0:01

And let's move on to another case now and I put

0:04

in the caption of elephant in The Blind Men because

0:07

this is the story that came to my mind when we were

0:10

encountering this case in clinical practice.

0:13

I'm sure a lot of you might be familiar with the story.

0:16

But just to give you a very brief synopsis the

0:19

idea is when Blind Men are facing

0:22

an elephant and the only have

0:25

a very short or a concise perspective

0:28

of the entire animal they can

0:31

come up with conclusions that don't quite match the

0:34

entire picture, but they have a very restricted view

0:37

of a problem.

0:39

So for instance, imagine a blind person who's been

0:42

told to feel the elephant's trunk

0:45

and that's all they can feel so they might

0:48

perceive that as a rope or as something else but not really as

0:51

part of the elephant similarly. Somebody feeling

0:54

the elephants ears can think of it as a large

0:57

fan.

0:58

So each of them is correct in their own interpretation, but

1:01

as a whole the truth is something totally different.

1:06

So with this introduction, let's talk about this case. This was a

1:09

72 year old me had chronic kidney disease.

1:12

Colon cancer and had prior resection

1:15

and radiation therapy.

1:17

This patient is also received AAA abdominal aortic

1:20

aneurysm repair.

1:22

And had had aortic regurgitation after a transcutaneous

1:25

tablet procedure.

1:29

So the patient was now admitted to the

1:32

acute symptoms like shortness of breath and right shoulder

1:35

pain and at the same time was found to have

1:38

back to rhemia with severe aortic regurgitation and there

1:41

was a question of the patient having para valvular abscess.

1:46

So obviously you can see with that history. There's a big concern about something

1:49

periodic. So this patient under rent an

1:52

echocardiography. They found findings related to

1:55

The Tavern. They also saw moderate aortic insufficiency,

1:58

but really no findings of any vegetation abscess

2:01

or a paravalvular lesion were seen

2:05

When you talk about the cardiac function, the left ventricular

2:08

systolic function was Miley decreased, but

2:11

that was about it.

2:13

So at this point the focus of the scan shifted towards

2:16

determining the source of infection and the patient received a

2:19

PET scan.

2:20

So let me play these movies for you. This is

2:23

the fdg pet portion of the study and

2:26

I will let the scan run and I want you to just think

2:29

about what you're really looking at.

2:32

So again, let me play it one more time for you. This patient

2:35

was found to have dyscitis.

2:39

But apart from that the main finding that I want you to actually focus

2:42

on is something here. You

2:45

can see The myocardium but then a butting it and extending into the

2:48

chest wall is a very very empty gave it

2:51

lesion.

2:52

Now here is the CT portion of the study. And again just

2:55

to give you another look at what we are seeing it. What

2:58

does it anatomically look like?

3:00

So here is this abnormality?

3:03

It's intimately related to the LV. Myocardium.

3:06

I'm scrolling up and down so you can have a better look at

3:09

it.

3:10

So it's very intimately related to the LV myocardium, but

3:13

then it's extending out into the chest wall.

3:16

And if you look very closely you can even see there

3:19

is some kind of a linear hyper density

3:22

related to the LV. Myocardium.

3:26

So let me pull up some still images so you

3:29

can actually see the abnormality a lot better.

3:32

So we are going from cranial to the Cardinal aspect here is

3:35

the first image and here is that linear hyper density.

3:38

You see related to the left ventricular myocardium.

3:42

And adjacent to it is a fair amount of stranding and soft

3:45

tissue which is extending out into the left anterior chest

3:48

wall. And here it is and this is what corresponded

3:51

to that fdga-vidity.

3:56

So this is what the pet report said they call septic

3:59

arthritis of the right acromioclavicular joint, which obviously

4:02

explains the patients right shoulder pain symptoms. There

4:05

was evidence of disguitis. There was

4:08

also some findings in the pelvis, which we're not going to talk about right now.

4:12

But the main concern or the main finding that I

4:15

wanted to discuss was this hyper metabolic soft tissue

4:18

along the left lateral chest wall, and this

4:21

was deemed to be consistent with inflammation.

4:26

So luckily this patient had a prior CT. It

4:29

was a very limited City that we had from an

4:32

outside institution. And this was shortly

4:35

after the tower procedure that the patient had received

4:38

the CT, but it was at least a year or

4:41

so old compared to the current exam.

4:45

So here is again you can see this is the patient's Tavern

4:48

in place here. This is as I mentioned a post

4:51

hour CT.

4:52

There's a fair amount of coronary arterial calcification as

4:55

you keep scrolling. This was

4:58

that area of hypertensity that was seeing on the

5:01

current pet exams and this corresponded to this

5:04

lb Apex.

5:06

I'm scrolling it further, but you can see that that

5:09

chest wall lesion is absolutely new. So this is a new

5:12

finding that the patient has.

5:15

With this background in mind I want you to think about the

5:18

next question and really what is the next

5:21

best step. What should we be doing next?

5:24

And they may not be one correct answer here,

5:27

but I just want you to think about what would

5:30

you possibly do? Would you like to sample the chest wall

5:33

lesion for microbiology so you could better Target

5:36

which antibiotics to give to the patient. Would

5:39

you like to do an ultrasound contrast enhancity

5:42

or would you like to treat the patient and

5:45

empirically?

5:47

So again, like I said, there might be in fact more

5:50

options than this but this is just to get you to thinking what you

5:53

would do next.

5:56

Okay, so

5:58

so it doesn't look like everybody answered but

6:01

one third it's an N of

6:04

1 but one third people said that they would sample the

6:07

chest while lesion for microbiology and some people

6:10

thought that they would do a contrast and CT and that's

6:13

the majority of people thinking about contrast enhanced CT.

6:16

So again, like I said, there's really no right or wrong

6:19

answers. But the point

6:22

I wanted to make in this particular question was

6:26

and you will see it in the subsequent slides is

6:29

that sampling the lesion could actually

6:32

be a problem. So it's a good idea to investigate

6:35

this lesion a little bit further on.

6:39

What happened was in fact this patient when they had presented and

6:42

they got this PET CT the clinical service understandably was

6:45

quite concerned about it being an abscess or some kind of

6:48

focus of inflammation and they wanted the start

6:51

of this nation to be sampled as quickly as possible so that

6:54

they could stop the appropriate antibiotics.

6:57

But the radiologist on call and this was requested after hours.

7:00

So the radiologist on call refused to

7:03

do this given that it was so close to The myocardium and

7:06

they asked to get an ultrasound done.

7:09

So I'll just share some images with you. This is that lesion here.

7:12

But what you see when you put the color Doppler on

7:15

is that this lesion is markedly vascular just fills in

7:18

with contrast.

7:19

So you can see that putting a needle Could Happen really problematic

7:22

and this is really the moral

7:25

of the story. I wanted to show you today or share with you today.

7:28

And I think one of the reasons this which

7:31

also contributes to this problem is

7:34

the fact that the echo didn't really show much.

7:37

All it had shown was some paravalvular regurgitation.

7:41

But it hasn't shown anything related to the LV Apex.

7:45

So the other thing that we learned from this is that Echo could be really problematic.

7:48

We are looking at the true lb Apex that

7:51

could be Appliance for echocardiography. So just something to remember

7:54

in mind.

7:56

Now this patient actually underwent an MRI here is

7:59

the left ventricle. This is a two chamber

8:02

image and I'll show you I'll play the movie for

8:05

you so you can have a look this was that lesion we

8:08

were talking about. So here is that lesion filled with blood and this

8:11

is basically related to the LV

8:14

Apex and it's an outpouching from the left ventricular

8:17

Apex.

8:18

So this is the LV by the way, and then

8:21

you were seeing the left atrium and some of the other images. So

8:24

here is the left atrium.

8:25

So you're looking at the Apex where there is an out

8:28

pouching and this is consistent with the

8:31

left ventricular pseudo aneurysm. So this was

8:34

a left ventricular Soldier aneurysm. And this is the point I

8:37

was trying to make when we were discussing the elephants in The Blind Men

8:40

because you're just looking at a PET CT with a very

8:43

focused clinical question of looking for inflammation. So you

8:46

can see how this would be diagnosed as possible inflammation

8:49

and just like

8:52

we also saw in our holes and the same

8:55

way The Clinical Services really wanted to get the sampled.

8:59

So the moral of the story is just remember the product clinical

9:02

picture.

9:04

And always make sure if something is touching a

9:07

vascular structure that you get some kind of more dedicated Imaging to

9:10

exclude a more vascular structure.

9:14

The next part of this case is thinking about

9:17

what is the likely etiology of the pseudo aneurysm. So

9:20

I'd like you to again think about it and water if you can do you

9:23

think this aneurysm in the LV Apex is related

9:26

to post to my cartil infarction in

9:29

the past. Could it be ayatrogenic or is

9:32

it related to blunt trauma?

9:36

Excellent. So everybody thought of citrogenic and

9:39

I totally agree with you. So let's see what kind

9:42

of a procedure would have led to this pseudo aneurysm.

9:48

So if you remember we had talked about a history of Tavern in

9:51

this patient now incidentally this patient actually had

9:54

a trans apical Tower when the when the

9:57

surgeon or the interventionalist they actually go via

10:00

the left ventricular Apex and that explains why we

10:03

have seen this hyperdense structure located in

10:06

the lb Apex.

10:08

So this was a trans apical approach to the

10:11

Taver procedure?

10:14

And with increasing number of towers that we

10:17

are doing in patients, you're going to encounter these situations more

10:20

and more which is why I wanted to share this case with you.

10:24

The other thing to remember is Tower usually is done from a transfemoral

10:27

approach. So we may not see this quite as often.

10:30

But in this case the presence of that hyper density

10:33

in the LV. Apex was a clue towards a transaipicular

10:36

approach adopted in this particular patient.

10:39

And if you do adopt a trans apical approach, then you could

10:42

have will be apical complications like you saw in this particular

10:45

case where you had a pseudo aneurysm.

10:48

So just keep this in mind whenever you look at

10:51

cases like this.