0:00

Okay, this next case is a pediatric patient. I

0:03

believe around 12 years old who had

0:06

concern for an anomalous right cornea

0:09

artery. So this is a companion case to our

0:12

previous abnormal left coronary artery. This is a case

0:15

of a right corner artery from the left cusp within

0:18

into arterial course. So here's that you were

0:21

group.

0:22

Here's the left main coronary artery and this little thin

0:25

sliver here is the right corner

0:28

artery. You can see that it's located between the aorta and

0:31

the pulmonary artery. So it has an inter arterial

0:34

course.

0:36

And then it comes over here into the right AB Groove and

0:39

the normal position.

0:41

If we March backwards we can see the left main looks

0:44

good. And there's a split between the LED and the circumflex.

0:47

I mentioned that treatment of this is a

0:50

little bit controversial or it's a little bit more of a gray area. So

0:53

if you have a left coming from the right cusp with

0:56

an intern atrial course, those are all going to go to surgery. However,

0:59

if you have a right coming from the left cusp, it's

1:02

a little more uncertain and they they actually

1:05

present quite a dilemma for management some

1:08

places out there just watch

1:11

these patients and leave them alone. Some places uniformly will

1:14

perform surgery on these places and then

1:17

other places which I think is probably the majority if a

1:20

patient's completely asymptomatic we'll watch

1:23

them. But if they have some sort of symptoms attributable perhaps

1:26

to this lesion, then they'll

1:29

go ahead and fix it. Obviously that they concern is

1:32

sudden cardiac death the risk of sudden crying death is

1:35

not as high as patients with the left from the right.

1:38

However, there still is a

1:41

Small risk. So hence the the uncertainty

1:44

and the debate

1:47

about what to do with these lesions. So this particular patient did

1:50

have some symptoms referable.

1:52

To the right coronary so they did actually undergo repair. But

1:55

first I want to go over how to work this up again from

1:58

the previous video about the LED

2:01

coming out the right cost. We want to assess the inter arterial

2:04

course for the presence of an intramural course,

2:07

so I do that by making multiplayer reformatted

2:10

images

2:12

We want to scroll up to they were to group. We want to

2:15

drop our cross hairs.

2:19

On the middle of the vessel align our

2:22

plane perpendicular to the long axis of the vessel.

2:25

Find the vessel in the other long axis.

2:29

And align ourselves as best we can parallel to

2:32

the long axis of vessel and what you're left with is this

2:35

view right here.

2:37

So we're just sort of looking at the space between the aorta

2:40

and the pulmonary artery and this is where the vessel lives

2:43

and again if you see that it's much.

2:46

Taller than wide. Then that is considered a

2:49

slit like appearance and that is what

2:52

has been correlated with an intramural course. So

2:55

we see in this patient. Here's the origin. We have a slit-like narrowing

2:58

of the proximal part of the RCA and

3:01

then eventually it becomes rounded and sometimes you

3:04

may be asked by the surgeons. How long is the

3:07

intramural course? And so how do you figure that out? Well, you

3:10

basically just take your crosshairs and

3:13

you figure out well, I'm kind of slit like

3:17

here and it looks a little slow like there and kind of

3:20

slit like there but I think I'm pretty round right there. So

3:23

I think that seems to be beyond the intramural

3:26

course and then you figure out where that is on the corresponding long

3:29

access image and you basically go from the

3:32

origin to that spot and you measure

3:35

and you get in this case looks like five millimeters so roughly

3:38

five millimeter length intramural

3:41

course, and as I mentioned before an

3:44

instrument of course actually is good news for

3:46

Surgeons because it's easier for them to fix they

3:49

just go in they actually cut open the

3:52

aorta Above This lesion they go

3:55

and they put a probe in the origin of the coronary and

3:58

then they use their Bowie to cut away that inner

4:01

lining of aorta and expose the more normal

4:04

osteum Downstream. And for this case actually we

4:07

have a follow-up scan. This next set of

4:10

images is a postoperative cardiacct examination.

4:13

The patient has some recurrent symptoms

4:16

that suggested maybe there

4:19

might have been a problem with the operations that they wanted to just make sure that the

4:22

unroofing procedure was successful.

4:25

And so if we look at this case, you can see that here's the

4:28

origin for the right corner artery

4:31

and now unlike before where there was that narrowed segment

4:34

approximately as it arose from

4:37

the left corner of cusp the new ostium is

4:40

right here and heads over rightward. So this unroofing

4:43

remember basically cut away this

4:46

whole intramural segment here.

4:48

And the new ostium is there I can just show

4:51

it to you on another reconstruction. This shows

4:54

the unroofed right corner area.

4:57

So that's what you expect to see postoperatively after

5:00

unroofing of that intramural course.