that. And I learned a lot from, from Clint and our other radiologists.

00:04:24:23 - 00:04:28:07
Dr. Marcotte(Cardiologist)
So it's really I learned a lot. I can tell you I'm really happy.

00:04:28:07 - 00:04:29:16
Reggie
Nice. It's pretty cool.

00:04:30:00 - 00:04:40:07
Robert
Well, it's because you guys are happy to share your knowledge. And that's one of the reasons why he brought you here. Because, you know, I've worked with a lot of radiologists and not very many cardiologists, but you guys are awesome to work with. So thank you.

00:04:40:09 - 00:04:40:23
Reggie
Yeah, thank.

00:04:40:23 - 00:04:58:12
Robert
You. Thank you for being here today. I appreciate it. So we kind of want to dove into it. We don't really know the direction because really, you're the experts on today's subject. So we'll kind of follow the guidelines. But we kind of wanted to go over anatomy. We want to go over physiology. We wanted to go over pathology as well.

00:04:58:12 - 00:05:12:20
Robert
So you mentioned earlier that originally you started it with ultrasound as being you get diagnostic imaging, go to I'm I'm curious about how that compares to like the height of scale, which is usually in conjunction with an ultrasound like a stress test.

00:05:13:10 - 00:05:13:19
Dr. Marcotte(Cardiologist)
Yes.

00:05:14:00 - 00:05:17:03
Robert
How those two would compare like an MRI as far as information provided?

00:05:17:03 - 00:05:24:09
Dr. Marcotte(Cardiologist)
Yeah. I mean, if we want to go to the second slide, maybe we can. Do I have a comparative node here.

00:05:24:18 - 00:05:31:12
Robert
Yeah. So Mark, I, we love prepared guests, so thank you. We love on prepared guest so thank you to so.

00:05:32:03 - 00:05:52:10
Dr. Marcotte(Cardiologist)
So sorry just to see patients with heart disease are faced with the nice thing about cardiology it's there's there's a very fairly limited number of clinical problems people have you know, they're short of breath, they have chest pain, they have palpitations, they pass out or, you know, they have swelling. We're, you know, and then so we have a number of tests.

00:05:52:10 - 00:06:14:03
Dr. Marcotte(Cardiologist)
And typically as a first line test, we'll do chest x ray EKG and echocardiogram. But some of the limitations we have with Echo is the what we call the spatial resolution, the ability to to to see small things. This is something so this is a slide that shows the various capabilities you were talking about scans and stuff like that.

00:06:14:03 - 00:06:36:03
Dr. Marcotte(Cardiologist)
So so Echo has a very high temporal resolution, which means it's very quick, it's got a high frame rate. So you can see small things, but medium to small things that move quickly like vowels. It's very good to record velocity like Doppler in that type of thing, but it doesn't see, well, for example, if there's air, if there's bone, a lot of fat.

00:06:36:03 - 00:06:55:00
Dr. Marcotte(Cardiologist)
So we're limited in terms of the of the ability to to to penetrate some of these structures in the chest, especially right now. We're lucky because the heart's kind of midline. We can you know, we can finagle our way between the ribs to see the heart. But that's one of the things that CT doesn't quite I don't do the city but Clinton.

00:06:55:00 - 00:07:01:20
Dr. Marcotte(Cardiologist)
CT Yeah, I can. And City has got a fantastic spatial resolution. It's under a millimeter. Yeah.

00:07:02:03 - 00:07:23:08
Robert
Something I wanted to touch up on today was just the difference in the modalities and what value each one brings. And what's your preference for sure? Yeah. You mentioned a radiograph or chest x ray, but I'm thinking like in my experience as an X-ray tech beyond CHF or some sort of abnormality and within the size of itself, I mean, like, like you wouldn't be able to diagnose infarct or something like that, so.

00:07:23:11 - 00:07:42:09
Dr. Marcotte(Cardiologist)
You'd need an EKG and echo. And the thing if I carry on, the society has very good spatial resolution in terms of temporal resolution. It's the opposite of echo. So it doesn't it doesn't have a high frame rate, but there are improvements and Klint can talk more about that. Yeah, the nice thing about MRI is just in the middle.

00:07:42:09 - 00:08:04:17
Dr. Marcotte(Cardiologist)
So it's got the best of of both and that's why I put it right in the middle. So it doesn't have quite the frame rate that Echo has, but it's got a better frame rate than CT, right? It's got a spatial resolution that's better than Echo, but unfortunately not as good as CT. The good thing is that it doesn't expose the patient to radiation like CT and nuclear medicine do.

00:08:05:10 - 00:08:25:17
Dr. Marcotte(Cardiologist)
And the the really the the hidden gem is that the fact that we do nice pictures of anatomy but really if you look at MRI, it's been invented as a tool to analyze tissue. So it's a it's like a histo chemical analysis. You generate great pictures, but you can tell whether you're dealing with that with blood, with muscle, with, you know, etc..

00:08:25:17 - 00:08:45:00
Dr. Marcotte(Cardiologist)
So it brings to the to the to the table the whole concept of tissue characterization, which is kind of more difficult with that. But we do have a sense, you know, we can see if something cystic or solid or, you know, but, you know, once it's solid, then you can you can you can get a lot more information.

00:08:45:07 - 00:08:47:08
Dr. Marcotte(Cardiologist)
I know about CT are.

00:08:47:14 - 00:09:03:00
Dr. Jokerst (Radiologist)
Kind of the way I like to think about it is echo and CT are kind of sort of one trick pony. And so if you think about it, what are you doing with echo? You're imaging sound waves, right? That's all you're doing. There's nothing else you can do with Echo, right? CT is the same thing. What are you doing?

00:09:03:00 - 00:09:28:17
Dr. Jokerst (Radiologist)
You're blasting somebody with photons. Some photons are going through and some are stopping. So you're imaging how tissue attenuates photons you can change the profile by giving somebody contrast, you know, with iodine or barium or whatever. But at the end of the day, you're kind of you're just looking at one thing. Basically, whereas with MRI, you can make all these little tweaks and adjustments and like Francois was saying, really characterized tissue.

00:09:28:17 - 00:09:59:09
Dr. Jokerst (Radiologist)
But it can do so much more. And just another kind of plus of MRI, thank you know, Echo is great. It's widely available. It doesn't require any ionizing radiation. There's no dangerous magnetic fields. It's definitely first line when when we're looking at the heart for a lot of different conditions. The Echo is very operator dependent, and it's kind of like the way I like to think of it is imagine you're going into a dark room and you kind of know where to look in the dark room, and you have a flashlight and you're looking around in that dark room.

00:09:59:09 - 00:10:00:02
Reggie
Oh, I like that.

00:10:00:02 - 00:10:03:13
Dr. Jokerst (Radiologist)
Yeah. MRI is basically turning on the overhead light.

00:10:03:13 - 00:10:04:01
Reggie
You know.

00:10:04:01 - 00:10:20:04
Dr. Jokerst (Radiologist)
Animating the entire room so you don't have to spend as now. That being said, you know, of course, if they're that probe, that go probe is in the hands of an accomplished sonographer, it's not a big deal because they know where to shine the light. But, you know, not everybody has, you know, Vincent Van Gogh IV.

00:10:20:19 - 00:10:49:17
Dr. Marcotte(Cardiologist)
Although when we say technical dependance and I think you're right about that for for echo, it's also you need technical expertize to do MRI. It's probably one of the most difficult MRI or one of the most challenging types of MRI, even though the vendors are trying to put some very automated protocols and help you with defining planes and stuff, it it requires a lot more hands on ride.

00:10:49:22 - 00:11:12:12
Dr. Marcotte(Cardiologist)
I mean, I'm from an era and I guess you might be as well. But so when initially we didn't have all these tools, so the technologists had to know the anatomy, understand, know where to cut. So we had some set protocols. And the thing with the heart is that unlike most, most static organs, it makes it it earns its living by moving constantly.

00:11:12:12 - 00:11:16:01
Dr. Marcotte(Cardiologist)
And so, as you know, in MRI's, moving constantly is like.

00:11:16:19 - 00:11:16:23
Dr. Jokerst (Radiologist)
If.

00:11:16:23 - 00:11:17:20
Reggie
You stop.

00:11:18:02 - 00:11:47:11
Dr. Marcotte(Cardiologist)
And it's hard enough, the lungs also move. So, so you introduce the breathing motion. So we, we thus have to rely on, on sequences that are very fast and we have to rely a lot on breath holding to sort of stabilize it, to limit the variables to simply the heart moving. And then a lot of the sequences we use are called segmented sequences where we chop the, the cardio, everything's gated, so we chop off the up the, the cardiac cycle, right?

00:11:47:14 - 00:12:01:17
Dr. Marcotte(Cardiologist)
To get our images and get all these all these phases with the best possible resolution. So you see it's kind of a tour de force that MRI does to be able to get to get cities, to get motion and to get resolution.

00:12:01:20 - 00:12:22:01
Dr. Jokerst (Radiologist)
So it's the it's the most difficult organ to image with them are. And as you look at how MRI technology kind of trickles down, you're usually neuro like brain MRI drives it because the brain is easy. It's just like a tub of water that just sits there. You can stick it in a coil and you know, you start moving around.

00:12:22:01 - 00:12:40:14
Dr. Jokerst (Radiologist)
There's a little bit of CSF pulsation and that, you know, a bit like MSK, things like that. And then you've got body imaging. It's tough because there's, you know, breathing and stuff, but the heart is a whole nother level. So a lot of times the innovation takes a while to get down to the cardiac level because, you know, there's a lot going on there.

00:12:40:14 - 00:13:00:23
Dr. Jokerst (Radiologist)
And cardiac in a lot of ways drives innovation because you have to have really fast sequences to image the heart. You have to, you know, be able to do these really slick reconstruction and algorithms to be able to even make a useful image. And so, yeah, it's it's got its pluses and minuses, but it drives innovation, but it's also kind of, you know.

00:13:01:03 - 00:13:03:18
Dr. Jokerst (Radiologist)
Right. It's waiting for stuff to trickle down.

00:13:04:02 - 00:13:05:02
Reggie
And, you know.

00:13:05:02 - 00:13:12:16
Dr. Marcotte(Cardiologist)
We'll look at some pictures maybe just to show what kind of sequences so they that if you want to move on to the next slide, we can show you some examples.

00:13:12:16 - 00:13:31:14
Robert
And just real quick, I was going to throw in there just for the you know, for the patients who are curious about how we compensate for motion for the heart moving and for the lungs moving. We do breath hold instructions for in most of the sequences. So I'm a cardiac scanner myself. So I do hearts and and another thing that we do is we call it gating.

00:13:31:14 - 00:13:37:00
Robert
So we'll set you up with some EKG leads and we just kind of compensate.

00:13:37:01 - 00:14:00:17
Dr. Jokerst (Radiologist)
Yeah. Yeah. The way to think about it is if something is moving, but we're taking a picture. If you always take a picture when when something is in the same spot, it doesn't look like it's moving right, you know? But the faster it moves, the more chances your picture is going to be blurred. So heart rate is kind of an important thing to and, you know, if something's moving up and down, you're going to take a picture every time it's down.

00:14:01:04 - 00:14:12:21
Dr. Jokerst (Radiologist)
But then it starts moving left and right to one. So you're going to have a blurry image. So that's the dating takes into account all cardiac motion, but any other motion, be it respiratory B, a patient that's not taken into account.

00:14:12:22 - 00:14:13:06
Reggie
Right.

00:14:13:14 - 00:14:19:18
Robert
So is there a optimal rate range for cardiac scanning as well?

00:14:19:18 - 00:14:33:18
Dr. Jokerst (Radiologist)
I will say it's speaking as somebody who like, you know, is involved in operations and has to keep an eye on my time on the scanner, you know, cardiac CT, you know, like as flow, the slower, the better. So if we could stop people's heart and do a CT, it'd be great.

00:14:34:06 - 00:14:35:10
Reggie
For the contrast.

00:14:35:10 - 00:14:39:17
Dr. Jokerst (Radiologist)
To go in the corner. Is probably on the patient probably wouldn't be too happy about that.

00:14:39:18 - 00:15:04:11
Dr. Marcotte(Cardiologist)
That's the advantage of MRI. You don't require as slow what you need is regular heart rate because you're eating. Yeah so our our biggest enemy is when the patient has a lot of arrhythmia or when our gating capabilities are hampered by the RF signal. So we do it. We record in EKG. But as you know, Robert and you both you both have seen sometimes we we start out, we put the patient in the scanner.

00:15:04:17 - 00:15:25:04
Dr. Marcotte(Cardiologist)
We've got a great EKG signal. We get, and then we turn on the RF signal and then everything sort of disappears and then the gating just disappears and it becomes a headache. So we need regular rhythm. It doesn't have to be a slower CT, right? But, you know, a normal A and then the thing is, as you go faster, well, then you've got a compromise somewhere.

00:15:25:04 - 00:15:31:08
Dr. Marcotte(Cardiologist)
So if your heartbeat is faster than you, you get less phases. So you're you're so that that's that's.

00:15:31:08 - 00:15:38:07
Dr. Jokerst (Radiologist)
I would say 60 to 80% of the speed spot, you know, and when you get up north of 100, things start to break down.

00:15:38:13 - 00:15:38:18
Robert
So.

00:15:38:18 - 00:15:40:05
Dr. Jokerst (Radiologist)
Fast. And those faster.

00:15:40:10 - 00:15:41:09
Reggie
Faster, shorter which is.

00:15:41:11 - 00:15:46:20
Dr. Jokerst (Radiologist)
Yeah. It's a shorter breath hold if your heart rate's 80 like I love 80 over 60 because the scan gets done 10 minutes sooner.

00:15:47:04 - 00:15:59:21
Dr. Marcotte(Cardiologist)
You like having said that, MRI is very used in kids and children have faster heart rate so it can be used. It's simply the important thing is really to have a slow have a slow heart rate but first rate 60 to 80 is just.

00:15:59:22 - 00:16:00:07
Reggie
Right.

00:16:00:12 - 00:16:03:02
Dr. Marcotte(Cardiologist)
Now. So we can pack it in, get throws you.

00:16:03:02 - 00:16:11:18
Robert
Consider possibly medicinally providing some sort of I mean, providing the patient with some sort of medicine that's going to help.

00:16:12:08 - 00:16:13:11
Dr. Jokerst (Radiologist)
You know, there's always a robotic.

00:16:13:11 - 00:16:14:13
Reggie
Constant, you.

00:16:14:13 - 00:16:31:11
Dr. Jokerst (Radiologist)
Know, to anything. And any time you give medication, you're piling something on the risk side, right? So it really depends the main thing. And like and so I was saying as you need a regular heart rate, so if you have somebody who has AFib an error rate control, then absolutely, you know, give them beta blockers, try to slow them down, trying to get a little more lit.

00:16:31:21 - 00:16:45:08
Dr. Jokerst (Radiologist)
You know, you're basically treating their arrhythmia is what it amounts to. But when it comes to actual like for cardiac c.t, we routinely do have medication to slow the heart down. We I don't think we ever really do that for cardiac stuff. I mean, it's very.

00:16:45:16 - 00:17:03:10
Dr. Marcotte(Cardiologist)
It needs a certain amount of regularity. And I guess you can do a arrhythmia compensation, which is you'll, you'll basically create like a like a corridor where you're where you going to accept, you know, a certain a certain time interval. And then those are much slower or those where faster you reach up, but you end up losing data, obviously.

00:17:03:10 - 00:17:08:07
Dr. Marcotte(Cardiologist)
And it takes a little longer for your scan. So longer breath holds or longer, longer scan times, right.

00:17:08:09 - 00:17:23:06
Robert
So consistency is also key with breath holds as well because I explain to patients when you're taking a deep breath, your anatomy moves down quite a bit on shallow breath, not as far. So we wanted to move to the exact same spot every time. And so we want patients to consistently taking the same amount of volume on every breath hold.

00:17:23:06 - 00:17:31:06
Robert
And actually, as far as inhalation exhalation, which one is better? A lot of times exhalation is better, for that reason more reproducible.

00:17:31:21 - 00:17:41:00
Dr. Marcotte(Cardiologist)
But it's at times the patient that we don't realize, especially if you're a sick person, you know, we're we're all healthy today or tested COVID negative. Right. And for.

00:17:41:00 - 00:17:44:17
Reggie
Now. Yeah, but we're so.

00:17:44:18 - 00:18:02:08
Dr. Marcotte(Cardiologist)
But you are if you are an elderly person who's mildly short of breath, you're, you know, lying in a tube with with antennas over you and, you know, covers and stuff like that. You can appreciate that the people get tired breathing in, breathing out, you know, doing that over and over again.

00:18:02:18 - 00:18:05:17
Reggie
Right, for cardiac studies. So 60, 70 breath.

00:18:05:18 - 00:18:11:11
Dr. Marcotte(Cardiologist)
Ideally, if we can make scan times as short as possible, we try. But these these scans tend to be.

00:18:11:11 - 00:18:21:07
Robert
And we were doing some protocol development stuff about a week or two ago and I was the patient on the table to do an exploration and I'm a guy in my thirties with dogs, had difficulty with it.

00:18:21:07 - 00:18:27:00
Reggie
So the favorite vendor or someone that's doing, you know, a pretty good job with that like kind of helping out the owner.

00:18:27:08 - 00:18:50:21
Dr. Jokerst (Radiologist)
When it comes to that, I think they're all kind of around the same. You know, that's always when it comes to talking about getting a quick acquisition, you know, working, getting the technical stuff later. But really, you know, what speeds up imaging is, you know, having a multi channel coil so that you can do parallel imaging. Yes. And then also this new thing, compressed sensing, which compressing itself isn't new.

00:18:50:21 - 00:19:15:20
Dr. Jokerst (Radiologist)
But, you know, they're basically the software hasn't been powerful enough to use. So as computer processors get more powerful, scanners now can start to do this compressed sensing. And you know, I'm not it you can definitely tell when you're using it. It looks it's not as good. It looks different. But you're scanning the entire heart in one or two breath holds instead of 12, you know.

00:19:15:20 - 00:19:18:00
Reggie
So if seven patients are going to need.

00:19:18:03 - 00:19:18:23
Dr. Jokerst (Radiologist)
Is a good enough.

00:19:18:23 - 00:19:20:18
Reggie
Right now that that's.

00:19:21:04 - 00:19:23:15
Dr. Jokerst (Radiologist)
That's but we can talk about that when we get into the Amazon.

00:19:23:15 - 00:19:43:11
Robert
Well that's actually I appreciate that about because I've had to call you about certain patients and we kind of tailored it to that specific patient based on their need. So speaking of needs, I'm curious about like what is the common indications for an MRI, cardiac, no imaging congenital is kind of your experience, but I imagine it goes beyond that.

00:19:43:21 - 00:20:04:02
Dr. Marcotte(Cardiologist)
Yeah. I mean, congenital is a rare indication. Congenital disease is about one in a 1 to 2% of the population. So it's quite rare. I mean, for the symptoms that I mentioned earlier, I mean, for for us, the diagnosis of cardiomyopathy, myocarditis or or viral infection of the heart. Right. Look for inflammation.

00:20:04:11 - 00:20:05:06
Reggie
Could get on.

00:20:05:17 - 00:20:31:06
Dr. Marcotte(Cardiologist)
It's used a lot in post post my cases because with the with the addition of gadolinium imaging in addition to tissue characterization looking for edema area at risk, we can calculate if but also we can image scar size right and the behavior pattern of gadolinium within or the topography of where a gadolinium accumulates as a breakdown of the barrier between blood and myocardium occurs.

00:20:31:19 - 00:21:02:02
Dr. Marcotte(Cardiologist)
As you remember, gadolinium is an extracellular agent that normally does not enter cells. Right? But in the case where cells have been damaged, or if you have an expanded interstitial space, then gadolinium may enter. So that's how we, we, we, we image. And each disease has kind of its own signature. Like heart attacks tend to be like in in the inside of the heart we call this sub into cardio or trans mural as as the heart attack progresses things like myocarditis tend to be on the outside of the heart.

00:21:02:02 - 00:21:06:07
Dr. Marcotte(Cardiologist)
And that's a kind of a big mystery for us why that occurs. So the cancer.

00:21:06:07 - 00:21:08:14
Robert
Of the heart, that's where it becomes enhances.

00:21:08:18 - 00:21:26:07
Dr. Marcotte(Cardiologist)
Yes. So along the pericardium. So there's often when people have myocarditis, which is an inflammation of the heart muscle, they sometimes can have pericardial tests, which is an inflammation of the wrapping around the heart, which is called a pericardium. So these things often travel together.

00:21:26:07 - 00:21:30:17
Dr. Jokerst (Radiologist)
You have a nice image in here showing some of the physiology of this. Oh, yeah. Let's let's pull that out.

00:21:30:19 - 00:21:33:18
Dr. Marcotte(Cardiologist)
This is an example of know.

00:21:33:21 - 00:21:36:09
Dr. Jokerst (Radiologist)
And it shows some cells and just kind of while we're talking.

00:21:36:09 - 00:22:04:04
Dr. Marcotte(Cardiologist)
So if we go back to the first one, the first double image we had. David Sorry. So that was just to show you the different sequences we have. So if we go one back of that, so these are our static images. So there's no gadolinium. But it just to show you what the versatility of MRI showing same patient, same slice, different machine adjustments.

00:22:04:15 - 00:22:32:11
Dr. Marcotte(Cardiologist)
One on the left is a T, one weighted fast spin echo black blood imaging nice. And the one on the right is a spin echo, but T2 weighted imaging with fat suppression. And you can see that we see different things. Yeah. And that's, that's some of the, some of the tricks we have in our bag to, to try to kind of characterize tissue black blood imaging because it is a slow technique will excite all the structures in within a slice.

00:22:32:11 - 00:22:59:15
Dr. Marcotte(Cardiologist)
But blood travels so it leaves the slice and thus it is replaced by unexcited blood so that when you turn up the excitation and you recoup the energy through your RF antenna, you get no signal from the blood. I'm simplifying it a lot, but and then my muscle muscle myocardium has sort of an intermediate density and fat in basically when imaging is very bright because it relaxes very quickly, gives us a very bright signal.

00:23:00:06 - 00:23:26:13
Dr. Marcotte(Cardiologist)
Now we can do inversion. So the one on the on the left is a double inversion recovery. The one on the right is a triple inversion recovery with a long TR. And then you can see and the way you can tell this is T2 weighted imaging. Well, CSF is is water and you can, you can see here I've pointed with a white arrow, you look at the image on the left, the CSF looks dark in at1 imaging and yet it is static.

00:23:26:13 - 00:23:45:20
Dr. Marcotte(Cardiologist)
It doesn't move like blood. So you can so and then you can see that on the right of the tissue weighted image. Then the CSF appears is bright. And also if you look at the there's there's fluid around the heart and around the lungs. So you have large pleural effusion bilaterally and pericardial effusion and inflammation within this matter.

00:23:45:20 - 00:24:09:16
Dr. Marcotte(Cardiologist)
So this is all static, no gadolinium, but it helps us understand the anatomy, but also the physiology, even if the heart's not moving. Now, these are this kind of of the workhorse, but the new workhorse is on a next slide. Do you want to hand jump that? So these are really that's this is what has become the workhorse of our of our cardiac exam, because the heart moves, as we said earlier.

00:24:09:16 - 00:24:35:20
Dr. Marcotte(Cardiologist)
Right. So this is the image on the left is a city basically, which is a white blood imaging SFP that is state of free perception, where your repetition time is about 200 times faster than a spinnaker. So blood doesn't have time to escape the slice. It gets caught and returns the signal. Plus, we give it a little help with kind of a rewinding gradient, which is a bit of that.

00:24:36:00 - 00:25:00:00
Dr. Marcotte(Cardiologist)
The principle between behind SFP and you can appreciate here, this is an example of a patient with pericarditis. You can see here if I move my arrow, I don't know if I can make it into there or just keep well, oh, so this is this is the heart. This is the the wrapping around the heart, the pericardium. You can see that there's thickening here.

00:25:00:07 - 00:25:25:03
Dr. Marcotte(Cardiologist)
And you see the heart muscle like this is the right ventricle, the left ventricle, left atrium, right atrium. You see the pulmonary veins there back the blood from the lungs to the to the left side. And then you see the septum, which is that that wall between the two ventricles is kind of wiggly a little bit. So this is an example of of an abnormal septal motion that we that we see now.

00:25:25:08 - 00:25:42:22
Dr. Marcotte(Cardiologist)
This is an image that's done during breath hold. That's why the image is so crisp and so nice. So the patient's not breathing. But then we can we can also a derivative of that is to do real time imaging where we say to the patient, Go ahead, breathe. So it exemplifies the limitations or and the tradeoffs you have in right.

00:25:43:01 - 00:26:02:18
Dr. Marcotte(Cardiologist)
In in in Sydney imaging you see that we've traded off spatial precision for temporal resolution. So we let that so we acquire more images. They are a little blurrier. But then what we can see here is that when the patient breathes in and how do we tell the patient's breathing in? Well, the heart goes down, the lungs inflate with air.

00:26:02:18 - 00:26:32:06
Dr. Marcotte(Cardiologist)
So as he's going down, so you see flattening of the septum. And then so this is a clue that we have that the patient has what we call constrictive pericarditis. So it's one of those pericarditis that's squeezing the heart and making it difficult for the patient to breathe. Now, this patient actually had severe renal failure, so we did not inject gadolinium for safety reasons, but yet we were able to do a very nice exam in this dialysis patient with chronic constrictive Burkhard itis.

00:26:32:06 - 00:26:41:03
Dr. Marcotte(Cardiologist)
So just to show that MRI, I mean gadolinium is is useful but we can get a lot of information even without the injection of gadolinium, you.

00:26:41:03 - 00:26:53:02
Robert
Know, since you got that free breathing scene. Yep. I did have a question for you. I've worked with you and you've told me to do make sure to include a free breathing city of a patient has history of pleural effusion. Okay. What's the reason for that?

00:26:54:05 - 00:27:14:02
Dr. Marcotte(Cardiologist)
Often when you have pleural effusion, you may have inflammation of the pleura paratus we call this, and you can sometimes have what we call pleural pericarditis. So it's possible for a patient to have inflammation of both the pleura and the pericardium. And the other thing is, if you notice on this patient, perhaps we didn't we don't see it as well in this patient.

00:27:14:02 - 00:27:34:20
Dr. Marcotte(Cardiologist)
But a patient with Constrictive Parker died just like that. We will have may develop a kind of heart failure. It's the function is good but these patients often have casual effusions as a result of their disease. So when I see when I see pleural effusion and the function seems to be good, our mind goes. And that's why it's very negative.

00:27:34:20 - 00:27:55:19
Dr. Marcotte(Cardiologist)
And and I'm I'm happy that you brought this up, Robert, because I think it adds to the need, to the flexibility and to sometimes make changes on the fly when you're when you see something because you sometimes discover things as as as you're imaging. So that's why it's important for for for for you guys to communicate with with Clinton and I.

00:27:56:02 - 00:27:56:18
Reggie
To to.

00:27:57:00 - 00:28:11:06
Dr. Marcotte(Cardiologist)
To tell us, hey, well, you know, I've got some images, right? What do you think? You know, where is are we proceeding? Is the plan because because we protocol cases. But sometimes surprises happen. Yeah. And and this is you know, this.

00:28:12:03 - 00:28:38:13
Dr. Jokerst (Radiologist)
Is also a nice illustration. You know, we were talking about the importance of breath holding earlier. But, you know, you can do some imaging on a patient that can't hold their breath. Right. It's not great. It's not as good. But but you can get something at least right now from patients. You know, that that short axis, real time imaging and as technical things like compressed sensing kind of come along and get better, you're going to be able to do more and more free breathing exams on patients.

00:28:38:13 - 00:28:38:20
Dr. Jokerst (Radiologist)
Nice.

00:28:39:05 - 00:28:41:22
Reggie
So eventually you want you have to hold your breath any more framework.

00:28:41:23 - 00:29:02:00
Dr. Jokerst (Radiologist)
That you just laying there, you know, but it's just a great example of it. With MRI, there's always almost always some sort of tradeoff, right? And answer nothing is free. So, you know, if we want to get it better temporal resolution and move away from a segmented case based feeling algorithm and get real time imaging, you know, we're going to we can do that, but we're going to pay a price.

00:29:02:00 - 00:29:07:08
Dr. Jokerst (Radiologist)
You know, the image isn't going to look as great. We're given up some spatial resolution.

00:29:07:08 - 00:29:25:09
Dr. Marcotte(Cardiologist)
These images were acquired with a3t magnet. And again, it it it shows you I mean, that it's a you you were wondering perhaps the the differences between 1.5 and three. T Well, I mean, for us in cardiac, I mean, 1.5 is what I, what I've used more.

00:29:25:22 - 00:29:28:17
Reggie
And we're talking about field strengths, their field strength. Yeah.

00:29:29:00 - 00:29:57:12
Dr. Marcotte(Cardiologist)
So, but this exemplifies the some of the strengths of I compared kind of like riding a bronco to riding, you know, a nice service horse. You know, the three t is is much more challenging for the for the technologies because you've got, you know, get your off resonance frequency, reduce your dark band artifacts. And so but once once you get that, the smoothness you look at that the smoothness of the of the myocardium on the left is really quite nice.

00:29:57:12 - 00:30:07:12
Dr. Marcotte(Cardiologist)
I've got other images later that were acquired on 1.5 and you'll see there are a lot I mean the, the, the, the signal to noise ratio is obviously.

00:30:08:03 - 00:30:08:21
Reggie
More of an issue.

00:30:08:22 - 00:30:32:09
Dr. Jokerst (Radiologist)
Yeah. And that's that's what, you know, the reason why we you know it almost like an arms race like when it comes to my field strength, you know, the original scanners were less than the Tesla. Right. And one of the half Tesla came out and three Tesla. Now they have some commercially available seven Tesla scanners. That's right. And you know, by doubling your magnetic field, you w automatically double your signal noise across the board.

00:30:32:21 - 00:31:04:19
Dr. Jokerst (Radiologist)
But everything else doubles, too, so your artifact gets worse. You know, you really have to tweak things now for the for something that doesn't move a lot like the brain. You know, we all do almost all our neuroimaging at three T because it's easy, you know, and there's not that big tradeoff. But imaging the body, you know, abdominal imaging, cardiac imaging, thoracic imaging, things that move, you know, things that where you've got a lot of these interfaces between areas that have protons in areas that don't like the lungs, you get into a lot of artifacts and you have to be able to kind of mitigate that.

00:31:04:19 - 00:31:50:03
Dr. Jokerst (Radiologist)
And it takes a sharp tack to be able to kind of make the changes that need to be made to improve your image quality there. But yeah, I see in the future as we move forward a return to lower field strengths and using technology using out the booth. Yeah, exactly. So rather like we can go to maybe point a T and make it look like it was done on a 1.5 T because of the technical, you know, the software side of things and the reconstruction side for.

00:31:50:03 - 00:31:55:00
Reggie
The safety factor. Yeah, just the fact there was a way of more.

00:31:55:00 - 00:31:57:03
Dr. Jokerst (Radiologist)
Yeah. So we can, we can delve into that later.

00:31:57:03 - 00:32:10:06
Robert
I dove into it. Now I'm curious if you just had like sort of hypothetically speaking, you're the director, you're about to buy, you're about to purchase just one machine for you to part of it for cardiac. What would you be a one, five or three?

00:32:10:10 - 00:32:11:07
Dr. Jokerst (Radiologist)
It would be a15.

00:32:11:08 - 00:32:17:22
Robert
Okay, let's just just because the real one is out because, you know, restrictions with MRI safety.

00:32:17:22 - 00:32:21:19
Dr. Jokerst (Radiologist)
And that's a big part of it. I mean, the bottom line is there's there's good enough.

00:32:22:08 - 00:32:24:10
Reggie
You know, just image quality.

00:32:25:02 - 00:32:27:12
Dr. Jokerst (Radiologist)
If you will, just based off of image.

00:32:27:12 - 00:32:28:17
Robert
Image quality for.

00:32:28:19 - 00:32:52:20
Dr. Jokerst (Radiologist)
The 10/2 thing. Now, if you give me a perfect patient that doesn't have any metal inside them on their behalf forever. Sure. Do you think you know how many of those do we get? And so, you know, taking practical considerations, I would rather get 95% good enough imaging on 5%. Yeah. On a one and a half t then like 80% good enough imaging and 20% we have to bring the patient back.

00:32:53:02 - 00:32:56:08
Dr. Jokerst (Radiologist)
Right, you know, because of some artifact or, or something.

00:32:56:08 - 00:33:18:15
Dr. Marcotte(Cardiologist)
So that's one thing, metal artifact that clinicians have trouble understanding because we we put so much emphasis on on patient safety. So we say, right, pacemakers and all this. So a lot of the of the biological implants are now MRI compatible, right? They are. You know, they can be used they will not cause injury or harm due to the patient's right.

00:33:18:20 - 00:33:48:18
Dr. Marcotte(Cardiologist)
However, the the problem with these is that they create a lot of artifacts. So we get patients sometimes sent to us to to look at people with prosthetic valves, for example. Yeah. And or pacemakers. And I guess we can we can see. But, you know, even, you know, a little coils or annual plastic rings, these are all biological implants that that create a fair amount of artifact and really are quite a bit of a hindrance to do quantitative measurements, you know, you want to get a precise ejection fraction look flows.

00:33:49:04 - 00:34:07:23
Dr. Marcotte(Cardiologist)
Some of these implants are actually a big problem which is not as much of a problem with CT. CT has less of a problem with artificial valves and with the improvements, I guess that that that you guys have seen I mean I've seen some wonderful images of prosthetic valves would CT where you can see the, the, the valve disks and it's.

00:34:08:02 - 00:34:08:23
Dr. Jokerst (Radiologist)
Actually so.

00:34:09:03 - 00:34:23:00
Dr. Marcotte(Cardiologist)
This is stuff you can't really see. IMR So for the clinician it's important. Clinicians don't, don't understand always this, this thing. So I struggle we try to, we try to to, to, to bring this, you know, to get the right test for the right patient.

00:34:23:00 - 00:34:25:21
Dr. Jokerst (Radiologist)
And implants aren't getting less common. They're getting more.

00:34:25:21 - 00:34:27:06
Reggie
Common. Oh, yeah, for sure.

00:34:27:09 - 00:34:45:14
Dr. Jokerst (Radiologist)
Just because it's more compatible doesn't mean it doesn't throw off a lot of artifact. There is a little those implantable loop recorders, actually, they throw out a fair amount of they throw out a pretty good amount of artifact. And the thing to remember, too, is with them are everything is based off of us knowing what the magnetic field is.

00:34:45:15 - 00:34:45:22
Reggie
Right.

00:34:46:02 - 00:35:01:16
Dr. Jokerst (Radiologist)
And the problem with metal or any other kind of foreign body is it disrupts that magnetic field and so it results in artifact in and of itself. But it also degrades your magnetic field. It makes it more heterogeneous. So just overall image quality takes a hit to a lot of times.

00:35:01:23 - 00:35:18:15
Dr. Marcotte(Cardiologist)
What are the things that that are metal but do not cause major problems or coronary stents. People who have like angioplasty stents. So that's not as much of an issue on those are they're they're kind of more discreet and and we can do the exam with those so that they will cause a blow out region. You'll see a black or.

00:35:18:15 - 00:35:19:01
Reggie
Dark.

00:35:19:20 - 00:35:25:02
Dr. Marcotte(Cardiologist)
Area. But we can we can still navigate with that. They're not they're not a problem.

00:35:26:03 - 00:35:34:12
Robert
That's pretty cool. One thing I did want to talk about, I think we kind of touched up on it was a necessity in the role, the contrast place. So it sounds like it's not always necessary.

00:35:34:12 - 00:36:09:20
Dr. Jokerst (Radiologist)
Well, it really depends on what you're looking for. So if you had to MRI can do a few things that other things basically can't do or can't do very well. And one of those things is demonstrating myocardial damage, fibrosis, you know, amyloid deposition. Yeah, old infarct. Infarct, whatever you need contrast really to do that. Well, and that is the main I think when we give up contrast, that is the main thing we're giving out because even high, yeah, we're getting better at doing more angiography.

00:36:09:20 - 00:36:20:00
Dr. Jokerst (Radiologist)
Without contrast, we haven't really you know it's still in process of trickling down. But when it comes to the delayed other, what we'll see with the parametric mapping a lot of times what the team wants.

00:36:20:03 - 00:36:21:16
Dr. Marcotte(Cardiologist)
You to predict.

00:36:21:16 - 00:36:22:07
Reggie
Yeah, we have.

00:36:22:07 - 00:36:26:17
Dr. Jokerst (Radiologist)
No pre time where an infarct is going to be based off of you know that the t one and two.

00:36:26:22 - 00:36:52:06
Dr. Marcotte(Cardiologist)
Yeah. But don't have the confidence though that we have when I think they're complementary. I mean late gadolinium enhancement is a macroscopic phenomenon that you see, whereas the maps give you sort of that microscopic that sort of diffuse fibrosis that you may not be able to see at the naked eye. So so the advantage, I guess, of gadolinium for for scar imaging is that when it's big, it's really helpful.

00:36:52:06 - 00:36:53:07
Dr. Marcotte(Cardiologist)
You really see it.

00:36:53:07 - 00:37:05:16
Dr. Jokerst (Radiologist)
But it drives clinical decisions too. When we're talking about liabilities and far right, you know, is it worth re vascular, a ms. territory? Is there any living myocardium? If it wave, it's enhancing, it's dead.

00:37:05:23 - 00:37:07:19
Reggie
So you're not going to get any of that from CQ.

00:37:07:20 - 00:37:26:13
Dr. Jokerst (Radiologist)
You can't get that from CTE and you can't really get it without control as you can kind of make some assumptions and not that it's they have all end all, be all, but definitely the viability imaging with the delayed enhancement and then, you know, other places where it has kind of a prognostic capacity would be like hypertrophic cardiomyopathy.

00:37:26:13 - 00:37:40:14
Dr. Jokerst (Radiologist)
You know, the people that have more myocardial fibrosis, delayed enhancement tend to have more issues with fatal arrhythmias. So, you know, if you have what is a 2010 to 20% of your myocardial mass or more demonstrates enhancement, they get an act, whereas.

00:37:41:18 - 00:38:05:21
Dr. Marcotte(Cardiologist)
So when you find enhancement, it's really a it's a bad thing for the patient whatever the disease's prognostic we you look at all the kaplan-meier curves in a given disease be it coronary disease, myocarditis, hypertrophic cardiomyopathy, hamlet everywhere. In the more gadolinium you have, the more patients die. Yeah, and fibrosis is something that interferes with the conduction of electricity within the heart.

00:38:06:09 - 00:38:22:10
Dr. Marcotte(Cardiologist)
So it makes the the electrical system less effective. Mistakes occur. And then that's how a arrhythmias start when there's like short circuits that occur. Fibrosis is a is a terrain for this problem to occur. And that's how it correlates with which should set.

00:38:22:10 - 00:38:25:08
Reggie
In so healthy heart. You won't see any contrast in enhancement.

00:38:25:08 - 00:38:37:01
Dr. Jokerst (Radiologist)
Well, here's an important distinction. The heart enhances. Okay, so what can you do? We have some Dillards in here. I think there might be. I don't know, I they might be.

00:38:37:05 - 00:38:39:16
Dr. Marcotte(Cardiologist)
These were. Yeah. So this here.

00:38:40:08 - 00:38:43:16
Dr. Jokerst (Radiologist)
Next one I think has to delay it. Yeah. We're getting into the.

00:38:43:17 - 00:38:44:16
Reggie
Here we go. Nice.

00:38:44:18 - 00:39:15:15
Dr. Jokerst (Radiologist)
So you see those white areas there. So basically with delayed enhancement, that myocardium is it's either not myocardium or it's dead myocardium. So I mean, it's like so I was saying it's it's an issue, you know, you don't want to have the weight enhancement and lots of different things cause it. So having delayed enhancement, that's not specific. So specific specificity is kind of like, all right, this is what this is because, you know, I don't know, sensitivity, specificity.

00:39:16:04 - 00:39:37:23
Dr. Jokerst (Radiologist)
It's not whether or not you have the enhancement, it's the pattern of the enhancement against specificity. So in this case, if we're seeing delayed enhancement, it's band of cardio, it's in a vascular distribution like left circumflex. Those are all things telling you. This person has a big infarct and you look at it and say, all right, there are areas where it's trans male, more than half the wall is involved.

00:39:38:07 - 00:39:53:03
Dr. Jokerst (Radiologist)
You can re vascularized that region and there's a high probability it's not going to make a difference. But there are other regions where more than half of the myocardium is looks like it's still alive. So, you know, if you re vascularized, that area might perk up and the ejection fraction might come back up.

00:39:53:08 - 00:39:58:12
Reggie
You know when you say in delayed enhancement. Yeah. So you're saying like so technically it should wash in in in Washington.

00:39:58:13 - 00:40:00:01
Dr. Jokerst (Radiologist)
That's right. That's the whole point of this.

00:40:00:02 - 00:40:00:10
Reggie
Yeah.

00:40:00:11 - 00:40:02:12
Dr. Jokerst (Radiologist)
Is the heart enhancers.

00:40:02:19 - 00:40:04:02
Reggie
So what you.

00:40:04:03 - 00:40:32:21
Dr. Marcotte(Cardiologist)
Do the previous slide we can show you an example. So before that. So listen if we play that city on the right, this is an example of a yeah. Of a stress perfusion. So this I must say, however, this is not yet an approved FDA use for for gallium Gatling really was mainly engineered as a Andrew graphic agent.

00:40:33:00 - 00:41:03:10
Dr. Marcotte(Cardiologist)
Oh or however some very intelligent and very observant radiologists in the 19 the early 1990s. And cardiologists probably found that not only would you be able to pacify the cardiac cavities and the great vessels to do great angiography, you also could see the hue of of gadolinium that this sort of graying that you see. So this is an example of a short access view where you have here the of my arrow is going to work again.

00:41:03:18 - 00:41:29:08
Dr. Marcotte(Cardiologist)
So so this is this is the right ventricle and then the left ventricle. So we inject the gadolinium in in an arm after administering a pharmacological stress agent in this particular patient we gave adenosine. But there's different drugs that can be given Dennison or or deprived of all these or other medications that that can be used for for stress.

00:41:29:13 - 00:41:54:18
Dr. Marcotte(Cardiologist)
They're very safe. And what we see here is there's an area that that enhances here in the in the anterior territory. Whereas you see the perfusion, as Clint was saying earlier, occurs more normally in the inferior and the lateral. And it just turns out so these were the images in this patient who then moved on to have lead gadolinium images that showed no late gadolinium enhancement.

00:41:54:18 - 00:42:13:07
Dr. Marcotte(Cardiologist)
So this patient had what looked like coronary disease without having an infant. And this is the patient's coronary angiogram that confirms this. This really, really critical proximal left anterior descending stenosis. So the patient underwent coronary angioplasty and stenting. So additionally before sustaining this.

00:42:13:07 - 00:42:39:05
Dr. Jokerst (Radiologist)
Is a mimic myocardial. It's not that, which is why it doesn't show an enhancement. Right. This is also a great example is I don't know, like if you're not used to cardiac MRI, you might say, like, why is in this guy's heart beating exactly. But it's moving up and down. And so, you know, this is an EKG gated study where basically we're looking maybe 70 times at the same slice, but we're only looking at the heart a specific point in the cardiac cycle.

00:42:39:06 - 00:42:54:13
Dr. Jokerst (Radiologist)
We're not watching the heartbeat. We're only looking at, you know, usually late diastole. Right. And so that EKG gating takes into account that heart beating. And we were only looking at one specific point. So that's why the heart doesn't look like it's moving. But we're looking at that point over and over again over time. So we're watching the contrast.

00:42:54:13 - 00:43:15:11
Dr. Jokerst (Radiologist)
You can see it coming to the right ventricle, go out to the lungs, come back, you know, into the left ventricle and out through the coronaries, and then, you know, profuse the myocardium. And the reason it's bouncing up and down is because the patient's breathing right. Easy gating doesn't take into account respiratory motion. Right. So it's just a good example of how important the gating is for here.

00:43:15:11 - 00:43:35:18
Dr. Jokerst (Radiologist)
And, you know, the thing that that you'll see here is the myocardium enhances. And when we talk about delayed imaging, really what we're doing with delayed imaging, we don't mention it. But this is an inversion recovery sequence where one of the things that's really important to get good delayed imaging is we want to take normal heart and make it black right?

00:43:35:18 - 00:43:43:02
Dr. Jokerst (Radiologist)
And so if there's any abnormal heart, it stands out. It's easier to see on a black background than it is to see white on a gray back.

00:43:43:02 - 00:43:43:18
Reggie
Right.

00:43:43:18 - 00:43:55:08
Dr. Jokerst (Radiologist)
And so that, you know, I don't want to say the heart doesn't enhance, it does enhance. It's just we are trying to null out. We're specifically targeting normal myocardial and said let's make them normal myocardium black.

00:43:55:10 - 00:43:55:18
Reggie
Right.

00:43:55:18 - 00:44:04:00
Dr. Jokerst (Radiologist)
Because there's contrast in the myocardium, it's alive. So, you know, it's not in the myocardium proper, it's in the caterpillar beds inside. It's a.

00:44:04:14 - 00:44:05:08
Reggie
Pressure.

00:44:05:08 - 00:44:16:13
Dr. Marcotte(Cardiologist)
In fact, the heart enhances, but then the the gadolinium escapes and gets eliminated by the kidneys. It's the fact that it remains stuck and it can't escape. That determines that. So the.

00:44:16:13 - 00:44:17:04
Reggie
Pathology.

00:44:17:07 - 00:44:17:11
Dr. Marcotte(Cardiologist)
That.

00:44:17:17 - 00:44:22:07
Robert
Is that also it's so important for the contrast, the adjacent tissues I guess.

00:44:22:12 - 00:44:47:16
Dr. Jokerst (Radiologist)
Yeah. And one of the reasons why, you know, there's one of the things about amyloid is, you know, amyloid with amyloid deposition. You've got so much of these amyloid proteins around the body and they kind of sponge up the contrast and it pulls the contrast out of the blood pool rather quickly. And so a lot of times we'll have a lot of trouble setting our inversion time, first of all, because there's really not much contrast left.

00:44:47:16 - 00:44:57:05
Dr. Jokerst (Radiologist)
It's almost like, have you guys ever tried to do a Thai scan on somebody where the Ivy infiltrated and you didn't notice? Oh, right. Yeah. You're trying to set the and like, this looks weird. Like, this doesn't.

00:44:57:05 - 00:45:00:21
Reggie
Look like a contrast. Yeah, I can see.

00:45:01:11 - 00:45:17:18
Dr. Jokerst (Radiologist)
The other part of that too is Mark amyloidosis. It can be very subtle, but it's usually very diffuse process, right? You need to have some normal myocardium somewhere to decide like this is what we're going to try to know. If you don't have any normal myocardium, if it's all full of chock full of amyloid, where do you what do you know?

00:45:17:18 - 00:45:18:00
Dr. Jokerst (Radiologist)
Right.

00:45:18:01 - 00:45:40:04
Dr. Marcotte(Cardiologist)
So the key technical aspect with an inversion recovery sequence is that you should image every second beat. So every two beats you need to let the signal recover. So you can't do it every every heartbeat somehow. So if you're if you're analyzing, if you're doing it for the first time, that's that's one side of your specialty. The vendors have it properly adjusted, but then it's a little trick.

00:45:40:12 - 00:45:42:06
Dr. Marcotte(Cardiologist)
It's important not to forget.

00:45:42:06 - 00:46:02:06
Dr. Jokerst (Radiologist)
That's the other important point with cardiac you know, cardiac imaging, we have all these time constraints. You know, the heart's beating, the patient's breathing. They have to hold their breath. You know, there's the thing you have to remember with some of these pulse sequences, especially the T2, is, you know, it is like a horse, basically, and you're beating it with, you know, and sometimes you have to let the horse rest so it can run.

00:46:02:06 - 00:46:20:08
Dr. Jokerst (Radiologist)
And if you just keep beating this horse and don't give it time to relax and you get the signal time to recover so that you have something to work with, with your next pulse, you know, you can get some erroneous exam, some, you know, you might you know, your teats might not look like there's any T2 signal because.

00:46:20:16 - 00:46:21:07
Reggie
The ride horses.

00:46:21:07 - 00:46:28:20
Dr. Jokerst (Radiologist)
Often. No, I like what I took my daughter on a horse ride a couple of years ago and I was too fat to ride a horse.

00:46:28:21 - 00:46:36:15
Reggie
I had a mule on the old man. So I guess once you get up.

00:46:37:02 - 00:46:38:18
Dr. Jokerst (Radiologist)
Beyond two bills, you know, you're.

00:46:39:07 - 00:46:39:20
Reggie
Approaching.

00:46:39:20 - 00:46:40:14
Dr. Jokerst (Radiologist)
Your country.

00:46:42:03 - 00:46:42:20
Reggie
Which is fine.

00:46:43:00 - 00:46:47:02
Dr. Jokerst (Radiologist)
You know, so the meal and I got along with it really stubborn and slow.

00:46:47:04 - 00:46:49:06
Reggie
And that's also I didn't.

00:46:49:06 - 00:47:09:18
Robert
Want to kind of talk about pathologies and what are some of the most common ones. Now we talk kitayama infarct in layman's terms as a heart attack, but we also talk about amyloid as well. What are, if you would, just kind of break down some of these most common things that we see as far as pathologies goes and what would be like some of the common treatments for it?

00:47:09:23 - 00:47:10:14
Reggie
Yeah.

00:47:11:08 - 00:47:42:05
Dr. Marcotte(Cardiologist)
Well, so coronary disease, I mean when we image patients who've sustained a heart attack, the importance is reestablishing flow in a blocked artery and then modifying risk factors so that patients don't do it again. So if you're smoking, stop smoking. If you're a diabetic, take your diabetic pills. If you're hypertensive, take your blood pressure pills. And if you have coronary disease, well, you also need blood thinners that reduce the risk that a that a blockage may occur.

00:47:42:05 - 00:47:59:06
Dr. Marcotte(Cardiologist)
Blockages can occur from cholesterol plaques, but also because of blood clots that form inside as a result of the the cholesterol plaque being exposed and then the the blood in your in your bloodstream to see this cholesterol. That's it. And that just clumps on it and blocks the artery.

00:47:59:15 - 00:48:20:09
Dr. Jokerst (Radiologist)
But, I mean, it's just I just want to pile on that with a tangent because I was listening to a podcast about evolution and the evolution of blood. Using our blood is fascinating because it has to be fluid and flow, you know, to get from one place to another. But also it has to clot. You know, if it didn't clot and you had a paper cut, you'd bleed to death.

00:48:20:09 - 00:48:20:22
Reggie
Oh, yeah.

00:48:20:22 - 00:48:42:00
Dr. Jokerst (Radiologist)
So, you know, it's it's interesting. And so one of the things, if you think of the blood, the cells that line your blood vessels and heart are very specialized. They're there. If blood you know, blood is designed to kind of slide through that. And if blood see something that's not that it clots, it activates a clot. So what happens with these atherosclerotic plaques that rupture?

00:48:42:15 - 00:48:59:23
Dr. Jokerst (Radiologist)
You know, you've got this normal endothelium. Well, not normal, but endothelium over it. But when that endothelium gets damaged and if you tear a hole in it, basically you've got this thrombus genic stuff underneath it. And so when people die from a heart attack, they don't die because they have this really tight coronary artery that they've had for ten years.

00:48:59:23 - 00:49:23:04
Dr. Jokerst (Radiologist)
And now it's went from 99% to 100. They die because they have a plaque and maybe that a 30% lesion in our last name in it, it went from 30 to 100% in a second. And that's when you die because you're not you're not compensating for, you know, the right. I'm always amazed we see these patients that have bypass grafts like we very common we image them and you know, ten years out, a lot of those bypass grafts are gone.

00:49:23:04 - 00:49:40:12
Dr. Jokerst (Radiologist)
You know, they're just not there anymore. They're occluded. So the bypass graft is kind of like a bridge to the patient, can build collaterals. Blood really doesn't want to go through the bypass graft. It will let if it has to fit. Over time. You build these collaterals around and eventually the bypass graft. If it's gone, that's good. It means your body didn't need it so well most of the time.

00:49:41:01 - 00:49:43:09
Dr. Jokerst (Radiologist)
Sometimes they block off and you don't want them to. Right.

00:49:43:21 - 00:49:48:22
Dr. Marcotte(Cardiologist)
So what's the benefit by doing an MRI in someone who's had a heart attack? Because you can see the extent of the heart attack.

00:49:49:06 - 00:49:50:19
Robert
So that where do you usually see it?

00:49:51:15 - 00:50:12:07
Dr. Marcotte(Cardiologist)
It depends which artery has been occluded. So if it's the led, the left anterior descending, it's going to be the anterior wall in the apex. If it's the right coronary, it's going to be the inferior wall, sometimes the right ventricle. And if it's the circumflex, Clint mentioned the circumflex earlier. We saw an example of a circumflex infarct. That's the side of the heart now.

00:50:13:06 - 00:50:40:20
Dr. Marcotte(Cardiologist)
I mean, it's a heart attack is a heart attack is a heart attack. The thing that you may get from from from m.r can also be obtained by echo the function and stuff. But what the EMR brings to the table is the amount of scar you have prognostic that can be useful. What also happens is that for the reasons Clint mentioned, some people will develop heart attacks without having those cholesterol plaques, but they will develop the blood clots within their system.

00:50:41:08 - 00:50:48:12
Dr. Marcotte(Cardiologist)
And we call this myocardial infarction with normal coronary arteries. Minorca So that's.

00:50:50:18 - 00:50:50:19
Dr. Jokerst (Radiologist)
What.

00:50:50:20 - 00:51:25:12
Dr. Marcotte(Cardiologist)
Was occurring. So M.r is actually a very useful technique to look at these patients who've had what seems like a heart attack. They have an abnormal EKG, their blood enzymes have gone up and yet we don't have an explanation. Right. And some of the explanations may be inflammation of the heart from a virus. So myocarditis, what we were talking about earlier, you can have other types of of of so like a vasculitis, some sort of an inflammation of the blood vessels, some hyper coagulant states, meaning your blood clot system is to either to define clots.

00:51:25:21 - 00:51:53:09
Dr. Marcotte(Cardiologist)
So so sometimes MRI can be useful in those patients as well too to see the extent. So finding how big the MRI is and finding alternate causes when you don't have coronary disease, and then the prognostic information is that the more gadolinium enhancement you have and the lower your power of your heart as determined by what we call the ejection fraction, about 55, 60%.

00:51:53:13 - 00:52:20:04
Dr. Marcotte(Cardiologist)
So if it's very low, then these patients have to be watched really carefully. They should be on some some specific medications. So you can tailor the treatment following, a heart attack with the use of an echo or an MRI to to give the patient the best treatment, you know, including reestablishing coronary blood flow, for sure. So other diseases that we have, we have things like valve problems.

00:52:20:12 - 00:52:37:01
Dr. Marcotte(Cardiologist)
So again, ultrasound is really good echocardiography to diagnose. But we do have in our in our bag of tricks, Seema, we have face contrast or PC sitting so we can measure blood flow and we can actually calculate how badly a valve leaks.

00:52:37:10 - 00:52:39:12
Reggie
And they don't need to go much further into how.

00:52:39:12 - 00:52:48:20
Dr. Marcotte(Cardiologist)
Much of vegetation. So we can use that to see. Sometimes ultrasound is really good, but sometimes we're not always sure of the amount of leakage. So that.

00:52:49:01 - 00:52:51:12
Robert
So that when you would order like velocity flows.

00:52:51:12 - 00:53:13:02
Dr. Marcotte(Cardiologist)
Velocity flow, yes. For contrast PCR image or velocity slows and then so you can use that for that. Yeah. Yeah. Congenital heart disease is one that I use a lot. And that's that was one of the reasons I started getting interested in that. And there we use 3D and geography and we had an example I think.

00:53:13:17 - 00:53:14:22
Dr. Jokerst (Radiologist)
Me coming up good.

00:53:15:02 - 00:53:25:05
Robert
While you pull it up doctor jokers, when you see these velocity flows and you're looking for aliasing and whatnot, what else is it that you're looking for? How do you what is it that you used to? What tools you use to evaluate that?

00:53:25:09 - 00:53:52:22
Dr. Jokerst (Radiologist)
So when we're talking about let's phase contrast imaging in general if you keep going backwards. But so basically that is the Doppler slash pulse Doppler equivalent from Echo. So you've got phase contrast imaging. Basically what we're doing here is I want to get too deep into the physics, but you can look at proteins and see how many of you are moving in what direction they're moving and how fast they're moving.

00:53:52:22 - 00:54:27:17
Dr. Jokerst (Radiologist)
And so from that information, you can get a variety of things. And so you had mentioned aliasing and so analogous to color Doppler on echo. Basically when we're imaging using this technique, we have to decide what velocities we want to look at going in. And if our velocity scale isn't set properly, if it's not broad enough, what happens is if you have some protons that are moving faster than your velocity scale, the MRI does, the scanner doesn't know where to put that signal because it ran out of space.

00:54:27:17 - 00:54:53:13
Dr. Jokerst (Radiologist)
Right. So, you know, if you're set at 200 centimeters per second as your top and it's going to 50, there's no 250. It doesn't know what to do. So wraps it around and sticks it at the bottom. Now, that is an immensely oversimplified explanation. I mean, we to get into phase aliasing, we could talk about, you know, the true nature of reality and now, you know, quantum electrodynamics or, you know, field theory.

00:54:53:19 - 00:54:55:19
Reggie
Is really into that. If we.

00:54:55:19 - 00:54:56:18
Dr. Jokerst (Radiologist)
Really. Yeah, we would.

00:54:57:03 - 00:55:07:15
Dr. Marcotte(Cardiologist)
To simplify it's white blood imaging basically. And it does basically it does exactly the opposite of fast spin echo where the blood the blood is black.

00:55:07:16 - 00:55:08:03
Reggie
Yeah.

00:55:08:12 - 00:55:32:06
Dr. Marcotte(Cardiologist)
In velocity mapping, what we do is we basically add a supplemental all equal but opposite direction gradient that are that are and that sort of nullify the signal of stationary tissue and highlight what moves in and out of the plates. So with blood, blood imaging, we try to suppress the blood signal. With velocity mapping, we suppress everything else.

00:55:32:10 - 00:56:00:23
Dr. Marcotte(Cardiologist)
But what travel and the the way the sequence is engineered is that the amount of phase change is to the velocity of flow, basically. So we can we can take an educated guess. And as as we're saying, often the patient's going to have an echo or something where we can measure blood velocity so we can ahead of time sort of say, hey, the echo got to 50 on the, on the velocity.

00:56:00:23 - 00:56:03:13
Reggie
So let's see that lets you know maybe.

00:56:04:01 - 00:56:11:13
Dr. Marcotte(Cardiologist)
Do 260 or 270 so we can so we make sure we don't alias and so we can take like an educated guess.

00:56:11:21 - 00:56:16:04
Reggie
That one of the recommendations like do people usually have echos right before they have an MRI or it's.

00:56:16:04 - 00:56:18:04
Dr. Jokerst (Radiologist)
Pretty, pretty convincing these 80%.

00:56:18:04 - 00:56:30:04
Dr. Marcotte(Cardiologist)
Yes, typically echo is more of a first line test because it's cheaper, it's fat it's faster to do its real time. Right. And it's portable. So if you're whether you're in the ICU, the emerge.

00:56:30:06 - 00:56:31:16
Reggie
Or for a.

00:56:31:17 - 00:56:34:01
Dr. Marcotte(Cardiologist)
Patient. Yeah, the machine can be wheeled in.

00:56:34:01 - 00:56:35:07
Reggie
Now the MRI.

00:56:35:07 - 00:56:42:23
Dr. Marcotte(Cardiologist)
Is a little more not going to Fort Knox, which is like a little more and more of a secure, secure area. So we've got to be really careful with that, with.

00:56:43:00 - 00:56:44:01
Reggie
Especially where we work.

00:56:44:02 - 00:57:10:02
Dr. Jokerst (Radiologist)
And I'm going to use this as an opportunity to talk about 40. Flo Oh yeah. And so when we're talking about phase contrast imaging, what we're doing here is we're it, we, we set up our flow gradients. Our phase gradients are either to, to look at flow. Basically the tradition has been to we can look in one direction, right hand, foot left, right up, down, whatever we want to set that direction to where we can look in.

00:57:10:06 - 00:57:43:07
Dr. Jokerst (Radiologist)
Basically, we can look in one direction and the it would be ideal to look in three directions because we have three spatial dimensions. Right. So you could go had foot left, right, front back. And then by looking at in any particular spot in your scan volume, any voxel, how that changes kind of up, down, left, right, front back, you can actually take those three coordinate systems into account and get actual true wow and velocity.

00:57:43:22 - 00:58:17:08
Dr. Jokerst (Radiologist)
And so the problem with looking in one direction say we're looking head for it is the equation that we use to figure all this out I think has a cosine function in it. And so for if you're not exactly perpendicular, 90 degrees for every little bit you're off you become less accurate, you lose a peak velocity. And another thing I will mention, too, is a weakness of Mark compared to Echo is when we're using this one dimensional technique like this, we're looking and we're like setting up a imaging plane and scanning it, but it's not a real time.

00:58:17:08 - 00:58:49:06
Dr. Jokerst (Radiologist)
We're like, we scan it and then we look at the image with Echo. You've got a probe and you're looking around and you can kind of like turn and twist and go like, Oh, here's the worst spot, the vena contract, a so-called right. And so you can kind of dial in right away on that with m.r it's kind of like you're chasing your tail like, all right, we need to go up a little bit and then this patient takes a different sized breath and now you're too high or so you know, and so one of the advantages of of the ability to to look in all three directions and do that is now what we

00:58:49:06 - 00:59:14:23
Dr. Jokerst (Radiologist)
can do is we have this volume of 4D data. The fourth dimension is time. We can load that into a post-processing program and retrospectively change our imaging planes to wherever we want is typically m r will underestimate velocities and flows relative to echo because we can't get exactly on the tightest spot or exactly 90 degrees I you.

00:59:15:02 - 00:59:15:13
Reggie
Yeah.

00:59:15:18 - 00:59:18:10
Robert
So something you do on circle 42 or. Yes. Okay.

00:59:18:12 - 00:59:39:11
Dr. Jokerst (Radiologist)
Yeah but all the processing is retrospective. What this. We can't really you know what I mean? Like you're going to give me a something, I'll throw it in a circle 42 and process it. Now, the 44 you can imagine every single a voxel is a pixel in 3D. So yeah, 2d display we can show no height, you know, front back, left, right, you know.

00:59:39:11 - 00:59:52:12
Dr. Jokerst (Radiologist)
Yeah a voxel is that plus slice thickness and so right with M.r you know we we could you really get into space time now we're talking about you know is is the universe pixel and.

00:59:54:00 - 00:59:54:02
Reggie
That.

00:59:54:05 - 00:59:55:19
Dr. Jokerst (Radiologist)
You know we there's.

00:59:56:00 - 00:59:58:15
Reggie
There's up for another podcast there's.

00:59:58:15 - 01:00:22:01
Dr. Jokerst (Radiologist)
A smallest unit kind of this length with height then that's a voxel and we can't get any more precise than that. We're more assigning signal. And so when run so I was talking about spatial resolution earlier, you know, that's, that's the rate limiting stat. So I can't if I can tell how much signals coming out of a voxel but I can't tell anything beyond like it's coming from this part of Oxley, that part of the voxel.

01:00:22:01 - 01:00:38:01
Dr. Jokerst (Radiologist)
So that's, that's your rate limiting step. But so for this 4D flow technique, we have all this information for all these voxels you can imagine, you have this, this phase information of the cardiac cycle in all three dimensions and we're going to kind of like look at add them together and try to figure out what's really going on.

01:00:38:01 - 01:01:00:19
Dr. Jokerst (Radiologist)
The post-processing is immensely time consuming. It requires very powerful computers, very powerful programs. And so the 4D flow is just now kind of coming on the scene. It's going to be great because we can it's very much like ctDNA. You get a data set that you can slice and dice retrospectively and so we can dial in on the tightest spot and make sure we're 90 degrees.

01:01:00:19 - 01:01:02:02
Dr. Jokerst (Radiologist)
So there's no gap anymore.

01:01:02:03 - 01:01:02:16
Reggie
Yeah. Yeah.

01:01:02:22 - 01:01:25:01
Dr. Jokerst (Radiologist)
But the problem is these sequences take a long time and this is where compressed sensing comes back. And compressed sensing is just a it's a mathematical technique. A four way transform is a mathematical technique. It's just a different mathematical technique, basically to take I don't want to get into sparsity and all that kind of stuff, but basically it's math magic.

01:01:25:06 - 01:01:27:01
Reggie
So yeah, and like so.

01:01:27:01 - 01:01:50:11
Dr. Jokerst (Radiologist)
By using this math magic, we can take what used to be unattainable, a sequence that would maybe take 40 minutes just to run one sequence and do it in 5 to 10 minutes, which is a little more useful than usually through breathing, you know. Yeah, guided cardiac aided and respiratory gated. But that will that will be a game changer, I think for car, for cardiac EMR, the ability to do this 4D flow.

01:01:50:21 - 01:02:11:16
Dr. Jokerst (Radiologist)
Because now think about it when I say we want to do a flow control like a gentle heart case, we're going to flow the flow quantum ap flow quite there or there flow quite the left and right and a minimum, if any of those are at a plane or if there's aliasing to repeat it. Right. With 4D flow, it's one thing and you have you can do flow anywhere you want.

01:02:11:17 - 01:02:35:00
Dr. Jokerst (Radiologist)
Oh no, every vessel yet out of it is a game, but that makes it a lot easier because especially if you've got patients with complex baffles or rerouted anatomy, you can kind of add up the blood coming from all these different spots. Now, here's the problem. You only have one velocity scale, right? And so you kind of have to pick, you know, if you get it wrong on a 40 flow and it took 12 minutes, now you've got to do another 12 minute.

01:02:35:00 - 01:02:35:07
Dr. Jokerst (Radiologist)
Right?

01:02:35:07 - 01:02:36:23
Reggie
Right. So but the.

01:02:36:23 - 01:02:45:18
Dr. Jokerst (Radiologist)
Bigger your velocity scale, the less accurate your measurements become. So if you want to measure the aorta, but you also want to measure pulmonary veins, which have very slow flow.

01:02:46:19 - 01:02:47:18
Reggie
You can't scale.

01:02:47:19 - 01:02:57:00
Dr. Jokerst (Radiologist)
You need a tight scale for the veins in an open scale for the arteries. And so they're working on figuring out ways to kind of do two for 2 hours, same time. Right.

01:02:57:16 - 01:02:58:21
Dr. Marcotte(Cardiologist)
What's the fourth dimension?

01:02:59:23 - 01:03:00:13
Robert
Tai chi.

01:03:01:04 - 01:03:16:20
Dr. Marcotte(Cardiologist)
Good. The thing that that that's important, though, also, is that when we use the the velocity mapping is we try to pick a spot that's relatively quiescent. We try to stay away from turbulent areas when we want to measure. Oh yeah. When you have.

01:03:17:04 - 01:03:19:09
Robert
That way, you go just proximal to the valve.

01:03:19:09 - 01:03:25:10
Dr. Jokerst (Radiologist)
Or like we go to the T junction instead of at the sinuses of the salvor because the sinus, the vessels, there's lots of there.

01:03:25:12 - 01:03:27:05
Reggie
There's what we call eddies.

01:03:27:17 - 01:03:53:14
Dr. Marcotte(Cardiologist)
Okay. So this introduces flow disturbances. I mean, the flow dynamics are quite complex. So you want to pick an area that's relatively calm. So maybe the sound of tubular junction or ascending aorta, the same thing for the pulmonary artery. The thing that Echo does better is that it has in its armamentarium something called continuous wave Doppler, and that's is able to take the maximum velocity.

01:03:53:14 - 01:04:29:15
Dr. Marcotte(Cardiologist)
So it can always overdo EMR by obtaining higher velocities because it's able to obtain the maximum velocity along an axis. It does not have any precision in terms of location, however. So what there's always a trade off in in in science and in imaging for sure. What we have here is we're better than ultrasound in my hand. In my comparison, my experience to measure flow were perhaps not as good to measure peak velocity because we're not necessarily at the area that's the narrowest where the velocity accelerates the most.

01:04:29:23 - 01:04:56:14
Dr. Marcotte(Cardiologist)
And I'd call that the vena contract. That's that's the technical term for for that. So, so that's one thing. So certainly, I mean, it's, it's a useful thing that we that we can that we can use for for full quantitation. We can use it to look at shunts. We can like if there's a hole in the heart or between the two circulations, you can compare the flow in the pulmonary artery and the aorta and understanding how the flow dynamics are where the hole is.

01:04:56:20 - 01:05:03:11
Dr. Marcotte(Cardiologist)
You can deduct how much shunting there is and and that can determine an indication for for an operation. For example.

01:05:03:23 - 01:05:07:08
Robert
If you might just explain to an idiot like me what a hole in the heart is.

01:05:08:01 - 01:05:45:09
Dr. Marcotte(Cardiologist)
A hole in the heart is a common malformation, a congenital malformation. The heart develops in the fetus between the, let's say, the sixth and the 12 weeks of gestation. It starts earlier. It starts, you know, since right. Since day one. And it becomes a heart, you know, with time, the blood cells organize into tubes and these tubes basically come together and fold on it on themselves and generate it through kind of a miraculous process.

01:05:45:11 - 01:06:15:22
Dr. Marcotte(Cardiologist)
Right. Cells and and ventricles and atria and during the embryogenesis, which is the when when when you have an embryo that becomes a fetus, the the the the the tubes need to need to close. There needs to be a what we call cetacean, which is closure within those those cardiac tubes to separate the circulation that goes to the lungs from that that goes through the systemic circulation.

01:06:16:00 - 01:06:23:14
Dr. Marcotte(Cardiologist)
Right. And there are little mistakes. The commonest hole in the heart or septal defect is one between the ventricles.

01:06:24:02 - 01:06:25:05
Robert
Like a fistula, sort of.

01:06:26:03 - 01:06:39:18
Dr. Marcotte(Cardiologist)
You could say that. I mean, it's it's it's basically a hole that that allows blood from the high pressure chamber, typically the left ventricle to send blood to the right ventricle and pulmonary artery.

01:06:39:18 - 01:06:41:04
Robert
So that detriment is it, too?

01:06:41:12 - 01:07:09:10
Dr. Marcotte(Cardiologist)
Well, it can if it's very small, none. But if it's fairly large, what it can do is it can with with the amount of blood that travels through the lungs, it can overwhelm the lungs. Circulation damaged the pulmonary arteries and cause something called pulmonary hypertension, which is not not a good thing. And then so so those are for certain shut not all holes in the heart will cause pulmonary hypertension.

01:07:09:10 - 01:07:12:23
Robert
And again, I'm an idiot, but I'm curious, are you able to say, is that something you could graft.

01:07:13:04 - 01:07:13:22
Reggie
Or.

01:07:14:00 - 01:07:15:07
Robert
The tissue could regenerate?

01:07:15:19 - 01:07:36:17
Dr. Marcotte(Cardiologist)
It does sometimes, yes. Many, many if not most, of the septal defects can close spontaneously. Not all of them. If you have a very large one, it will grow. But it it's a bit of a race against time when the baby is just born. This you have this large hole. And as the baby grows, the hole tends to close down a little bit.

01:07:36:17 - 01:08:00:02
Dr. Marcotte(Cardiologist)
But sometimes it just takes too much time. And it's and if the and if the doctors don't intervene and patch that hole either through surgery or sometimes in older babies and adults and adolescents, we can use devices that can be implanted by catheter. These are also available so you can close these defects before they cause pulmonary hypertension.

01:08:00:08 - 01:08:03:02
Robert
So you're able to diagnose it while the baby, while it's.

01:08:03:10 - 01:08:27:23
Dr. Marcotte(Cardiologist)
Still present through the heart murmur that's that becomes manifests in the weeks that follow birth, the more complex defects, the ones that have like septal defects or missing arteries that cause mixture, blue and red blood will be much more manifest sometimes as early as birth. So those complex defects, which are fortunately very rare, can be diagnosed shortly after birth.

01:08:28:08 - 01:08:30:14
Robert
Thank you. I don't always have a cardiologist across the table.

01:08:31:22 - 01:08:35:14
Dr. Jokerst (Radiologist)
A cyanotic is the term that's cyanotic heart disease.

01:08:35:20 - 01:08:37:05
Robert
Okay. And how common is it?

01:08:37:07 - 01:08:45:06
Dr. Jokerst (Radiologist)
Blue cyanosis is when you send deoxygenated blood out in a systemic and it means different things in kids versus.

01:08:45:14 - 01:08:48:04
Robert
Is that mean that you could be a schematic as a result?

01:08:49:01 - 01:09:03:23
Dr. Jokerst (Radiologist)
It could be typically. But you know, ischemic heart disease in children is is pretty rare. And, you know, there are a few things that cause it, but it's it's not heart ischemia. It's body ischemia, basically, like you know, your child is blue fingers.

01:09:03:23 - 01:09:05:05
Reggie
Blue lips. Yeah.

01:09:05:07 - 01:09:30:07
Dr. Marcotte(Cardiologist)
So congenital heart defects occur in about 1% of individual and complex defect like those that cause cyanosis is about a 10th of that. So in so let's say 1%, it's point 1%. It's very rare point 1%. So 99.9% of those born do not have this these complex cyanotic defects.

01:09:30:12 - 01:09:37:04
Dr. Jokerst (Radiologist)
And they used to be a death sentence really, you know, as recent as what, the forties or fifties. When did they start.

01:09:37:07 - 01:09:37:15
Dr. Marcotte(Cardiologist)
I mean.

01:09:37:22 - 01:09:47:07
Dr. Jokerst (Radiologist)
Surgery. Yeah. I mean there's there are things now like in it's a kind of M.E. that somebody can fix through your femoral vein. Yeah, like 15 minutes now.

01:09:47:07 - 01:09:48:21
Reggie
Outpatient procedure, right.

01:09:48:22 - 01:09:52:10
Dr. Jokerst (Radiologist)
And whereas, you know, in the thirties, it was a death sentence.

01:09:52:15 - 01:09:57:08
Robert
So is there any pharmaceutical thing that you could do to kind of help Janet regenerate that tissue?

01:09:57:19 - 01:10:19:01
Dr. Marcotte(Cardiologist)
We don't have that yet. But once you have pulmonary hypertension and unfortunately, if you if your defect was not corrected and you have pulmonary hypertension, then it's no longer time to correct it. You have to treat with medications and there are some medications that can be given to people with pulmonary hypertension to reduce the the the vascular impedance.

01:10:19:02 - 01:10:28:12
Dr. Marcotte(Cardiologist)
Yes. And stress and those individuals sometimes can can go on to have heart lung transplant. Sometimes they have pulmonary hypertension and and a sick heart.

01:10:28:14 - 01:10:31:17
Dr. Jokerst (Radiologist)
Sounds like you're talking about stem cell therapy, though.

01:10:32:06 - 01:10:34:11
Robert
Well, that's what I kind of what I was thinking. You know.

01:10:34:21 - 01:10:36:12
Reggie
It's on the horizon. And I think.

01:10:36:12 - 01:10:40:02
Dr. Marcotte(Cardiologist)
There is research ongoing that we can decide on treatments. Yeah.

01:10:40:02 - 01:10:41:06
Robert
Yeah.

01:10:41:06 - 01:10:52:17
Dr. Marcotte(Cardiologist)
Where you could regrow like a septum or hair or or. Yeah, that is probably research that is ongoing right now. I don't think it's ready clinical primetime yet, but I.

01:10:52:17 - 01:10:58:09
Reggie
Think maybe ten years. It's hard to say, right? It's had just so many hurdles.

01:10:58:09 - 01:11:12:15
Robert
But it seems like it's going that direction. I mean, they're using stem cells to regenerate like lab rooms and stuff like that within joint spaces. And yeah, you're avoiding surgeries that way, but you're mouses. I mean, and if you could avoid a heart surgery, right?

01:11:12:15 - 01:11:14:08
Reggie
Oh, my gosh. Or a transplant.

01:11:14:14 - 01:11:29:18
Dr. Jokerst (Radiologist)
Yeah, it depends on what where you need to be. You know, the great thing about stem cells is you put them next to stem cells and they turn into those science and the stem cells where they need to go. And keeping them there is.

01:11:30:07 - 01:11:31:09
Reggie
Which so.

01:11:31:12 - 01:11:31:19
Robert
Yeah.

01:11:32:02 - 01:11:37:14
Dr. Jokerst (Radiologist)
So you can imagine in the heart. Oh yeah, it's moving and beating. Insulin was gradual as well.

01:11:37:14 - 01:11:37:20
Dr. Marcotte(Cardiologist)
Are we.

01:11:37:20 - 01:11:40:08
Dr. Jokerst (Radiologist)
Going to make these these cells that don't yet know they're supposed.

01:11:40:08 - 01:11:41:06
Reggie
To? Not it is.

01:11:41:12 - 01:11:50:05
Robert
So I've never given this any thought. But in my mind, I think if you grafted it right and you created that link between and so you gave that and.

01:11:50:05 - 01:11:52:09
Dr. Jokerst (Radiologist)
You think if you take a chunk of stem cells.

01:11:52:15 - 01:11:53:07
Reggie
And put it.

01:11:53:14 - 01:11:55:01
Robert
We're probably making myself like an idiot.

01:11:55:02 - 01:11:56:18
Dr. Marcotte(Cardiologist)
But the thing is, how do you get.

01:11:56:18 - 01:11:58:02
Dr. Jokerst (Radiologist)
Them there without doing surgery?

01:11:58:02 - 01:11:59:05
Reggie
Oh, for sure.

01:11:59:08 - 01:12:07:16
Robert
And Like you said earlier, it's a lot less invasive now. You're going through your femoral artery just down in your groin. So it's not like it's, you know, their crack in your chest anymore.

01:12:07:19 - 01:12:15:23
Dr. Jokerst (Radiologist)
But they I mean, they're doing experiments in pigs and rabbits and all that kind of stuff. They had a crack in their chest and bright patches when fuzed with stem cells. You know, I didn't.

01:12:15:23 - 01:12:39:08
Robert
Want to since we are just talking about hearts and you mentioned pigs at our facility soon we're told that we're going to be doing some research on cardiac scanning for pigs and stuff like that. And I'm curious about you two, your impression of, the similarities between the two anatomies, because I tell you, you know, when I was in X-ray school, I was given, you know, the assignment of a class presentation or whatever it is that you wanted.

01:12:39:10 - 01:12:57:12
Robert
I chose to do hearts and I brought in some pig hearts as like a visual aid. And I, I brought up an example of how I think, you know again, I'm an idiot. But probably back in the seventies or so there was an experiment where they actually did a transplant, was successful for, I think about 12 minutes or so.

01:12:57:20 - 01:12:59:09
Reggie
Oh, like a heart into a human.

01:12:59:11 - 01:13:01:00
Robert
Transplanting heart into a human.

01:13:01:10 - 01:13:01:22
Reggie
Really.

01:13:02:00 - 01:13:09:03
Dr. Jokerst (Radiologist)
I was actually involved with a research project and my last place where we actually scored on squirrels, they were pigs.

01:13:10:00 - 01:13:10:09
Robert
But then.

01:13:11:04 - 01:13:23:10
Dr. Jokerst (Radiologist)
We would take a patch with stem cells on it and basically they would give the pig an idea and fart and then put the patch on top of the and it and see if the stem cells would like regrow myocardium.

01:13:23:16 - 01:13:24:12
Robert
Sort of thing concept.

01:13:24:12 - 01:13:54:12
Dr. Jokerst (Radiologist)
Then yeah, the same kind of concept. But when it comes to imaging pig anatomy versus human anatomy, I'll tell you the first thing I noticed pigs are buff compared to humans and like they, their musculature is way more to the point where you would artifacts dielectric effect from all the water of the muscle cells so right you know it's you don't really appreciate how weak humans are right yeah even weightlifters, you know, you got nothing on, right?

01:13:54:16 - 01:13:57:07
Reggie
So it's like imaging the rock every time it was directly.

01:13:57:15 - 01:13:59:13
Dr. Jokerst (Radiologist)
You mounted pigs and that's.

01:13:59:13 - 01:13:59:22
Reggie
Funny.

01:14:00:02 - 01:14:08:21
Dr. Marcotte(Cardiologist)
So it's a it's a good model to compare it to the human in terms of the way the heart is made. I mean, if you compare it to other animals, there's been attempts that other.

01:14:09:10 - 01:14:11:15
Robert
Animals use valves, right?

01:14:11:15 - 01:14:12:02
Reggie
I mean.

01:14:12:02 - 01:14:54:15
Dr. Marcotte(Cardiologist)
Dogs, for one, have I mean, they're they're cute and they're amazing. We like them like dogs or something. But one of the advantages that dogs have over humans is a much richer amount of collateral flow, whereas pigs does not have that. The pig's actually a very, very delicate heart. I mean, I remember imaging doing CMR in in a pig model for infarction and a stress model and these whenever you, you, you occlude an artery, a pig, they they they arrest they they're really because they have a very poor collateral flow sort of like humans and worse even so they were they're very, very, you know, they're very, very delicate.

01:14:54:15 - 01:15:03:18
Dr. Marcotte(Cardiologist)
And you have to be really careful if you do experiments on pigs, rats or mice. Well, the thing is that they're smaller and the heartbeats are like, well.

01:15:04:13 - 01:15:04:20
Reggie
Yeah.

01:15:05:03 - 01:15:24:19
Dr. Marcotte(Cardiologist)
They're a rat is maybe, you know, 200 to 300 a minute mouse. 4 to 6 beats per minute. So it's like it's just like. So it defies the capability. Yes, you can you can do high field imaging at 70 and a little more. And, you know, you can do that. But I mean, it's it's just it's just a different ballgame there.

01:15:24:20 - 01:15:25:06
Reggie
Right.

01:15:25:14 - 01:15:27:22
Dr. Marcotte(Cardiologist)
So in terms of so that's why I mean, it's.

01:15:28:07 - 01:15:29:06
Reggie
It's it's close.

01:15:29:06 - 01:15:34:09
Robert
And again, I found it interesting. I went to a food city in Boston pig hearts and brought it into the class.

01:15:34:09 - 01:15:36:02
Reggie
You could do by Taggart's out there like the.

01:15:36:02 - 01:15:37:00
Robert
Food city you can't.

01:15:37:09 - 01:15:37:19
Reggie
The way.

01:15:37:20 - 01:15:43:09
Dr. Marcotte(Cardiologist)
Also humans are made if you look at our shape we're sort of we're sort of I guess horizontally.

01:15:43:09 - 01:15:43:19
Dr. Jokerst (Radiologist)
Deep.

01:15:44:06 - 01:15:44:15
Reggie
There are.

01:15:44:15 - 01:16:05:21
Dr. Marcotte(Cardiologist)
Around so when you do imaging I've done a fair amount of ultrasound imaging on rats and on mice and it's the the the windows are not the same the for chamber view that we can easily get in humans because the heart sort of splayed right it's much more difficult to get in a rat or in a mouse even if you have the proper probes.

01:16:06:02 - 01:16:33:14
Dr. Marcotte(Cardiologist)
And then so so things are a lot more cylindrical in rats, mice and pigs compared to humans, which are we're flatter. Our thorax are flatter. I mean, if you're a big smoker, you can get bare chested after many years of smoking. But we're typically fairly flat right at our heart. This so we're we're we're I guess easier to image in terms of ultrasound than I guess MRI doesn't care because it's it's cool I'm.

01:16:33:14 - 01:16:41:20
Robert
Curious because you mentioned the word chronic smokers were just long term smokers. But what about people with alcohol, this arm or something like that? Does that affect any heart disease?

01:16:41:20 - 01:17:20:23
Dr. Marcotte(Cardiologist)
Yes, it can. Actually, alcohol is a is a bit of a depressor of cardiac function. So if you drink if you drink a lot, you can sometimes develop what's called a cardiomyopathy where your heart muscle is weakened by the alcohol. The other thing is that this depressant effect sometimes can cause stuttering in the electrical activity. So typically if you go for a party out on on on Saturday that we see, we often see as cardiologists on Saturday morning and the emergency rate of 30 year old comes in with what we call atrial fibrillation because of the effect of alcohol.

01:17:20:23 - 01:17:26:03
Dr. Marcotte(Cardiologist)
So you got to be really careful. Some people are very sensitive. It is probably genetically determined.

01:17:26:03 - 01:17:26:13
Reggie
Your.

01:17:26:18 - 01:17:38:18
Dr. Marcotte(Cardiologist)
Your genetic propensity to arrhythmia and your genetic ability to metabolize alcohol. And and and it's sometimes the byproducts that that can that can also play a role so.

01:17:39:04 - 01:17:40:21
Dr. Jokerst (Radiologist)
Don't drink yourself into an arrhythmia.

01:17:42:04 - 01:17:42:07
Robert
Or.

01:17:43:17 - 01:17:45:11
Dr. Marcotte(Cardiologist)
Slightly for the liver. It's it's hard.

01:17:45:23 - 01:17:46:09
Reggie
Right?

01:17:46:09 - 01:17:55:01
Robert
I'm happy. I feel like we've covered a lot today. I appreciate you guys being here. I am curious, though, is there anything that you feel like maybe you would like to touch up on before we close out the episode?

01:17:56:14 - 01:17:57:02
Dr. Jokerst (Radiologist)
Go ahead.

01:17:58:00 - 01:18:02:15
Reggie
We are excited about that's coming. I mean, I've been in stem cell and I was out for a little bit before.

01:18:02:15 - 01:18:30:23
Dr. Jokerst (Radiologist)
So I think I think it's a good for flow definitely is going to change the way we do cardiac MRI. You know we had had a little experience with a strain imaging that said segmental strain you know that that's another thing I think that's an up and coming. But I think in general what we're going to see is we're going to it's that it's computers basically that are changing and Moore's Law and I right.

01:18:30:23 - 01:18:51:11
Dr. Jokerst (Radiologist)
That is really, you know, one of the things that people are always talking about and things like, you know, venues like this is artificial intelligence and machine learning and that is already starting to change as some of the things we do. Right. But, you know, you're going to see MRI, I think, continue to get safer, to get faster, to get better.

01:18:51:11 - 01:19:14:20
Dr. Jokerst (Radiologist)
The types of pulse sequences we can do are going to get better. And then the other thing that you're going to see that people don't really think about is the post-processing, right? I mean, that's going on in the background. But, you know, fourth low case and complex congenital heart disease. Right. You know, it might even with the best software available now, you know, I might take two to process it, whereas, you know, in the future, who knows, I might be.

01:19:14:21 - 01:19:17:02
Reggie
Automatic and it's done right when you send it over there.

01:19:17:02 - 01:19:35:22
Dr. Jokerst (Radiologist)
And we're going to take time because a cardiac is hard enough. Yeah. That subset of cardiac congenital heart disease. So, you know, we have some algorithms now that are pretty good at like automatically segmenting the left ventricle but feed them, you know, ADT, DTJ Plus all with a systemic, you know, ventricles their morphologic right ventricle.

01:19:36:04 - 01:19:38:17
Reggie
It just it is confusing and it's.

01:19:39:02 - 01:20:04:19
Dr. Marcotte(Cardiologist)
A word for the technologists. I mean, as we, you know, we've talked about in this in this segment, that it is a complex area MRI. Right. We do have credentialing for physicians, you know, level one, level two, level three. And I think, you know, if realistically, if you are a technologist and you want to get into cardiac MRI, it takes it takes practice.

01:20:05:05 - 01:20:05:12
Dr. Marcotte(Cardiologist)
And you.

01:20:05:12 - 01:20:06:22
Reggie
Get to watch this podcast, by the way, not.

01:20:07:04 - 01:20:07:09
Dr. Jokerst (Radiologist)
His.

01:20:07:09 - 01:20:32:19
Dr. Marcotte(Cardiologist)
Wheelhouse, but also you need to read up on the anatomy. Right? Understand the physiology, basic stuff. Right. We know for us as physicians to achieve a certain level, we need, you know, you know, like a level one is five is 50 cases, a level 250 cases and a level three, 300 cases in training. So I'm just saying that you have to be patient, right?

01:20:33:00 - 01:20:56:01
Dr. Marcotte(Cardiologist)
You have to you have to read and you have to have a good amount of support team around you. Sure. And it will not happen overnight. You need you need to do cases and it takes time because these these require even even if the vendors are offering great tools to help you with the planning, there's always stuff that that happens, you know.

01:20:56:06 - 01:21:07:06
Dr. Marcotte(Cardiologist)
And so I think it's it's it's probably one of the most difficult areas of of MRI. Yeah. And I think that yeah, I think we need more people.

01:21:07:06 - 01:21:11:20
Robert
To feel like I can relate to what you're talking about because I'm just a new cardiac scanner myself, level.

01:21:11:20 - 01:21:12:02
Reggie
One.

01:21:12:19 - 01:21:13:14
Robert
As our you want to call it.

01:21:14:05 - 01:21:14:09
Reggie
Like.

01:21:14:14 - 01:21:24:11
Robert
I feel like I'm a three, but I haven't done 300 cases yet, but probably then about a 50 maybe. But you're right, there's a lot of.

01:21:25:14 - 01:21:27:03
Reggie
Records different, right out.

01:21:27:07 - 01:21:39:16
Robert
Of different factors you're taking. And when you first come in and it's a lot of unknowns. So the anatomy itself is kind of new to you. You get kind of a foundation of cross-sectional anatomy, but usually heart anatomy is it usually, you know.

01:21:39:16 - 01:21:53:05
Dr. Jokerst (Radiologist)
It's it's different from person to person. It has its own its own anatomical planes. You know, I guess MSC is kind of analogous, but with MSC, yeah, there's only so much a joint can be like the, you know the joint.

01:21:53:05 - 01:21:53:12
Reggie
Yeah.

01:21:53:14 - 01:22:09:17
Dr. Jokerst (Radiologist)
You know you still have like your three planes. It's just relative to the joint. But with cardiac, you know, you've got your like horizontal axis, vertical long axis, three chamber LV at contract, right ventricular outflow tract perpendicular you I mean, it's, you know, it's it's just takes time.

01:22:10:06 - 01:22:16:20
Robert
And he mentioned a good support group behind you and if you can if you lucky enough to have a Dr. Marcotte that you work with.

01:22:16:20 - 01:22:18:16
Reggie
And Dr. Joe Griffin questions.

01:22:18:16 - 01:22:22:15
Robert
Often you always happy to answer them. And I find that a lot of you guys are happy to answer them.

01:22:23:00 - 01:22:23:20
Reggie
Yeah, we're going.

01:22:23:23 - 01:22:24:10
Dr. Jokerst (Radiologist)
To address.

01:22:24:10 - 01:22:30:11
Robert
As well. I mean, that's why we're not every doctors approachable, but obviously these two are. Yeah, no, thank.

01:22:30:11 - 01:22:33:00
Reggie
You. So we're letting you guys borrow them through this podcast.

01:22:33:05 - 01:22:42:19
Dr. Marcotte(Cardiologist)
Know one tool that I found really useful from from certainly from the cardiology standpoint they're the European Society of Cardiology has a a nice app.

01:22:43:02 - 01:22:43:12
Reggie
Oh yeah.

01:22:43:12 - 01:22:44:21
Dr. Marcotte(Cardiologist)
It's called CFR Guide.

01:22:45:12 - 01:22:46:14
Reggie
Maybe you could pull that up.

01:22:47:02 - 01:23:11:00
Dr. Marcotte(Cardiologist)
Very well made it that you can download and basically it offers you a lot of information on the the organization of a of an exam the scan planes some of the indications. Right. And it provides very nice video content and examples of some of the sequences used. So if you're interested in that, I would definitely check it out.

01:23:11:03 - 01:23:20:12
Dr. Marcotte(Cardiologist)
There is they also have a calculator that that that comes with it that can help you quantify how ventricular mass.

01:23:20:12 - 01:23:21:15
Reggie
Is this a free resource?

01:23:21:21 - 01:23:33:18
Dr. Marcotte(Cardiologist)
I think it is, yes. Wow. They have resources, congenital heart disease. They have a physics handbook. So it really explains things really quite clearly. So the Europeans have been I've been.

01:23:34:03 - 01:23:34:14
Reggie
On top.

01:23:34:14 - 01:23:51:17
Dr. Marcotte(Cardiologist)
Of pioneers in cardiac MRI. Physicians in the UK and Germany in particular have played major roles in the advancement of CMR. Right. I Want to tip my hat to their hard work?

01:23:51:17 - 01:23:52:08
Reggie
Yeah, for sure.

01:23:52:09 - 01:24:15:05
Robert
Shout it out for sure. Awesome. So you mentioned earlier that you see safety being something that is more to more a focus in the in the future. But you also mentioned earlier in the podcast you see like Tesla strengths becoming reduced, but you know, the magnet. So that's.

01:24:15:05 - 01:24:15:16
Reggie
Technology.

01:24:15:17 - 01:24:17:17
Robert
And that's kind of related to like safety. Yeah.

01:24:17:17 - 01:24:38:11
Dr. Jokerst (Radiologist)
So You know, as as magnetic field strength increases, of course, you know, the danger increases. Yeah. And one of the other things, too, that a lot of people don't think about is, you when you have a magnetic field, you know, we've got this magnetic field inside the border that's through Tesla, right? There's a magnetic field outside the bar that's got to be, you know, balance that out.

01:24:38:11 - 01:24:38:20
Dr. Jokerst (Radiologist)
Right.

01:24:39:02 - 01:24:39:14
Reggie
Exactly.

01:24:39:14 - 01:25:09:11
Dr. Jokerst (Radiologist)
And so one of the things that that engineers have been doing and doing well is they've they call that a French field. They're getting better at shaping that and getting that smaller. But there's a downside to that because as you approach a three Tesla magnet with something ferromagnetic in the olden times you would feel a tug and maybe the tug would get stronger within a fall right now with those really tight French fields because they're trying to, you know, get it all in the out of, you know, zone three as much as possible.

01:25:09:12 - 01:25:09:20
Reggie
Right.

01:25:11:03 - 01:25:35:08
Dr. Jokerst (Radiologist)
You might go from a tug to getting ripped out of your hands on that flight. Yeah. Now and in the future it's not inconceivable as we move towards weaker and lower field strength and used, you know, computers and technology to kind of compensate for that. I we one of the big thrusts in my is getting away from using hundreds and hundreds of liters of liquid helium.

01:25:35:08 - 01:25:49:22
Dr. Jokerst (Radiologist)
So I know there are a few scanners, at least one scanner coming out of the market. Yeah, I think just six liters. I'm pretty impressed such that, you know, one of the things is when you put an MRI scanner somewhere, it weighs a lot. It's one thing. But the other thing is if you ever have to quench it.

01:25:50:11 - 01:26:09:11
Dr. Jokerst (Radiologist)
So I don't want to get into, like, superconductors and how cool they are. It's like the bottom line is, if you want to turn an MRI magnet off, that's a good point. Here is it's always on the MRI, as always. Always the magnetic field is always on. The only way to turn off quickly is to heated. The only way to heat it up is to evaporate out all the healing.

01:26:10:08 - 01:26:29:07
Dr. Jokerst (Radiologist)
And so you need a VAT capable of taking 2700 liters of liquid helium, which is about to turn into tens upwards of liters of gas. It's it limits where you can put an IMR. Now, if you only have six liters that becomes, you know, how many hundreds of liters of gas you can actually quench the magnet inside. You can have like a chamber.

01:26:29:14 - 01:26:32:06
Dr. Jokerst (Radiologist)
Yeah, I might just divert the gas somewhere and.

01:26:32:06 - 01:26:32:16
Reggie
Manage to.

01:26:32:16 - 01:26:49:00
Dr. Jokerst (Radiologist)
Turn the magnet on. And so it saves helium two and then you can bring it back and aim at the magnet wherever you are, not to worry about the VAT. So that's a big deal I could foresee. Now this this is just me, right? But in the far distant future, you could potentially turn a magnet on and off that way, right?

01:26:49:01 - 01:27:02:16
Dr. Jokerst (Radiologist)
Oh, the problem is you have to sham, you know, and every time you quench it, it kind of it's hard on the gradients. But, you know, the engineers have dealt with much more difficult problems in the past. We can detect gravitational waves, you know, we should be.

01:27:02:16 - 01:27:04:06
Reggie
Able to do.

01:27:04:06 - 01:27:23:16
Dr. Jokerst (Radiologist)
That. But yeah, future could foresee one of the one of the big things from our my safety would be, you know, basically being able to turn the magnetic field off and on. And maybe if you can turn it on, you could turn it on slowly. And then a patient can be like, Ah, I forgot, I have, you know, an eyelash curler in my pocket.

01:27:23:22 - 01:27:51:15
Dr. Jokerst (Radiologist)
Yeah, I feel it today. So I think that there's, there are a lot of exciting things on the horizon. And, you know, I don't want to get into my philosophy on life, but, you know, if you look back at kind of what things have developed and wiped out in him the course of history and kind of where we go, it's really capricious and a lot of it is based off of, yeah, just like random chance or luck.

01:27:51:20 - 01:27:56:11
Dr. Jokerst (Radiologist)
And so honestly, I have no idea what's going to stay where it's going to. You know.

01:27:57:00 - 01:27:59:21
Robert
I think you're on to something for sure. Yeah, that's Marco.

01:28:00:02 - 01:28:31:11
Dr. Marcotte(Cardiologist)
I just had another comment in terms of educational materials. The the Society for Cardiovascular Magnetic Resonance as the EMR is also very important cycle based here in the U.S. but for cardiologists, radiologists, technologists, world wide as Seema and I think that's a really great website, lot of educational material also produces the Journal of Cardiac MRI.

01:28:31:19 - 01:28:32:13
Robert
They have a forum.

01:28:32:14 - 01:28:35:04
Dr. Marcotte(Cardiologist)
Jcmr and you.

01:28:35:11 - 01:28:36:00
Reggie
Know, so.

01:28:36:00 - 01:28:50:12
Dr. Marcotte(Cardiologist)
That's that's a great they've got great modules, teaching modules for cases and it's a great forum for technologists. It's, it's non it's only people who are interested in MRI. Well.

01:28:51:04 - 01:28:52:06
Reggie
All right. So we like the.

01:28:52:07 - 01:29:10:13
Dr. Marcotte(Cardiologist)
So it it it highlights the importance of collaboration between radiology and cardiology and the the very special and important place of technologists right within within the field of cardiac MRI. So that's another great tool. And I wanted to make sure I.

01:29:11:06 - 01:29:12:19
Reggie
Yeah, I think you made a.

01:29:12:20 - 01:29:15:16
Dr. Marcotte(Cardiologist)
Plan for them. I think they're doing great work and I think it's.

01:29:16:05 - 01:29:16:19
Reggie
And it's a great.

01:29:16:19 - 01:29:17:14
Dr. Marcotte(Cardiologist)
Organization.

01:29:17:20 - 01:29:23:18
Reggie
So I'll definitely be in the show notes below. So don't try to have to write everything down. Would definitely a link for you at the bottom.

01:29:23:18 - 01:29:39:16
Robert
So it's a Dr. Joker's Dr. Marko said as far as techs out there, we really like for you to kind of focus your attention on learning the cross section, anatomy, learning, the physiology of the heart itself. What would your message be to those? And our techs are just learning how to scan a cardiac.

01:29:39:17 - 01:29:56:23
Dr. Jokerst (Radiologist)
Well, I of course, that's the most important is being able to appreciate the anatomy because you need to be able to do that to even get started in the physiology and kind of the next level is going to be understanding the physics to some extent.

01:29:57:02 - 01:29:57:09
Reggie
Right.

01:29:57:20 - 01:30:11:10
Dr. Jokerst (Radiologist)
And, you know, physics is a, you know a wormhole or rabbit hole that will go. There's no limit to how deep it goes. Right. We really don't under I mean, what is time, what is space? What makes it that bang.

01:30:11:11 - 01:30:15:04
Reggie
Right mean but not to the same like the average like. Right.

01:30:15:05 - 01:30:16:12
Dr. Jokerst (Radiologist)
We don't know the answer to that.

01:30:16:13 - 01:30:18:19
Reggie
You I guess the physics.

01:30:18:19 - 01:30:39:07
Dr. Jokerst (Radiologist)
Is that's why I like about physics. It's it's very you know, we we fall into this trap of thinking that why this is why things are two reasons why they're t one. Well, we have an explanation that fits why things are the way they are. But, you know, Newton had a great explanation of gravity and it sent a man to the moon.

01:30:39:08 - 01:31:14:06
Dr. Jokerst (Radiologist)
Right. But it couldn't explain a small variation in the orbit of Mercury. And so now we have general relativity and George is great. But there, you know, we are creating theories and models that explain things and predict things. But that doesn't mean that that is why things are what they are. And so getting back to the physics, being able to understand basic artifacts and how to troubleshoot them, I think is very critical with m r because there are some that I, you know, I've seen it before their text and I say, hey, we can't do this right?

01:31:14:06 - 01:31:44:10
Dr. Jokerst (Radiologist)
This isn't going to be great, you know, but then you change around a little bit and you know, it's okay, we can get by, you know, by knowing when to use pulse skating versus, you know, if EKG gating isn't working. Yeah, I know. And, you know, when to try to revert back to spoiled gradient echo instead of steady state repossession knowing you know why Spin Echo has less artifact in which sequences are spin echo versus you know, gradient recall that go searcher.

01:31:44:23 - 01:32:06:14
Dr. Jokerst (Radiologist)
I would I would yeah. I'm always talking about the physics side of things and I would say it's, you know, you don't have to be a physicist, but it's important to know the common artifacts and how to troubleshoot them for sure. That would be my plan. Yeah. And if you really want to get into the why of M.R physics, there's a website called The Way to My Questions Scholar.

01:32:06:17 - 01:32:07:17
Reggie
And my question.

01:32:07:18 - 01:32:12:04
Dr. Jokerst (Radiologist)
That you can really get into the weeds on that website but like you know that.

01:32:12:04 - 01:32:15:20
Robert
We represent website before, it's visited before for sure. And I'll.

01:32:15:20 - 01:32:16:19
Reggie
Put that at the bottom of show.

01:32:16:19 - 01:32:28:00
Robert
Notes. So that's the message that you would say from our that are learning how to scan. What would you say, a cardiac site? What would you what would your message be for your peers? Those those rays are looking to be cardiothoracic grads.

01:32:28:01 - 01:32:29:23
Dr. Jokerst (Radiologist)
I mean, the same thing. You know.

01:32:30:00 - 01:32:30:13
Reggie
Understand.

01:32:30:21 - 01:33:00:19
Dr. Jokerst (Radiologist)
You got to know the physics. It's you know, we we have a luxury where we are to have Francois and yeah, you know, people I mean, they can get on the you know, you can tell me on the phone what's going on and we can troubleshoot troubleshoot in a in person. But lots of places may or may not have that kind of ability and being able to kind of troubleshoot that, you know, I would say for for cardiologists and radiologists out there, you know, we're interested in cardiac imaging.

01:33:01:12 - 01:33:25:07
Dr. Jokerst (Radiologist)
Again, just just having a good understanding of the basic physics, because by understanding the physics, you can predict what's going to make things better, what's going to make things worse. See, somebody can't hold their breath. You're not going to run any segmented sequences, right? They're just they're going to be garbage. It's automatically, you know, are and I'm pretty brave and cut that cut that cut that you know.

01:33:25:22 - 01:33:33:00
Reggie
So well, you know, as a backup, what we'll do is we'll just put these guys phone numbers in the show notes as well. Yeah, yeah. Okay.

01:33:33:01 - 01:33:36:02
Dr. Jokerst (Radiologist)
Just paged me any time you guys are. Yeah, it's two in the morning.

01:33:36:07 - 01:33:48:10
Robert
Can anybody have serious answer for your for your peers out there? What advice would you give as far as IMR specific advice would you give to those other cardiologists?

01:33:48:10 - 01:34:21:07
Dr. Marcotte(Cardiologist)
I think it's a great field to to to work in. I think we're now more and more focusing on what we call multimode imaging. So that's in cardiology. Certainly we have three big tracks for make tracks. Let's say we have those of us who like to want to do angiograms. Cath Angioplasties, interventional. We have electrophysiology which takes care of which is also an invasive strategy that deals with the arrhythmias but procedures, pacemakers, that type of thing.

01:34:21:19 - 01:34:55:06
Dr. Marcotte(Cardiologist)
We have heart failure transplant. These are specialists for that for that population's growing population. And then finally, what I do, noninvasive imaging and more and more we are we are advising our trainees to be good in more than one modality simply to increase your your. I think for me personally, I think MRIs helped me become a better Echocardiography, and I think Echo helped me understand M.R better, although the physics has no.

01:34:56:08 - 01:34:56:16
Reggie
Kind of.

01:34:56:17 - 01:35:15:20
Dr. Marcotte(Cardiologist)
Correlation to it. You have to start right from from scratch. I think that the heart is the heart. So if you look at it with ultrasound or with MRI and in the case of Clint, while you look at it with CT MRI, so we come from different angles towards the MRI. And I think that's the that's what makes the strength of our team.

01:35:15:20 - 01:35:50:21
Dr. Marcotte(Cardiologist)
I think you need to you need to find it. You need to work and collaborate. And I think you need to to build bridges with with other professionals. Yeah. And not to be collegiate about it. And I think it's the way you it's the way the, the world should watch. Right. That would be my take that I think we need more collaboration and and I think cardiologists when the when they order because often they're the ones with the patients but there are other professionals that will order tests, internists and family practitioners that also may want to.

01:35:51:07 - 01:36:25:21
Dr. Marcotte(Cardiologist)
But MRI is kind of a very specialized tool, not a first line tool. I think it's it's it can help answer some questions about characterization, infarct, scar flow, very flexible. It adds it's got great added value, but it has a few Achilles heel in particular metal implants, a bit more of a problem than with CT. Understanding that understanding that patients with irregular heartbeats, older individuals who don't have the endurance to do breath holds may have a may have a hard time with these.

01:36:26:11 - 01:36:46:14
Dr. Marcotte(Cardiologist)
It's a test that takes a little bit of time. So when you prescribe an MRI, you have to be you have to tell the patient, this is a longer test. This is this is physically more demanding. Right. And even though we're we're we're we're doing our best to do it as quickly as we can. And you both know, when you do it, you're you want to get this done efficiently by clock.

01:36:46:18 - 01:37:05:18
Dr. Marcotte(Cardiologist)
It's a test. It takes time. Basically. It's but you get you get a lot of information out of it. And I think that that would be so that would be my message for the trainee and then for the practitioner to understand what that what it does, understanding the strengths and weaknesses of CT, EMR, ultrasound and nuclear.

01:37:05:18 - 01:37:17:12
Dr. Jokerst (Radiologist)
And I think these are you bring up an excellent point to the heart as the heart and you know it's amazing how many radiologists won't actually look at an echo. You know, it's an ultrasound of the heart. Right.

01:37:17:14 - 01:37:19:01
Reggie
There's no scary, though, right.

01:37:19:05 - 01:37:45:18
Dr. Jokerst (Radiologist)
I they made sure they threw all these numbers on there, you know. Right. Half of them never looked. SAPIEN Yeah. Amara's headed that way too, right? That's true. But yeah, I mean, the heart is the heart. And, you know, I think you should be able to recognize pathology on all these different modalities. You know, it is a little bit tricky because the artifacts are different, you know, and they just have a different look and feel to them.

01:37:45:22 - 01:38:12:07
Dr. Jokerst (Radiologist)
But at the end of the day, it's still the heart said, don't be afraid to to look in a new match, you know, perfusion study or to look at an archeologist for radiologists out there because, you know, and obviously, you know, number one, collaborate, talk to cardiologists. You know, we are all allies in trying to take care of these patients and give them the knowing that they get the information that people need to take care of them.

01:38:12:07 - 01:38:21:23
Dr. Jokerst (Radiologist)
And so, you know, at the end of the day, you know, what we do is, is take care of people and try to take make people well or keep them well or yeah.

01:38:22:01 - 01:38:23:19
Reggie
So get the best outcomes, right? Yeah.

01:38:23:19 - 01:38:45:00
Dr. Jokerst (Radiologist)
You, we all need to work together. So that's, that's been what I think the biggest, you know, advancement medicine over the past couple of centuries has been olden times. You had the one doc that did everything right. Yeah. Now we have this sub specialized system now that, you know, they're, they're downsides because they're now there are all these cooks in the kitchen and the right hand might not know what the left hand is saying.

01:38:45:05 - 01:39:02:01
Dr. Jokerst (Radiologist)
Right. But, you know, if the left hand never asks the right hand, what it's doing, of course, is it's not going to know. Right. So we need to go. And technology, I think, is going to play a role in helping us kind of communicate more. But, you know, we're all part of the same team trying to do the same thing ultimately.

01:39:02:01 - 01:39:06:02
Reggie
So thank you, guys. Again, we do like.

01:39:06:02 - 01:39:19:12
Robert
To wrap up every show with a couple of questions. One, so basically, what is it we'll start left or right. So what has been the most satisfying or fulfilling experience you've had since starting your career and radiology?

01:39:20:09 - 01:39:21:09
Dr. Jokerst (Radiologist)
Oh, gosh.

01:39:21:17 - 01:39:21:21
Reggie
It's a.

01:39:21:21 - 01:39:23:07
Dr. Jokerst (Radiologist)
Loaded. Yeah, that's.

01:39:23:12 - 01:39:25:16
Robert
Way you and we did prepare him for this.

01:39:25:18 - 01:39:54:20
Dr. Jokerst (Radiologist)
Yeah I, I made the, the end of the day what we're doing and like I said, is we're taking care of people. Right? And radiologists work very much behind the scenes. It's a very rare to get any kind of feedback. Right. So on those rare cases where either a friend, clinician or an actual patient reaches out and says, hey, you know, this, you you figured something out that nobody else could figure out or, you know, something.

01:39:54:20 - 01:40:18:06
Dr. Jokerst (Radiologist)
A lot of times it's it adds in finding like, oh, you know, 16 year old girl with thyroid cancer, you know, it's a half you know, it's like, you know, a 34 year old with breast cancer that somebody picked up. Right now, it's just you're feeling like I really directly contributed because it sometimes it's a slog, you know, and you're looking through 100 ICU films, you know?

01:40:18:06 - 01:40:18:16
Dr. Jokerst (Radiologist)
Yeah.

01:40:18:17 - 01:40:19:19
Robert
You're desensitized.

01:40:20:11 - 01:40:42:06
Dr. Jokerst (Radiologist)
You know, and and yeah, but, you know, there's there's we we do all make a difference. And so I would I would say, you know, the few instances where I actually get feedback from patients or clinicians where they're grateful or thankful to me that that really brings them into focus. Right. Because I you know, I do work in a darkroom without windows.

01:40:43:21 - 01:40:44:07
Dr. Marcotte(Cardiologist)
Right.

01:40:45:04 - 01:40:46:17
Robert
For you. Dr. Mark II.

01:40:46:17 - 01:41:13:17
Dr. Marcotte(Cardiologist)
I think it's been having a cardiologist for 30 years and I've enjoyed every day. I mean, for me, I come in to work and and, you know, it's it's not a you know, obviously, you get a high when you diagnose something and you you make a difference in patient's life. You agonize when you've missed something and you haven't been able to deliver.

01:41:13:17 - 01:41:37:19
Dr. Marcotte(Cardiologist)
That happens. It happens more when you're young. It happens already at any time. So I try to stay humble. I when I when I, when I have a brief moment of victory, I, I it. But then you have to forget it and you have to get right back to work because the next case is around the corner. And if you're not sharp and you think you've got it all made and you think you're like, ooh la la, yeah.

01:41:38:03 - 01:42:03:23
Dr. Marcotte(Cardiologist)
Boy, medicine has a way of reminding you that you are human, fallible, and you can make mistakes. So. So for me, it's been it's been a great a great experience. I've worked in some great institutions. I've met some great people, patients, colleagues, nurses, technologists. And I guess for me, it's been it's been the team, it's been the adventure.

01:42:03:23 - 01:42:17:08
Dr. Marcotte(Cardiologist)
I think there's nothing that poisons a team more than people who don't work together. Yeah. And I think that the, the sad parts of my career would have been when, when I've, when I've had to work with individuals that, that didn't think of it as a team.

01:42:17:08 - 01:42:17:20
Reggie
That right.

01:42:18:10 - 01:42:37:05
Dr. Marcotte(Cardiologist)
And now, you know, we all have our, our good days and are bad days and we go through hardship. We go through we we each have our challenges. But I think it's trying to once you you enter the hospital, you have to say, I'm here to help. And right. And and that's it. But it's a bit of great.

01:42:38:05 - 01:42:46:03
Dr. Marcotte(Cardiologist)
I feel very fortunate due to to have chosen this line of work. I'm really happy with my choice and hopefully I can help people some more.

01:42:46:05 - 01:42:47:00
Reggie
That's very nice.

01:42:47:00 - 01:42:51:04
Robert
And I would say my experience just being around you guys, you guys seem super enthused about what you do.

01:42:51:04 - 01:42:52:20
Reggie
Yeah, it's. And it spreads like.

01:42:52:20 - 01:42:57:02
Dr. Jokerst (Radiologist)
Wildfire and to be able to do something that you actually like and want to do every day.

01:42:57:02 - 01:42:58:13
Robert
Is a minority for sure.

01:42:58:13 - 01:43:08:23
Dr. Jokerst (Radiologist)
Yeah, it's just so refreshing. You know, like I will say, lately I've been getting more and more kind of administrative duties and just, you know, that's how what I'm trying to do is.

01:43:09:15 - 01:43:12:05
Reggie
Follow you just kind of like I guess I.

01:43:12:05 - 01:43:18:08
Dr. Jokerst (Radiologist)
Would rather just sit in the reading room and and read cases all day. And I'd like to look at stuff.

01:43:18:18 - 01:43:19:00
Reggie
I don't.

01:43:19:01 - 01:43:26:00
Dr. Jokerst (Radiologist)
I don't want to be figuring that out. But, you know, you help however you can because at the end of the day, you know, that's important to you all. Taking care of.

01:43:26:00 - 01:43:26:23
Reggie
People. Yeah.

01:43:27:21 - 01:43:36:20
Dr. Jokerst (Radiologist)
You do what you can, but gosh, how lucky are we to be able to do it? You brought up a good point, too, with the humility it reminded me of. You know, you remember that movie Patton.

01:43:37:19 - 01:43:38:08
Reggie
Patton.

01:43:38:18 - 01:43:40:08
Dr. Jokerst (Radiologist)
About the General George Patton.

01:43:40:08 - 01:43:41:03
Reggie
Oh, yeah.

01:43:41:03 - 01:44:03:15
Dr. Jokerst (Radiologist)
At the he's walking out. He's here. His big deal is he thought he was a pioneer. Who knows, right. But he's a reincarnated Roman general and he was talking about how during the Roman tryouts, that the general would ride into Rome, you know, with all these captured people in front of him, and he'd be a slave holding the laurels over his head, but the slave would be whispering into his ear.

01:44:03:15 - 01:44:08:09
Dr. Jokerst (Radiologist)
All victory is fleeting. You know, I just I said that just reminded me.

01:44:08:21 - 01:44:09:07
Reggie
Yeah.

01:44:09:07 - 01:44:17:01
Dr. Jokerst (Radiologist)
You know, it's it's true. You know, life is, you know, there's ups and downs and you just you always have to bring your A-game and be ready to be humble.

01:44:17:09 - 01:44:21:01
Robert
So cool that we're surrounded by people bringing their A-game every day.

01:44:21:10 - 01:44:22:03
Reggie
So it makes us stronger.

01:44:22:04 - 01:44:30:05
Robert
To where we are and they work with us. So thank you again for coming today. Thanks for having me. So I guess that's it for today's topic today.

01:44:30:07 - 01:44:31:06
Reggie
I rise.

01:44:31:06 - 01:44:44:19
Robert
Thank you for watching. Thank you for subscribing. If you haven't subscribed, hit the subscribe button. Please leave comments. We read those comments. Give us show ideas, give us questions. We're happy to answer them. We would love to have these two back some time.

01:44:44:20 - 01:44:50:13
Reggie
Yeah. So as I said, yes, we'll do. Okay.

01:44:51:06 - 01:44:53:18
Dr. Jokerst (Radiologist)
So it's it's.

01:44:54:00 - 01:44:54:20
Reggie
Such a pleasure.

01:44:55:09 - 01:44:56:20
Dr. Jokerst (Radiologist)
To work with you. We're really.

01:44:57:08 - 01:44:57:15
Reggie
So.

01:44:58:09 - 01:44:58:20
Dr. Marcotte(Cardiologist)
Lucky.

01:44:58:21 - 01:45:02:14
Robert
Now already. Zone three Podcast. Thanks again for watching. We are out.

01:45:02:14 - 01:45:03:22
Reggie
Thank you, guys. Thanks, guys.