0:00

All right, let's go to the next case. This

0:03

is going to be case eight and let's look

0:06

at this. So right away. You see something abnormal

0:09

here. Pulmonarities are quite large. Let's scroll

0:12

down.

0:14

And see what the cause of that is.

0:26

Okay, and clearly here you're going to be able

0:29

to say more than one thing give more

0:32

than one abnormality. But besides the the chamber

0:35

abnormalities the chamber size

0:38

every Melodies here. What is the most significant cardiac abnormality?

0:41

And so what's open the polling and

0:45

what you vote on this

0:48

case?

0:50

Let me keep scrolling through this.

1:03

Okay, let's close the poll and see what people think

1:06

what's the most significant ad remodi

1:09

here? And some people said pericardium some people

1:12

said valves and I can understand that because there's

1:15

a little bit of pericardial fluid here the valve

1:18

so clearly the pulmonary artery

1:21

is very large. And so you could think well,

1:24

you know, there's going to be something wrong with the pulmonic valve. But

1:27

if you look you can actually see that there's a little wispy harmonic

1:30

valve here and that's actually

1:33

fairly normal appearance of God when

1:36

you see it at all. Sometimes you don't even see it. But when you see it all it

1:39

tends to be very wispy and thin but something's

1:42

clearly wrong with the pulmonary arteries. Let's scroll down and see what

1:45

that could be notice how the right heart is

1:48

very enlarged. So the right heart should only be

1:51

a fraction of the size. Usually it's about 70

1:54

percent certainly it's

1:57

it's never more than equal to the size

2:00

of the left ventricle, but here it's huge the right.

2:03

Feels huge also The myocardium the

2:06

right ventricle should never be as thick as this let's scroll

2:09

down and see how thick that myocardium it is. It's very

2:13

thick. And so when you have red heart enlargement like

2:16

this and you don't have a history of idiopathic pulmonary

2:19

hypertension, you have to wonder what

2:22

what is causing this and you can see here

2:25

in the lungs that there is a lot of bronchexes severe

2:28

a lot of severe Rock accessing

2:31

you'd think well, you know, perhaps the right heart is a

2:34

large because of that but I can tell you that this is even for

2:37

that. This is a huge right heart. So the real reason

2:40

is down here. Look at the interventricular septum.

2:43

Look at the contrast going into the right

2:46

side into the right atrium. You can

2:49

see how it's actually Crossing across the atrial septum

2:53

and into the left atrium. Not only that but

2:56

actually where where is the symptoms as we

2:59

saw in another case, sometimes it's it can be hard to see

3:02

a thin septum but here

3:03

It looks very very deficient. And

3:06

I don't see anything that looks like a normal septum here. There's

3:09

mixing of contrast across what should be the septum and

3:12

so this is actually a huge atrial septal

3:15

defect that was discovered actually

3:18

first at non-gated CT at this CT

3:21

actually and who knows if

3:24

there's a connection between the Brock exes if that's congenital as

3:27

well as this ASD, but this is a large ASD

3:30

that was first seen at non-gated standard chest CT.

3:33

That is the responsible largely

3:36

for the enlarge right heart and the thickened right

3:39

heart. So the lesson here is that always look for

3:42

asd's and vsts. Especially if

3:45

you have a right heart that's that's much larger

3:48

than the left heart like this.

3:51

And I can't tell you how many times been reading

3:54

a non-gated standard SCT and been really

3:57

the first two discover that a patient

4:00

had an ASD and this is one of the larger ones that

4:03

I've seen incidentally but this is incidentally discovered

4:06

at this chest CT.