 Role of cardiac hemorrhage in dilated cardiomyopathy Myself, Dr. B. Spandana, co-authors are Dr. Manjuri M. Joshi and Dr. M. Kiran Kumar. Dilated cardiomyopathy is characterized by dilatation of cardiac chambers coupled with impaired contractility. Resulting in systolic dysfunction, left ventricle is always involved. Right ventricle may or may not be involved. DCM is the most common type of cardiomyopathy. Clinical manifestations are orthopnea, dyspnea, synchrocardiac arrhythmias which may result in sudden cardiac death. Classification of DCM, they are classified into primary DCM and secondary due to LV dysfunction. Primary DCM is due to primarily abnormality in the myocardium, strong genetic inheritance, autosomal dominant disorders, diagnosis of exclusion and idiopathic DCM. Secondary LV dilatation is characterized again by ischemic and non ischemic. Non ischemic is primarily due to infiltrative cardiomyopathies like amylidosis, sarcoidosis, post myocarditis, drug induced, peripartum and valvular heart diseases. Coming to the general morphological abnormalities, dilatation of left ventricle is seen with increased end systolic volume and end diastolic volume. Right ventricle may also be dilated in few cases. Atrial dilatation can also be seen secondary to valvular regurgitation. Left ventricle wall thinning is seen in ischemic dilated cardiomyopathy whereas wall thickness is maintained or mildly reduced in non ischemic DCM. Functional abnormalities there will be decreased left ventricle contractility which is nothing but called hypokinesia resulting in systolic dysfunction, decreased stroke volume will be present, ejection fraction and cardiac output. Thrombus formation may occur in left ventricle epics due to decreased contractility and stasis. Late gadolinium enhancement imaging, it distinguishes ischemic from non ischemic DCM. Ischemic DCM shows areas of subendocardial enhancement with varying degrees of transpirality corresponding to specific vascular territory whereas non ischemic DCM shows mild myocardial or epicardial or diffuse subendocardial enhancement not corresponding to any vascular territory as such. Late gadolinium enhancement patterns subepicardial or transmural if it involves then it is ischemic DCM whereas no enhancement or subtle or mild myocardial enhancement that can be due to drug induced peripartum alcoholic idiopathic mid myocardial or subepicardial myocarditis or sarcoidosis happens in this one whereas diffuse subendocardial lg pattern is seen in myloidosis. Now coming to the aims and objectives to analyze the demographic profile of dilated cardiomyopathy in a tertiary care center. Cardiac MRA findings in various ischemic and non ischemic dilated cardiomyopathies distinguishing ischemic from non ischemic DCM and differentiating various forms of NIDCM based on lg pattern. Risk stratification of sudden cardiac death based on late gadolinium enhancement and guiding the clinician in patient selection for ICD implantation. Now meticules and methods this is a prospective done study done on 1.5 tesla MRA in MNR medical college in hospital Sangareti over the span of last two years 28 cases of dilated cardiomyopathy were analyzed. Coming to the patient preparation detailed history is elicited from all the patients anthropometric measures measurements like height and weight are taken chest wall preparation is done by shaving of the hair and cleaning with spirit to reduce electrical impedance. MR compatible electrocardiographic leads are placed in the anterior chest wall before imaging and attached to the MR imaging unit for electrocardiographic gating. Respiratory gating device is also attached to monitor breath hole. MRI protocol the following sequences were acquired in evaluation of dilated cardiomyopathy GRE three-plane localizer frequency scout to detect optimal resonance frequency study state free precision cinematic two chamber four chamber short axis three chamber and left ventricle routal cracked images were taken T2 still short axis images to detect edema significantly and we went face contrast sequence to determine the flow quantification was taken post-contrast gedobinid diamiglumine 0.1 millimolch per kg pymol per second is given first pass perfusion imaging dynamic imaging immediately after contrast injection TI scout is taken to calculate the myocardial nulling time LG PSIR sequence is done eight minutes after contrast injection optional sequences like myocardial tagging grid sequence and high resolution PSIR is also been taken now coming to the six distribution eight are males whereas three are females in case of ischemic dilated cardiomyopathy whereas non-ischemic dilated cardiomyopathy 11 are males and six are females coming to the age distribution ischemic DCM out of 11 cases of ischemic DCM the median age is 58 idiopathic number of cases are six in the median age group of 40 years post myocarditis four cases in the age group of 39 alcoholic DCM two cases in the age group of 30 douche nees muscular dystrophy one case in the age group of 12 sarcoidosis two cases in the age group of 35 postpartum DCM one case in the age group of 25 and LVNC one case in the age group of 12 years now ischemic sapendocardial to transmural enhancement is seen in 11 cases idiopathic may there is no late gadolinium enhancement and that is six and alcoholic also there is one case with no LG and there is one case with patchy mild mid myocardial enhancement and in myocarditis there is subepicardial and mid myocardial involvement one case with subepicardial and one more case with mid myocardial sarcoidosis also like one case is with mid myocardial and one more case is with mid myocardial and transmural involvement is seen whereas in case of postpartum and postpartum and LVNC there is no late gadolinium enhancement in each of their cases and there is and there is also no late gadolinium enhancement in muscular dystrophy in one case now coming to our first case number one idiopathic dilated cardiomyopathy it was diagnosed in six cases it it was the most common type of non ischemic DCM encountered in our study this is a case of 65 year old female patient presented with shortness of breath and atrial fibrillation cardiac MRI showed dilated ventricular and atrial chambers with moderately depressed LV and RV systolic function no evidence of any late gadolinium enhancement is noted you can see the SSFP 2 channel view showing dilated left ventricle and left atrium whereas this is a cinematic four chambered view showing dilated both atria and ventricles and moderate global hypokinesia and you can see the short axis imaging showing similar findings now this is a case number two which is alcoholic DCM alcoholic DCM was diagnosed in two cases this is a case of 30 year old male chronic alcoholic presenting with grade 3 SOV cardiac MRI showed severe global hypokinesia dilated ventricular and atrial chambers with severely depressed left ventricular and right ventricular systolic dysfunction systolic function patchy mid myocardial late gadolinium enhancement of left ventricular scene left and right ventricular thrombi is noted you can see the thrombi over here now this is a study state free position two chain two channel view showing dilated left atrium and left ventricle hypo intense thrombus is seen in the left ventricular apex okay this is a SSFP four four chambered cinematic view showing severe global hypokinesia and these two images depict the PSIR late gadolinium enhancement imaging showing mid myocardial enhancement in septum and in the in the septum and in the lateral walls of mid and basal third of the left ventricle now this is a case number three which is a case of post myocarditis DCM it was diagnosed in four of our cases this is a case of our DCM in a patient with a history of viral myocarditis cardiac MRI showed global hypokinesia with moderate bioventricular dilatation and severely impaired left ventricular ejection traction which is about 24 percent epi intramiocardial pattern of late gadolinium enhancement along the lateral wall in mid basal and epica third segments SSFP image short axis are showing dilatation of the left ventricle and this is SSFP four chambered view showing bioventricular dilatation with global hypokinesia whereas these two sequences demonstrate sub epicardial and mid myocardial enhancement along the lateral wall in mid and basal third segments this is a case of sarcoidosis diagnosed in a 35 year old male patient presenting with complete heart block moderately dilated left ventricle with no evidence of any regional wall motion abnormality and with preserved systolic function with ejection traction about 60 percent moderately dilated right ventricle with mildly depressed right ventricle systolic function by atrial dilatation noted linear mid myocardial late gadolinium enhancement is seen in the inferior wall in mid third of left ventricle now this is a SSFP two channel two chambered view showing moderately dilated left ventricle and mildly dilated left atrium cinematic four chambered view showing bi atrial and ventricular dilatation normal left ventricular systolic function and mild right ventricular hypokinesia these two sequences depict PSIR short short axis imaging linear mid myocardial late gas pedolinium enhancement is seen in the inferior wall in mid third of left ventricle this is case number five postpartum dcm 25 year old female presented with dilated cardiomyopathy three months postpartum um cardiac MR showed moderately dilated left ventricle with severe left ventricle systolic dysfunction with ejection fraction of about being about 14 percent moderately dilated left atrium and moderate mild MR is also there and no evidence of any delayed contrast enhancement is seen as such this is SSFP so showing cinematic two chambered view and this is four chambered view showing dilated left ventricle global left ventricular hypokinesia and mitral regurgitation and short axis imaging showing similar findings now this is a case of douchey's muscular dystrophy 12 year old male patient who is a genetically proven douchey's muscular dystrophy he presented with DCM cardiac MR showed moderately dilated left ventricle with severe left ventricle systolic dysfunction lvf to be about ejection fraction just to be about 20 percent and moderate my moderate to moderate MR mitral regurgitation is present late gadolinium enhancement images show no significant enhancement as such two chambered view four chambered view showing dilated left ventricle global left ventricular hypokinesia and mitral regurgitation and short axis image showing the same findings now coming to the summary and conclusion of it cardiac MR has become the gold standard method for quantification of cardiac volumes and function in dilated cardiomyopathy now cardiac MR has an advantage it is not limited by poor acoustic windows which can often limit ecocardiographic studies thereby enabling diagnosis of pathologies which are otherwise not readily recognized by ecocardiography now it helps in differentiating ischemic from non ischemic forms of DCM it has also the ability to differentiate and diagnose various forms of NIDCM the Cine SSF image can accurately assess regional and global by ventricular function ventricular volumes ventricular mass and wall thickness T2 weighted still sequence helps to detect myocardial edema so just to any active inflammation like in case of myocarditis cardiac MR helps in risk stratification and selection of patients for icity implantation based on the presence of plate gadolinium enhancement presence of this has been LGE has been a marker for increased risk of arrhythmias and sudden cardiac death these are the differences for the same CT and MR of the whole body hugger and granger analysis diagnostic radiology danbert radiology review lippencote williams and wilkins and radiopedia acknowledgments are i thank dr yaksit and our HOD ma'am dr manjari m joshi and dr m kiran kumar sir thank you so much