0:00

This next case is a coronary anomaly. This

0:03

is a 16 year old who had

0:06

a cardiac arrest.

0:08

And then had Return Of Consciousness after defibrillation.

0:12

Big scary thing to happen. And so one of

0:15

the things that we think about as a reason for somebody to have

0:18

Cardiac Arrest is coronary anomaly particularly if they're young patient and

0:21

their exercising at the time and so the

0:24

patient ended up having an echocardiogram and echocardiogram.

0:28

Showed what they thought was an anomalous coronary so

0:31

believer not Echo can be pretty good for identifying coronary

0:34

artery Origins.

0:35

In this case, they were able to identify this abnormal coronary.

0:38

So what are we seeing here? So if we

0:41

start from the top

0:43

And we go down. We see this vessel here coming off of the left

0:46

sinus of valsalva.

0:48

And it's not your normal left main, it just comes

0:51

off and then heads over into the left.

0:53

Davy Groove so it's behaving like a circumflex and then

0:56

you see from the right cusp you got this

0:59

vessel here.

1:01

Which is hugging the cusp and let me

1:04

zoom in to make that a little bit clearer.

1:07

It's hugging that right cusp and then coursing over.

1:12

Into the anterior interventricular Groove

1:15

in the LED region gives off a

1:18

diagonal branch and and right there. So in this

1:21

case what we have is we have the LED.

1:24

Coming from the right coronary cusp with what

1:27

we would describe as in inter arterial course

1:30

meaning of course between the aorta and

1:33

the pulmonary artery.

1:35

And then finally, here's the normal origin of the right

1:38

corner artery.

1:39

from the right cusp

1:41

so enter arterial course.

1:44

Has a different meaning depending on which vessel you're talking

1:47

about. So when you're talking about a left corner artery

1:50

from the right side.

1:52

Generally that's considered a very

1:55

severe lesion and I'm malignant lesion

1:58

that needs to be fixed.

2:00

Because of a high risk of sudden death a right corner

2:03

artery from the left side with an intartial course,

2:06

which we're going to show in the next case. That one's a little

2:09

bit more of a gray area.

2:10

Whether or not you'll fix it and I'll talk about that further on

2:13

that case.

2:15

How do you evaluate these lesions? Well, the main question that comes

2:18

up whenever you're talking to your referring cardiologist or

2:21

surgeons?

2:23

Is whether or not there's an interarterial course which in

2:26

this case is a course between the aorta and

2:29

the polarity which you see here. So we do have that and

2:32

what is it there's an intramural course and intramural

2:35

course means of course that goes within the

2:38

wall of the aorta.

2:40

And unfortunately, we don't have a resolution

2:43

on CT to identify the wall. So we

2:46

have to use secondary science to tell us whether there's an intramural course.

2:50

This has been worked out by researchers in the past.

2:53

and the general consensus is that if

2:56

you have

2:57

a region of the vessel that looks like a slit

3:00

like narrowing and I'll show you what that

3:03

means then usually that corresponds to an

3:06

intramural course meaning of course through the wall. They

3:09

aorta

3:11

so, how do you figure out if there's a

3:13

slit like narrowing

3:15

Well you start with your mprs.

3:18

You put your crosshairs on the vessel. You

3:21

want to align your plane perpendicular The

3:24

Vessel?

3:26

just like so

3:28

and then on the other long axis image you want to try to

3:31

make yourself as parallel to the long axis vessels possible just like

3:34

that and then what you're left with is this sort of

3:37

sagittal image of that you're root.

3:39

Which has the vessel here in the short

3:42

axis orientation?

3:45

And what we see here is that the

3:48

vessel is much taller than it is

3:51

wide, right? It looks like it's been squished in the AP

3:54

Dimension. You can also see that the vessel is between aorta

3:57

and the pulmonary artery. So that's the interarterial course.

4:02

And so in this case, this is a slit like narrowing that

4:05

slit, like narrowing is generally considered

4:08

to correspond to a intramural course

4:12

on pathology at the time of repair. So

4:15

again, what is an instrumental course mean? That means

4:18

actually that the coronary comes out.

4:21

From the Lumen travels within the wall

4:24

of the aorta. So that's this part that

4:27

looks really tall but not wide that slit like appearance and

4:30

then pops out later from the

4:33

aortic root in the normal servant more normal rounded configuration.

4:38

So basically the finding of an intramural chorus

4:41

puts the patient at a higher risk than solely

4:44

and interartreal course, so

4:47

it's kind of like inter arterial course is bad

4:50

intramural and into arterial is even worse

4:53

and higher risk for sudden death.

4:57

Now the other thing that is important about the

5:00

intramural course, is that it?

5:02

affects the presence of intramural course

5:05

dictates surgical management

5:08

And when getting into this with the RCA case, but basically when you

5:11

have an intramural course.

5:14

The surgeon can go in they can open up the

5:17

aorta look down into the aorta find the osteum

5:20

and then cut away this thin bit of aortic

5:23

wall tissue.

5:25

To open up or what they call unroof that

5:28

intramural portion.

5:31

So that now the sort of the new osteum is

5:34

the sort of standard normal.

5:37

osteum Down Here Without that intramural narrowing

5:41

and it turns out that that's the preferred way to fix these.

5:44

There are occasions where you may see an inter

5:47

arterial course of these vessels without that slit

5:50

like narrowing. It just comes out.

5:52

Has a nice rounded appearance from start to finish.

5:56

And so in that case you're dealing with an into arterial course without an intramural

5:59

course and those actually believe it or not are harder to

6:02

fix because the unroofing procedure is fairly straightforward. If

6:05

you have into our Trail course and you cannot do

6:08

an unroofing procedure, then you have to do a transplant

6:11

of the coronies or a bypass of some sort. And

6:14

that's a lot harder to deal with. I have

6:17

a slide. I think shows this really nicely that

6:20

I'm going to transition to to help Hammer home this concept.

6:24

Okay, so here's an image from the literature of

6:27

this intramural left

6:30

means and here's another corresponding path slide. So I'll

6:33

walk you through this. I think it's a little easier to appreciate

6:36

on the path Slide the complete Anatomy, but let me

6:39

show you here. This is the pathologic specimen. So imagine

6:42

this is the Lumina they aorta this is the wall they

6:45

order. So here's the vessel. It comes into

6:48

the wall and travels along here. It's traveling inside

6:51

the wall just like this traveling traveling traveling

6:54

traveling and then Downstream it

6:57

comes out and it's normal location. This segment

7:00

here is the intramural course

7:03

and the unroofing procedure would mean

7:06

that the surgeon would go in and just cut away this

7:09

inner lining of tissue so

7:12

that there's no longer any compression here. Now

7:15

the origin lives right here rather

7:18

than over here with an intramural segment.

7:21

Here's what it looks like on sort of a slide. You can

7:24

see here comes the left Main.

7:26

Intramural course, we're inside the wall of the aorta.

7:29

It's squished here. So you don't see the connection but it

7:32

would be there if it wasn't squished. Here's the connection and then

7:35

it pops out distally.

7:37

Now another thing to think about about this is if you actually have a surgeon who

7:40

just goes in.

7:42

And looks on the outside at the vessels. They're

7:45

gonna look perfectly normal.

7:47

So it's not a diagnosis that can be

7:50

made by observing the vessels on the

7:53

outside. Like let's say if you do open heart surgery

7:56

and you take a look you're not going to see this.

7:58

It needs to be picked up ahead of time by other echo or

8:01

coronary CT. And here's what looks like a different case on. Coronary

8:04

CT.

8:06

So this malignant course that's some into arterial course

8:09

that's considered malignant. And those are the things that we worry about

8:12

because of the risk of sudden death.

8:14

So in the next case, we're going to go over an RCA also with an introdial course.