0:00

Next patient, uh, I think was about 70, 71 years old,

0:04

just had non-specific chest pain.

0:06

So a pretty reasonable thing to do, uh, would be

0:09

to consider a coronary CTA.

0:11

It was not known that he had any atherosclerosis,

0:14

but I did wanna show you he had a prior abdominal CT

0:17

that was the only prior imaging.

0:19

Um, and one could look at the abdominal CT

0:22

and maybe pick out some aroma in either the aorta

0:25

or if you were lucky enough to get the bottom

0:26

of the heart on the abdominal acquisition.

0:29

Um, you might have a sense of it,

0:31

but often that kind of information goes undocumented.

0:33

Especially in the old days. We weren't as conscious

0:35

of coronary arterys sclerosis,

0:36

but one, look at this non-con calcium score.

0:39

Um, and you can see two things.

0:41

One good example of why single phase is never really great.

0:44

Uh, a lot of motion artifact in the

0:46

RCA, at least on this phase.

0:48

Some calcified, uh,

0:49

atheroma sclerosis would be the best

0:51

word in the aortic valve.

0:52

So I might comment on that.

0:53

I won't quantitate unless asked to, um,

0:56

or if I think he really has a lot.

0:58

And then you have, uh, extensive otosclerosis

1:01

in all three vessels.

1:02

Now, this is not an excuse

1:04

to use the word three vessel disease.

1:06

Best way to rephrase that would be

1:07

that there is multi-vessel atherosclerosis,

1:10

but I've told you nothing about the degree of stenosis.

1:12

So let's go on and look further at that.

1:14

So, uh, in fact, we can look

1:18

with our multiplanar reformats

1:21

and let's start like we always do.

1:22

Take a look at the left main already.

1:25

I see a little bit of narrowing there.

1:26

Um, just looking at axials, uh,

1:28

it's a longer left main than the last patient

1:30

was an immediate bifurcation.

1:31

This one got a couple centimeters of length, you know,

1:33

maybe a good 10 to 15 millimeters.

1:37

Really, there's not a lot of reasons to look on short axis,

1:40

but left main is one of them.

1:42

And so you could measure an area,

1:44

you can see it's probably borderline here.

1:47

Um, i, I have taken to measuring the areas in many cases.

1:50

Um, this one doesn't look like it's on the border,

1:52

like the last case,

1:54

but I think it's worth a quick measure just

1:55

to kinda give a rough, quick and dirty 10 millimeters.

1:57

So we know that's not a big deal.

1:59

Um, and so while there is a fair amount of plaque,

2:02

I don't think I'd call it anything more than mild.

2:04

It's certainly not gonna hit the 50% mark for me.

2:08

But as soon as I get to the LED I'm pretty concerned here.

2:13

There is some slab artifact right there,

2:16

so I don't wanna get tripped up,

2:17

but I can change the phases of the cardiac cycle.

2:20

Okay, so at the osteum it doesn't maybe look

2:24

as bad at second glance,

2:25

but as I kind of walk my way down the vessel,

2:29

I can see a fair amount of atheroma a little bit more.

2:34

Probably still mild there, right around here.

2:35

So we've already branched off to the first

2:38

large septal perforator and or diagonal.

2:40

So I know in the mid LAD

2:42

and densely calcified plaque, it's gonna be really hard

2:45

to clear this one actually.

2:48

And one of the reasons it could be really hard

2:50

to clear something is it could be a legitimate stenosis.

2:53

Uh, a smart CT reader once told me a stenosis is an artifact

2:57

until proven otherwise.

2:59

The thing that makes me more confident

3:01

to call this stenosis is that there's noncalcified plaque.

3:04

Um, so it's not just the, uh,

3:06

blooming from a densely calcified lesion.

3:08

So I'm pretty convinced already there's a,

3:11

at least a mid segment, um, moderate,

3:13

maybe even severe stenosis,

3:15

long segment Mitra myocardial bridge here in the distal

3:17

LAD, mid distal LAD.

3:19

That's fine. Um,

3:20

and I'm now training my eyes on the circumflex trying

3:23

to find my best motion free images.

3:25

I'm just paging through these.

3:26

And uh, again, I'm worried about a stenosis right here.

3:30

Um, let's look at this in a different plane.

3:32

So at least moderate on this segment.

3:34

And then kind of as you go from that's proximal,

3:37

maybe in the mid segment, um, moderate

3:40

and even possibly severe circumflex

3:43

and, uh, not my favorite image quality on this case.

3:47

Uh, but I'm just, just since I happen to catch it here,

3:49

I'm just gonna look at the RCA, um,

3:51

and show you that it does supply the inferior wall.

3:53

So it's a dominant RCA and um, lot of slab artifacts.

3:57

Uh, probably had some rhythm issues,

4:00

but sometimes

4:01

that's all you get in the more heart disease you have,

4:05

the more likely of having any arrhythmia.

4:07

So what you do is just do your best

4:09

and kind of capture a few phases.

4:10

If you have to piece things together.

4:12

May not make for the prettiest reformats,

4:14

but uh, you should be able to at least try

4:16

and find that stenosis.

4:18

So I at least have a moderate in the prox RCA.

4:21

And then I have a little bit of a challenge here

4:23

to piece together some anatomy.

4:25

Um, but again, I've already kind

4:26

of found two different lesions, one in the LED

4:29

and one in the circum, at least one in each, uh,

4:31

circumflex reasons to go to the cath lab.

4:33

So if I'm not evaluable here, I won't lose a ton of sleep

4:37

'cause I know that there's a high yield in the cath lab

4:39

and a need to go further though I am pretty suspicious here

4:44

in the distal, uh, RCAs that this noncalcified lesion, uh,

4:48

looks to me like that's gonna be a severe stenosis

4:51

and that's not gonna be blooming artifact.

4:53

That's gonna be the plaque that's causing the stenosis

4:55

and it might even be a much longer segment.

4:57

So that's distal RCA.

4:59

So if you're counting its potential, uh,

5:01

three vessel disease, let's take a look at the, uh, report.

5:05

This was called a CAD reds four B,

5:07

meaning three vessel disease

5:09

and they thought mid LED at the D one branch, OM two branch

5:12

of the circumflex and distal RCA

5:14

and the PDA, which I didn't even show you.

5:16

Let's go back and find that PDA, um, MIP can be used

5:19

for long axis and here is certainly one.

5:21

And so this is a vessel that's kind of in and outta plane.

5:23

We've, uh, looked at that here

5:25

and um, you wanna do a mip, give it a little bit of a slab

5:30

to it and I think there probably is

5:32

something significant there.

5:33

So have to agree. Um, let's move on to the cath.

5:36

So, um, and just to put it in perspective, in addition

5:40

to the risk factors he had, he had a calcium

5:41

score in the three thousands.

5:43

I don't think this is an on valuable scan.

5:45

Uh, I will point out one other thing is that there's a touch

5:47

of, um, slab artifact in the heart,

5:50

which must be rhythm related.

5:52

'cause I don't see a ton of, uh, motion on the sternum.

5:55

So when I look at the full field of view

5:56

Here, uh, really patient held their breath pretty well.

5:59

So it's probably a rhythm thing.

6:01

You can look at rhythm strips on most cts.

6:03

Uh, and in this case you can see

6:06

that there was a high variability.

6:07

In fact, um, there was probably either a PVC

6:10

or sometimes hard to find P waves.

6:12

I'm not sure I definitely can diagnose AFib here,

6:15

but probably because it's irregular.

6:18

Um, high variability is the, uh,

6:20

important, uh, hallmark there.

6:22

We find systolic imaging to be helpful and,

6:24

and prospective systolic triggering is very

6:27

helpful in this situation.

6:28

Um, but bottom line need for cath, uh, for sure.

6:31

On the question of three vessel disease,

6:33

left main looks pretty good,

6:34

at least no focal narrowings on this view.

6:36

Tortuous coronaries, um,

6:38

probably a longstanding hypertensive patient.

6:41

And, uh, let's try to suss out what that cath showed.

6:45

Okay, so the left main was deemed patent.

6:48

The LAD only proximal mild disease was called.

6:51

You can sort of see it here.

6:53

So it looked worse on the, the, uh, ct

6:55

that was a difficult ct

6:57

and the left circumflex was thought to be patent,

7:00

which I think you can confirm pretty well here.

7:03

So, um, that dense calcium, it's our enemy.

7:06

Um, however, on the right they did corroborate that.

7:10

And so you can see some little like, you know, narrowings,

7:12

I'll just try to pause it for you on one of these views.

7:15

But the, the vessels are irregular.

7:17

Um, here's just another view.

7:18

The LAD circumflex really know nothing that was severe.

7:22

But on the RCA you can see even

7:24

before they start injecting, there's some densely calcified

7:27

plaque and you've kind of got

7:29

what was called a severe calcific mid vessels disease.

7:32

So kind of the Apple core bite outta the RCA.

7:35

Always good to look at a couple views.

7:37

This one doesn't really pacify anything. Here's the circum.

7:40

So the RCA lesion in, uh, in profile.

7:44

And because there was a severe stenosis though,

7:47

we would've over called the other two vessels.

7:50

Um, this is still a per patient, nice predictive value.

7:54

And uh, the way the story ends is with a stent.

7:57

'cause now it's in the single vessel disease territory.

7:59

Um, and so that's, there's a stent being deployed.

8:01

Let's, let's check the angiographic result.

8:04

Beautiful results, they stented up that disease.

8:07

So, um, one of these difficult cases

8:10

where CT works at the limit of its physics,

8:12

however, story ends well

8:14

with a nice per patient positive predictive value.

8:17

So cadre's four B uh, was downgraded

8:21

to just a single vessel disease.

8:23

In the end.