0:01

So just like we did

0:02

before, if you have any questions about cases

0:06

or anything concerning that we wanted to look at

0:10

or something that wasn't clear, uh, let me know.

0:13

We can do that in detail.

0:14

Otherwise we can do, uh,

0:19

just kinda a look at the, at the coronary cases

0:24

and, and go from there.

0:25

So that's what we'll, we'll kinda evaluate.

0:28

So let's start with week in case one.

0:33

So on this particular case, we wanted

0:36

to continue building on the anos coronary anatomy as well

0:40

as the evaluation of coronary stents.

0:44

So in this particular case, we have, um, a gentleman

0:48

that has active chest pain

0:50

and has a history of non coronary disease.

0:52

And we wanted to kind of evaluate if the coronary disease

0:56

has to do with his stents

0:57

or it has to do with his omas anatomy.

1:01

So on this case, we can see from the beginning

1:03

that there's clearly an anomalous, uh, left main force

1:08

tends to be in between the pulmonary pulmonary artery

1:12

and the aorta.

1:13

And we get to see that it definitely has some,

1:17

some anterial course

1:18

and what we would consider a high risk binding.

1:20

So how do we best evaluate left main courses in these is

1:24

kinda ideally my approach is always

1:27

to kinda make sure you can create a short axis orientation

1:31

of the valve if you can.

1:33

So if you can get the, um,

1:37

coronary arteries to come up

1:38

and you wanna be able to clearly tell

1:40

which cusp comes from where.

1:42

So we should be expecting the left main origin

1:45

to come from the left side of the heart,

1:47

and then the right coronary cusp from the coronary come from

1:50

the right coronary cusp, which we see here.

1:52

We see that. How do you use aortic measurement tools

1:56

in tar recon?

1:58

Okay, so for that one really, um,

2:02

and this one you essentially use these,

2:05

you can use basic 2D measurements to kind of create, uh,

2:10

a measurement from here to here to, to do that.

2:13

That's most of the basic measurements.

2:16

Uh, the ruler in general allows you to make most

2:20

of the basic measurements for, for that particular purpose.

2:24

That that's how you do with double each

2:27

automated if you hit shift.

2:31

And it has to do with your workflows.

2:33

So if you have a workflow like for example, tavr,

2:39

uh, you can shift for measurements.

2:43

You know, you can do anything that's listed here.

2:46

So sending aorta and it'll give you the, the measurement.

2:50

Then you can just measure from here.

2:53

So it's automated whichever way, just we will just, uh,

2:57

label it for you and,

2:58

and create that picture if you want to.

3:01

Okay. So that's kind of how it does.

3:03

If you wanted to create like a curve multiplanar, right?

3:08

So you just have to change the workflow.

3:11

So if you go to this

3:13

and you do like LAD

3:17

or whichever, you can just press shift

3:20

to the vessel of interest.

3:22

That being the aorta, let me see if it didn't

3:28

go back, give it a maybe.

3:31

So, um, the auto

3:36

shift and there it goes, it will provide you with that.

3:42

Anywhere you see these lines is

3:43

where it'll automatically trace

3:46

and uh, you can just adjust those

3:48

and make those measurements.

3:50

See, it will provide them for you.

3:52

Now mind you, they'll need some fine tuning in some cases,

3:55

but you know that that part isn't really that hard.

3:59

You just scroll what you select threshold,

4:02

and just with the left click of the mouse,

4:03

you can adjust the threshold for, for the measurements

4:07

and just adjusting it and, and proceed from there.

4:09

So if you want it more automated, again,

4:13

threshold, then there you go.

4:14

See. So that's another way to do it,

4:17

and you can extend the vessel if you need it to.

4:20

So again, minimize, you can rotate

4:24

and you can kind of tell it where to extend to see.

4:27

So by simply clicking

4:29

or scrolling on this, you can just tell it to continue

4:32

on a certain location, et cetera.

4:35

Okay, wonderful. Any other question?

4:40

No. How do you differentiate share from separate?

4:43

That's a great question. So let's look at that.

4:46

So, uh, let me go back to cardiac.

4:51

When we do volume right brain.

4:53

So what we'll do is for common osteum versus shared osteum,

4:58

one of the things that you need

4:59

to do is actually look at the, at the cusp leaflets.

5:02

So what you do is you line up the aorta or the aorta root,

5:08

and what you're gonna do is magnify your,

5:13

your vessels or your cusps.

5:17

Here you can see that this has its own osteo in the sense

5:21

that we define an osteo by essentially having

5:25

all borders originate from the aorta.

5:28

So you can see this vessel has its own origin

5:32

separate from anything else,

5:35

right in there you essentially create a, as you would say,

5:38

a full circle around the borders of the vessel entirely.

5:43

In this particular vessel, you have it separate.

5:47

In this one you also have a separate, uh, ote.

5:50

See how it has its own, uh, assessment, its own

5:56

orifice, own, uh, origin in the same cusp,

6:01

but it's not a a branch meaning it, it, it comes directly

6:05

from the, the main artery or vessel.

6:08

Does that make sense? Sometimes you'll have the left main

6:11

and the left circum complex

6:12

and the LAD originate directly from

6:17

the same cusp,

6:18

but each one will have no shared, uh, origin,

6:23

but will rather come directly off the aorta.

6:25

That's the ones that you will, you'll often see.

6:28

So does it come off directly off the aorta

6:30

or does it come off another vessel?

6:32

Does that make sense? So very good.

6:35

In this case, you know, we're able to see

6:37

that there's clearly an anomalous artery

6:39

with an interrater course like we've mentioned.

6:42

And your, our job is to kind

6:44

of see if there's significant stenosis left main

6:47

with intraarterial courses are a high risk finding.

6:50

In this particular case, you can see

6:52

that there's like an oval like narrowing here, right?

6:57

You continue to go through it

6:58

and you can measure the length of narrowing, like

7:01

how long does the vessel stay narrow for before it stops.

7:05

So you can actually measure that directly

7:07

before it turns into a full oval.

7:08

So you can use, uh, your, your planes to kind

7:13

of align your cross hairs into it

7:15

and make a measurement for how long is that going

7:18

to be narrow versus how long is it going to be?

7:21

Uh, normal sizing here you can see some narrowing,

7:24

but it's not slit like, so it's an oval like orifice,

7:28

which tells you there's a less than 50%, uh,

7:32

uh, stenosis.

7:35

The angulation for this is also intriguing, right?

7:37

You see kind of has a, an acute angulation for

7:40

where quote unquote it should be.

7:42

So it's about less than 45 degrees for just

7:44

how acutely turned from the vessel to kind

7:47

of turn into the area.

7:49

So if you use this plane, kind of like,

7:52

let me see if I can get you the angle.

7:54

So you use the plane in which the vessel will run its course

7:58

and then, uh, I always get that one backwards,

8:01

but essentially, here, let me, let me delete it.

8:05

So again, angle, uh,

8:10

quick, too many

8:16

Okay, there, right?

8:19

We'll do that again.

8:20

So angle from here to here.

8:27

Okay, I'm using picture of too much.

8:31

So again here.

8:56

Okay, so terracon

9:01

here to here and then here to here.

9:04

That's right. There you go.

9:07

So again, the angulation, you kind

9:09

of use the plane on which the vessel's going to co

9:11

and then the plane on which, you know, the origin is going

9:14

to be in this case, the origin of the vessel should kind

9:17

of follow along this plane

9:19

and that's where you get the acute angulation.

9:22

Okay, so now that you've looked at the angulation

9:25

and the length of narrowing, we can always kind of determine

9:28

that the intraarterial po the oval like

9:32

orifice in the acute angulation.

9:35

They're high risk findings.

9:36

In this particular case,

9:37

even though there's not a greater than 50% stenosis,

9:40

we went ahead and see

9:42

what the exercise treadmill test showed.

9:44

And in his case, when he was at maximum exercise,

9:47

there was evidence of diffuse s st t wave changes consistent

9:51

with like obstructive flow to this left main

9:54

that subsequently required a referral

9:58

to cardiothoracic surgery for, for, uh,

10:02

essentially left main evaluation, which would,

10:05

in this case would be re reimplantation.

10:08

He also has coronary artery stents that were important

10:11

to see, but he also has disease in this optus marginal.

10:15

So a lot of, uh, the students were able to kinda identify

10:19

that there's, uh, coronary stents,

10:22

but like the, the stenosis here

10:24

and that Optus marginal, uh,

10:26

vessel was often kind of overlooked.

10:28

So that was a, an important eccentric plaque

10:31

that we threw in this case for, for, for the sake

10:35

of like for her evaluation.

10:36

So that's that first case. Any questions?

10:39

Any other concerns? No.

10:44

How to tell t tubular or is it region?

10:47

Honestly, if it's coming off the t tubular junction,

10:50

the origin from the sant tubular junction itself really

10:53

doesn't matter if it just comes above the sin, the,

10:56

the coronary cusp, meaning as long

10:58

as there's no intraarterial force, you really don't have

11:01

to worry too much about it.

11:03

Now you can come off the sin tubular junction

11:06

and have an acute angulation

11:08

or you can have like, uh,

11:10

significant stenosis from the course of the coronary osis.

11:15

So the location itself is not high risk.

11:18

How it comes off the center tubular junction can potentially

11:21

different d uh, vary

11:23

and be different, uh, depending on, on, on what the case is.

11:27

So it can, it can matter in some patients.

11:29

Okay, A very good question. Lets look at case number two.

11:36

And this is another kind of similar case to kind

11:40

of round up our, our anomal coronary cases.

11:44

Again, this a male who has a history

11:46

of known aortic valve stenosis

11:49

and we're getting a CT scan to look at his, um,

11:55

at his, uh, coronary CT as part

11:58

of his perioperative evaluation, right?

12:00

So again, in this particular case

12:03

we wanna get into the coronary

12:06

cus leaflets and take a look at this.

12:08

You can kind of see how this artery

12:12

is coming off the synott tubular junction.

12:15

It's coming right above the coronary cusp,

12:18

but it has quite the acute angulation.

12:20

So you can see there

12:21

that while the anoma take off isn't really

12:25

too significant bas on like sin tubular junction,

12:30

the intraarterial nature of it and the acute angulation

12:33

and the narrowing are what really, really end up being a,

12:37

a major, a major concern.

12:39

So again, in this case

12:42

you do have an acute tank angle takeoff.

12:46

You have evidence of an intramural slit like

12:49

or orifice with a length of narrowing that's quite long.

12:52

You can see how this stays very slit like for quite a bit

12:56

of time before eventually, uh, for quite a bit of length

13:00

before of, uh, before it opens into a non stenotic vessel.

13:04

So that's, that's of important.

13:07

In addition to that, you have mild disease throughout the

13:10

coronary arteries, nothing really, uh, obstructive,

13:14

but the combination of those symptoms is important

13:17

for the surgeons to know kind of twofold.

13:19

One, you obviously have to deal

13:21

with the right coronary artery as you're going

13:23

to be potentially putting in a new valve in the,

13:27

in the aortic valve position.

13:29

So you wanna make sure that whatever device ends up being

13:32

deployed or put in,

13:34

or more importantly whatever surgical repair ends up being

13:37

done, that the surgeons are aware of this location

13:40

and more importantly, the risk of having this vessel,

13:44

which ends up being kind of like a circumflex

13:46

that comes retro aortic,

13:48

not be an issue when you're implanting the artery

13:52

or implanting the valve to ensure

13:54

that you don't end up causing an infarction

13:57

on the lateral side of the heart given that there's

14:00

that other vessel that's clearly going from, from behind.

14:04

So that's a very, very important kind of finding in,

14:09

in this case, not only is the RCA off,

14:12

but the Lester conflicts kind of coming from the RCA

14:16

with a retro aortic force.

14:17

Okay, questions concern about this case?

14:24

No. Wonderful, wonderful.

14:27

So this case wasn't, I think that finish rounded up our,

14:31

our anomalous coronary cases.

14:33

Now we got is the aortic root D, right?

14:37

So we go back to, um, to this

14:41

and the question for our oric root dilatation, it has to do

14:45

with the, the aortic root dimensions

14:47

and how do we define, so in this particular case,

14:52

you can see that the root definitely looks

14:54

to be a little bit bigger than, uh, than it should be.

14:59

So you have the first kind of measurement

15:01

that I always encourage everybody to do,

15:03

especially when you suspect the order

15:04

of rehabilitation is just to do a traditional, um,

15:09

coronal measurement.

15:11

So here, 32.6, it does not appear to be dilated.

15:15

And again, a lot of it has to do with the asymmetry of it.

15:19

So if you're looking at this

15:22

and you get into the aorta itself, you can see

15:26

how there's this asymmetry of the, this, uh,

15:31

sinuses of al Salva

15:33

and you wanna make sure that your cross hairs go

15:35

to the largest dimension of the aorta to the, uh,

15:39

widest dimension in that.

15:41

So here we can see that and we can see the work here.

15:44

So let's take a look.

15:46

As we're looking through this, we wanna ensure

15:48

that we are crossing things where they're supposed to.

15:52

I always like to zoom in on my, in my vessels, um,

15:58

to ensure that I can really see the borders of that vessel.

16:01

And then last but not least, measure.

16:03

So now if you're measuring from sinus

16:07

to sinus measurements,

16:09

you're probably gonna get more accurate measurements than

16:12

you're probably going to do

16:14

or at least less underestimated measurements

16:17

that if you do from sinus to commissure, right?

16:21

And that's where a lot of these, uh, almost that kind

16:24

of be off here, there, I see it.

16:26

Um, and that's where you can see a lot of these, a lot

16:29

of these measurements being off.

16:31

So let we get here, you get on this

16:36

and then push over here.

16:39

Yeah,

16:45

mid centered rotate

16:50

here, right there.

16:53

Very good.

16:57

Lean right there.

17:02

Okay.

17:15

Okay, very good. So now let's measure.

17:19

So from here to here, you got one

17:24

from this sinus

17:27

or this sinus to sinus measurement, you have that

17:31

and you got one more, which would be this sinus

17:34

to this sinus measure.

17:35

So about 31, 32.

17:39

So this, this one really that dilated,

17:43

especially when you come looking at it further down

17:46

the move in there.

17:47

So no, no dilatation here, just normal dimensions.

17:53

Okay. Alrighty, let's move on to case,

17:59

um, case three.

18:05

So case number three, this one's an interesting case.

18:08

'cause this particular case we see an anomalous right

18:12

coronary artery,

18:14

but we also have evidence

18:15

that there's prior cardiac surgery.

18:18

We see a a, a surgical clip here near this vessel.

18:24

And you can then follow along a very intriguing graph.

18:28

It's, uh, internal thoracic artery graft.

18:31

You can see how it's been closed off

18:33

and it comes off the, uh, sub again.

18:36

So it continues to come down and can follow along,

18:40

but it's rather atretic, meaning it's relatively small

18:43

and makes a connection into the posterior descending artery

18:46

to lateral branches.

18:48

But the question is, why, why did it, it it fail?

18:53

And it goes down to something

18:55

that we've learned about anomalous ordinary quads

18:58

that in order for this arteries to really be significant,

19:03

we really need to have a pretty significant severe stenosis

19:07

because without it, the arterial grafts really are not going

19:11

to mature.

19:13

And if they don't mature, then you end up having a tree shot

19:18

of those vessels, like, like you saw in this case

19:21

where you can bypass to the artery itself.

19:24

But there's enough competitive flow from the native vessel

19:27

that the graft is never really going to need to be done

19:31

despite some of this, this high risk anatomy

19:34

and and characteristics.

19:36

Now when we say high risk, it's important for us

19:38

to differentiate high risk for revascularization,

19:41

meaning the likelihood that you will need some sort

19:44

of procedure because of symptoms versus high risk

19:48

of sudden cardiac death

19:49

and the high risk of sudden cardiac death

19:51

from when anomalous.

19:52

Right? Coronary artery really is not think nothing

19:55

that would be too often seen.

19:58

A lot of the times the ano is left main is the one

20:01

that tends to be most associated with higher risk

20:03

of ion cardiac death.

20:06

But these coronaries from their right interrater courses,

20:09

they really don't seem to have that issue.

20:12

So that was the issue that we were wanting to emphasize

20:15

that in patients who really just have an almost coronary

20:18

but they don't have true evidence

20:19

of significant ischemia from it

20:21

or any other high risk findings,

20:23

that sometimes even revascularization can fail

20:26

and it can lead to, uh, a recurrence of the symptoms

20:30

and the graft itself will won't mature

20:33

because of the competitive blood flow

20:36

or maybe they have microvascular dysfunction

20:38

that can occur from the phenomenal SPL area.

20:41

Okay, next case, uh,

20:45

on this one on this week,

20:47

and this one kind of starts transition things into a little

20:50

bit more of a structural, a little bit more of a more,

20:55

more kind of daunting tasks.

20:57

In this particular case, we have a case of a male

21:01

that has a history of, um, of,

21:07

uh, prosthetic valve, right?

21:10

And we wanna see if there's any involvement for symptoms

21:13

of shortness of breath

21:14

and bowel prosthetic valve dysfunction type of anatomy where

21:19

there's anything that could explain his symptoms.

21:21

So in this case, we kinda introduce the concept

21:23

of not only looking at the coronaries,

21:25

but also looking at the valve anatomy.

21:27

So that's what we're going to do.

21:29

So when you look at coronary arteries and, and

21:33

or I know aortic valve grafts

21:35

or any type of surgical prosthesis, you want to ensure

21:38

that you are lined up at the actual annulus

21:41

of the valve prosthetic, right?

21:44

Okay. You wanna be located in it

21:46

and you want to assess for a handful of things.

21:49

One, is there any evidence of calcification within those?

21:53

In this case, you can actually see, excuse me,

21:58

you can actually see the, um, the ano the leaflet itself.

22:03

You're being quite calcified.

22:05

You can see the level of calcification

22:07

and extent essentially courses, majority of the leaflet

22:11

in this other particular leaflet.

22:13

Again, you follow it along

22:14

and you can see the entire leaflet.

22:16

All the margins of the leaflet tend to be quite thickened,

22:20

very visible originating from the, from the base of the,

22:25

of the ring all the way to the leaflet tip, which again,

22:29

it's a marker of like hypot continuating leaflet thickening,

22:33

which oftentimes we see in patients

22:35

who have bowel prosthetic valve dysfunction.

22:37

Last but not least, you can see that it not only is one,

22:41

but all of the leaflets tend to have this degree of,

22:44

of progressive and degeneration that can come from it.

22:48

Another rule to remember is

22:50

that if the valve prosthetic valve leaflets

22:53

are thicker than the native valve leaflets, uh,

22:57

particularly like the say the ponic valve

23:00

or might the mi the mitral balcony generates,

23:02

it's not uncommon for it to be seen like that.

23:04

It also is a marker of of function.

23:08

Last but not least, when you see that level of hyper

23:11

leaflet thickening, we also want to look at the ring

23:14

for any evidence of like panas formation

23:16

or thrombus formation.

23:18

'cause a lot of these tend to be either precursors

23:21

or markers of prior, uh, thrombosis.

23:23

In this particular case,

23:25

you can see this irregularities along the annulus and,

23:28

and ring even calcification.

23:31

And that's one some of the things that you can see as

23:33

above prosthetic valve pans can quite form there and,

23:36

and can manifest as other phyics uh,

23:41

bioprosthetic, uh, valve dysfunction.

23:43

And in the long term they can cause quite a bit

23:45

of of issues.

23:47

Okay, now yeah,

23:51

myocardial per pericardial valvular

23:54

ification differentiation.

23:56

Yeah, it's important in any bioprosthetic valve

24:00

where you see calcifications like this,

24:03

essentially you are dealing with only one process

24:06

and that is previous thrombus that has degenerated.

24:10

So bioprosthetic valves,

24:13

any calcification is the end stage of,

24:16

of degeneration,

24:18

meaning there was a clot there at some point in time

24:20

or hypot leaflet thrombosis that's been there

24:24

in this particular, uh,

24:26

other valve like say the mitral valve here

24:28

and we, we'll use it as an example, right?

24:31

You have evidence of degenerative changes

24:35

and you can have thickening kind

24:36

of like fibrosis replacement.

24:38

You can sometimes see calcifications within these

24:41

valves that can occur.

24:43

So again, if you see the calcium within the leaflet tips,

24:45

which is tends to be one of the most common sites,

24:48

you can see that in this particular patient,

24:50

not only do you see that, but you see

24:52

that there's degenerative changes along the mitral annulus

24:55

and it tends to have two calcification soft tissue

24:58

continuation consistent with case use.

25:00

Uh, caius are calcification, uh,

25:05

MIT or calcification.

25:06

But here you can see how in this degenerative valve here on

25:09

the interior of the mitral valve,

25:11

you can see some ponte calcification.

25:14

So that's important in VA native valve.

25:17

When you see that calcium, again,

25:19

it's degenerative changes in the pericardium.

25:22

When you see calcifications it's usually a marker

25:25

of prior pericarditis.

25:26

And in this particular, in some cases chronic pericarditis,

25:31

uh, tuberculosis, radiation therapy can also do that.

25:35

And last but not least, calcifications in the myocardium,

25:39

especially if it follows the mitral annulus, this tends

25:42

to be degenerative mitrals annular calcification.

25:45

If you see calcifications in a laminar

25:49

sub endocardial pattern, meaning the inside

25:51

of the ventricle, and it tends to be along a coronary uh,

25:56

distribution and it's associated with wall thinning,

25:58

it's more likely applied or thrombus or prior infarction.

26:02

Sometimes when the mitral valves are degenerative,

26:05

they will have some of the degenerative changes reached down

26:08

into the papillary muscles, which is not uncommon

26:11

for you see papillary muscle calcification

26:14

from degenerative changes.

26:17

But myocardial infarction

26:18

to cause issues like an infarcted papillary muscle

26:22

that has calcium or like an infarct anex is not likely the

26:26

case usually for you

26:28

to have calcium in the myocardial from

26:30

from prior infarction.

26:31

It tends to be a pretty extensive transmural myocardial

26:35

infarction and usually associated with s

26:37

and significant replacement fibrosis.

26:39

So it's not uncommon for you to see her in the annulus

26:42

of the mitral valve in the, in the pericardium,

26:45

in the valves, less common in the myocardium

26:48

and the cell endocardium one itself.

26:50

Does that answer your question?

26:54

A good question so far. I like this one.

26:58

I like this one so very good.

27:01

So we have all that information. Yeah.

27:04

And then last but not least in this one we also kind

27:07

of threw in the range to kind of see,

27:09

we could also get you guys into the,

27:11

let's see how well we reviewed.

27:13

And in here you can see that there's a significant stenosis

27:16

in the right coronary artery

27:18

that's pretty difficult to raise.

27:20

And I think almost all the students, uh, got it,

27:25

everybody had no difficulty finding this one.

27:27

So again, you have obstructive coronary disease,

27:30

you have bioprosthetic valve dysfunction,

27:33

that together you're going to have, uh, pretty good reason

27:36

for having some symptoms of short of breath dyspnea as well

27:40

as abnormalities in, in the case.

27:42

So very, very, very good.

27:45

Very, very, very intriguing case.

27:48

So that kind of set that up for some of the cases.

27:52

You can, you guys can start here on week nine.

27:55

Can we differentiate infective endocarditis?

27:58

No, you can only tell if there's vegetations

28:01

and abscesses in the aorta

28:03

or the, uh, leaflets.

28:06

But for you to be able to tell thrombus from this kind

28:10

of case, uh, you know, having unquote endocarditis,

28:13

you're gonna need pet, uh, pet would be the most, you know,

28:17

sense a specific finding for this, especially, you know,

28:21

if you see some annual thickening

28:24

or other inflammatory changes.

28:25

But the CT itself,

28:27

unless you see a clear vegetation in those types

28:30

of thickening things, it becomes very difficult

28:32

and challenging for it to be specific for, for, uh,

28:37

for endocarditis.

28:39

Now sensitivity wise, it's just as good as stress.

28:42

Esophageal liquid telling you there's definitely

28:44

nothing wrong here.

28:45

No normal thickening, no annular measurements, et cetera.

28:49

Okay, so a very good question. Any other questions?

28:55

Okay, so what we're going

28:57

to do next in this particular case, we're gonna kind

29:01

of review a couple of things When it comes to cardiac ct,

29:04

uh, I like to, um,

29:06

protocol all my cardiac CT bi facing injections,

29:09

not tri facing injections.

29:11

And the reason why is cases like this one

29:13

where you have patients who have so shorts of breath,

29:16

chest pain, and if you have a true biphasic injection,

29:20

you have a significant septal defect, you'll be able

29:22

to actually detect, uh, you know, basic congenital,

29:26

simple congenital coronary uh, uh, findings.

29:29

In this particular case, you know,

29:31

whenever I see the same level of ululation in the,

29:35

in the right ventricle to the left ventricle,

29:37

and I often think, uh, that I'm dealing

29:40

with a significant hun meaning A-Q-P-Q-S greater than one.

29:43

And in this case you can actually see that.

29:47

Now in this particular case,

29:50

you can take things a little further in the, in the fact

29:52

that yes, we can simply say there is, uh, anomalous, uh,

29:57

congenital findings, uh, and obvious atrial septal defect,

30:01

but I think we can provide more information than just that.

30:04

So the advantages of cardiac CT is we have really high

30:08

spatial resolution in a full three-dimensional

30:11

volume, which is a mod.

30:12

Now a lot of the other modalities don't necessarily have

30:15

that luxury at times.

30:16

So what we're gonna do is we're gonna get into the center

30:19

of, of this defect, right, of this secundum a SD

30:24

and we're gonna kind of look at the rims

30:26

and be able to determine if we can provide our referring

30:28

physicians and colleagues the information we need about,

30:32

do we need to do a transit of AAL echocardiogram

30:35

to assess this, this defect.

30:39

So one of the things that I often do when I try to answer

30:42

that question is I kind of try

30:44

to make things like we would on echocardiogram.

30:47

So, uh, what we're going to do is

30:51

echocardiography usually looks at the rims of the a

30:56

und uh, hearts by looking at a four chamber view.

31:00

So that's the first thing that we're going to do.

31:02

We're gonna get a good apical four chamber view,

31:05

and that's usually a line oriented in disposition.

31:09

And then that's what we're going to do.

31:10

And you're gonna get two rims, see the distinct rims, right?

31:15

So it's important for you to be able to know

31:17

what those rims are

31:18

and more importantly what they're, uh, located.

31:22

So, uh, the the defect itself, you're gonna use this view

31:27

to kind of measure rim sizes

31:29

and you're gonna get to where the,

31:30

you see the largest dimension in this particular case.

31:34

And you can kind of see the defect is quite notable in gap.

31:38

Uh, for there, uh, the ome defect, you're gonna have

31:42

to remember certain risks.

31:44

So off the aortic for of the four chamber view,

31:48

you always have the atrial ventricular rim, okay?

31:51

And that one tends to be opposite of the posterior

31:55

and superior rim.

31:57

So if you're looking at, let's say,

31:59

let me see if I can kinda put this, uh,

32:03

reconstruction into perspective.

32:06

Let me see if I can do, uh, a full poll here.

32:10

We do a right

32:14

and I'm gonna try to line this up here like this

32:18

so we can kind of use that as our,

32:21

as our point of reference.

32:22

Hopefully this does not move my my orientation,

32:27

but you can use this to kind see the defect.

32:30

See this orifice here, that's your, uh, your, your a SD

32:35

and we're gonna use this to kinda move

32:37

through along and kind of see it.

32:39

So the rims that we're interested in this rim,

32:41

atrial ventricular

32:43

and the posterior superior rim, which we can't see for you

32:46

to notice, is you need to have enough rim to be able

32:49

to anchor a device into this, uh, patient, uh, defect.

32:54

So at least you need a rim that tends

32:56

to be five millimeters from the, the muscle of the heart

33:00

or from the, the actual borders of the a SD.

33:03

So here you can see the atrial ventricular rim has quite a

33:06

bit of, of rim,

33:08

but here in the posterior sphere tends

33:10

to be a little bit more deficient, meaning there's some,

33:12

I'm not doubting it's existence,

33:14

but it's a little bit less prominent

33:16

than what you'd want it to be.

33:18

Usually you want at least more than five millimeters

33:21

to be able to have good anchoring of the device

33:23

to prevent any type of dislodgement.

33:27

So that's what we're going to look at.

33:29

So that's the first rim to keep an eye out for.

33:31

The other rim that you need to keep an eye out

33:33

for is located at the junction between the vena cava

33:38

and the vena cava.

33:40

So one of the things that I usually like to do is I like

33:43

to line up my, my vena cava.

33:46

Uh, so that's what we're going to do.

33:47

We're going to kind of have the SVC

33:50

and IVCV located, right?

33:53

So let's kinda align these two here

33:57

and we're gonna kinda walk through these two to kind of find

34:02

where, where that rim becomes a little bit more

34:05

noticeable and efficient.

34:07

That is going to end up being here.

34:08

You're gonna be able to see that rim deficiency here

34:12

where you have the SVC border and the IVC border.

34:15

Here's the or. So again, you're gonna want to,

34:20

to visualize this rim

34:22

and be able to make the measurements just like you see here

34:26

from the top of this one to the bottom of this one.

34:29

So those rims obviously are more than 10 millimeters in

34:32

diameter, definitely more than five millimeters in diameter.

34:35

Last but not least, the last rim that we need to do,

34:38

it's a little bit trickier

34:39

and I usually like to be more consistent

34:41

with echocardiography with it.

34:43

And that one tends to be your aortic rim.

34:47

And what you're going to do is you create the short axis

34:50

beyond echocardiogram, you have the outflow tract,

34:52

you have the right atrium and you have the aorta

34:55

because this is the most easy

34:57

and consistent way to see the aortic rim.

34:59

You can see here that as I scroll through the aorta,

35:03

there really isn't much rim meaning here it's barely any

35:07

defect and here, uh, any tissue

35:10

and here there's hardly any tissue.

35:12

So you can imagine if you're trying to put a device

35:15

that's anchored to a structure

35:18

and your structure anchoring you ends up being the aorta,

35:21

that could be a problem because this devices can erode

35:25

and you don't wanna have a fistula from a highly pressurized

35:28

systemic aorta to a lower pressure right atrium.

35:32

'cause then that will not go necessarily well

35:34

for the patient in the long term.

35:36

So this defect right here is what we're kind of looking at

35:40

and we're kind of now in a

35:43

multiple planer views of that orifice.

35:45

So see this thing that you see right here, that's the,

35:50

that's the secundum a SD

35:52

and that's why that's what we're kind looking at here

35:55

in, in this image.

35:57

So that's kind of the important information

35:59

that we wanted you guys to be able to do

36:02

and more importantly, have the opportunity

36:03

to utilize cardiac CT to, to be able to assess

36:08

how these rims can be used in the assessed

36:11

or for pre-procedural planning, avoiding the patient.

36:14

Another procedure. I can tell you doing a lot

36:17

of ts not a lot of patients are eager to come back

36:20

or three times for another VPTE when they can avoid

36:24

it if, if they can.

36:25

So that's an important finding.

36:27

So overall that's kind of what we have.

36:29

And you can look at the right ventricular chamber size in,

36:32

determine that this, this particular patient,

36:34

it is quite notable and significant in dimension.

36:36

So when you have a combination of right atrial dilatation,

36:40

right ventricular dilatation, equal ification

36:44

of attenuation of the chambers

36:46

and you have a orifice, uh, you can do that

36:50

and we differentiate premium from secundum defects.

36:53

Absolutely. And in this case, you're gonna look at

36:56

any associated uh, uh, pri defects,

37:00

which you would have like a partial ad canal if you think

37:02

about it here.

37:04

The membrane septum

37:05

of the left ventricular outflow tract tends to be quite

37:08

competent, meaning you don't see any residual defects here

37:12

and you don't see any clefting of the mi

37:14

of the mitral valve.

37:16

You don't see any issues with the AV groove itself.

37:19

So when you don't have those accompanying findings,

37:22

then you would end up having essentially, uh, findings

37:25

to system with more of as a condom type frame.

37:28

Meaning here the thing that's deficient is the,

37:31

the AUM premium and atrial secundum never

37:34

really fully developed.

37:35

You see components of the premium down here,

37:37

but the secundum brings never really did, uh, arrive on time

37:41

to, to be part of the conversation.

37:42

But yes, you can definitely use ARDI X

37:44

and team to evaluate for quality dose.

37:47

Very good. Any other questions? Any other concerns?

37:55

Uhhuh? So ventricular dilatation versus an aneurysm, right?

37:59

Ventricular dilatation means that the walls of the muscle

38:02

of the heart tend to be normal in thickness

38:05

and they don't have evidence of replacement fibrosis.

38:07

And that's a really, really important thing to

38:10

determine in this particular case,

38:12

if you look at the actual structure of the muscle

38:14

of the heart, the myocardium, there's no evidence

38:17

of any findings of like, uh, fighting metaplasia

38:21

or replacement fibrosis.

38:22

Replacement fibrosis

38:23

and old prior infarctions usually has a distinct dark

38:29

rim appearance where there's no conscious classification.

38:32

And then more importantly, you'll have a lot

38:34

of fatty metaplasia within the myocardium in areas

38:36

where you wouldn't see it otherwise.

38:39

So that's the importance.

38:40

Aneurysms tend to be more

38:43

broad mouth located in particularly in in the

38:46

coronary distribution.

38:47

'cause that's the only way you're gonna get a ventricular

38:50

aneurysm if you have something replacing the myocardium.

38:54

The right side of the heart can get aneurysmal,

38:57

especially in patients with alogenic cardiomyopathy.

39:00

But again, you're looking for evidence

39:01

of like abnormal wall thickness or abnormal outpouching.

39:06

It tends to be associated with like anything

39:08

that's replacing the myocardium to do that.

39:11

So if you don't have evidence

39:14

of myocardial replacement fibrosis, then the likelihood

39:17

that this is aneurysmal versus an actual dilatation is,

39:22

is more consistent.

39:24

So that's how I usually look.

39:25

Ventricular dilatation,

39:26

the myocardial cell structurally is intact or normal.

39:30

And aneurysm you have some sort

39:32

of defect in the myocardium from replacing fibrosis

39:35

that's going to lead into your column.

39:38

So very good question. Any other question?

39:41

Any other concerns?

39:46

No. Okay.

39:48

Well I think those are all the five cases

39:51

that we had a little bit easier to go through since,

39:53

you know, the next cases get a little bit more challenging,

39:56

but you know, we only have case nine cases coming up,

40:00

another gala of, of congenital findings.

40:04

So that's always fantastic to do a couple

40:06

of really interesting, uh, congenital findings.

40:09

So I hope you guys find all of them.

40:11

And then last but not least, with cases four

40:15

and five, we case nine, four and five to finish things off

40:19

and introduce you to the aortic valve replacement cases

40:22

and those can be quite the challenging cases.

40:25

So we'll go from there

40:27

and we'll look forward to those uhhuh inside on VSD.

40:32

Again, if you do a biphasic injection, you should be able

40:35

to see ventricular sal defect relativity easier.

40:38

They're more likely to see pseudo aneurysms

40:40

of the left ventricular outflow tract or the ous septum.

40:44

And you are a true VSD or less.

40:48

They tend to be related to a post myocardial infraction,

40:50

but they are definitely easy to detect on cardiac ct.

40:54

And a lot of the things you'll find with congenital CT is

40:57

ensuring that you're routinely due by face injections.

41:01

That way if there's a significant left to right shunt,

41:04

you'll be able to assess it by simply the level of, uh,

41:08

contrast attaining in the, in the,

41:10

in the structures of interest.

41:12

Okay. Very

41:14

good. All right,

41:19

Thank you Dr. Again,

41:20

Dr. Es

41:21

and, uh, just let everyone know that, um,

41:24

I'll be sharing this rough footage here over the next couple

41:26

of hours and if you have any more questions, just email 'em

41:29

to me and I'll forward them to the faculty.

41:31

So everyone have a good evening. Thanks again Dr. Punani.

41:35

Of course, anytime. Take good care.