0:01

This patient, um, is somewhat interesting in

0:04

that they showed up in our emergency department

0:08

and, um, like many patients started

0:11

with a pulmonary embolism rule out, uh,

0:14

dyspnea kind of vague symptoms.

0:16

And, um, turned out they were in some heart failure.

0:21

You can see the pleural effusions, no pe surprise, surprise,

0:24

uh, not the perfect study, also not much in the way of, um,

0:28

atherosclerosis on this pulmonary angiogram.

0:31

So, uh, now that we know they're in heart failure, one

0:35

of the important differentials is what's the

0:36

cause of heart failure?

0:38

And, uh, CT angiogram is a pretty good way to get

0:42

that first fork in the decision tree, which is,

0:44

is it ischemic heart disease or not?

0:46

Ischemic heart disease can be treated, uh,

0:49

non-ischemic heart disease can be very difficult.

0:51

Um, now I showed you a lot of high calcium scores.

0:54

This one's zero. So, uh, still see the CHFI can, I think

0:58

that left atrium is enlarged.

0:59

Um, but now that we know that there can be a disconnect

1:02

between the degree of calcium

1:05

and stenosis, uh, it can be very important.

1:08

And so, uh, this patient deserves a full evaluation.

1:13

I'm not gonna let my guard down.

1:14

I need to clear every segment.

1:16

Left main looks pretty good to me.

1:18

Um, but immediately you get to that LED

1:20

and look at that tight stenosis.

1:22

So, um, might an acute coronary stenosis cause

1:26

some heart failure symptoms?

1:27

For sure. Um, I'm going to give a little mip

1:31

and you can see that's a completely lipid rich stenosis.

1:34

So, um, there's a lot of cute hashtags on the, uh,

1:39

internet talking about, you know, power of zero calcium.

1:43

That all falls away.

1:44

In fact, I think it's a really huge disservice if you have a

1:47

calcium score of zero and you have symptoms.

1:48

I don't really care. It's a pretest risk thing,

1:50

but it's not a anatomic thing.

1:52

And so I can tell you now we've got a tight, uh,

1:57

it looks sub totally occluded,

1:58

but we know that based on the lesion length,

2:00

it's probably not a total occlusion.

2:02

Um, we know the resolution

2:04

of the catheter angiogram will be higher.

2:05

So, uh, about a nine 10 millimeter area of stenosis.

2:09

And I can see what looks like it may be an infarct just

2:12

'cause it's a, uh, little thinning of the myocardial wall.

2:16

RCA looks all right.

2:18

Uh, and circumflex really didn't notice anything.

2:21

But, uh, I am drawn to this interseptal wall,

2:24

so we're gonna remember to make cardiac planes.

2:27

We're also gonna remember to not use mip,

2:29

but rather average intensity projection.

2:32

We're gonna make our reformats

2:33

and we're going to look for relative thinning.

2:36

I do see that, see the interseptal wall is thinner

2:39

interlateral, inferior septal.

2:41

And so the interseptal thinnings,

2:42

that's a territory which sure does match the LED

2:45

and what picked up, uh, on our eyes on that, uh,

2:48

axial plane is confirmed here.

2:50

This is a true four chamber view.

2:53

And you can also then take this

2:55

and go into a three chamber

2:59

View.

3:00

And it does look like there's a little bit of a remodeling

3:02

and some sub endocardial hypoperfusion

3:05

of the wraparound LED territory.

3:07

It's nice to have a delay.

3:08

It's good for rolling out thrombus.

3:10

Um, this is a, a minute or two later.

3:14

Doesn't help me a ton in terms of late contrast enhancement,

3:16

but I do think I confirm that there is some of

3:19

that hypo density is, uh, persisting.

3:22

Let's take a look at the angiogram.

3:25

This is just part of the catheterization,

3:26

but this is an intravascular ultrasound, um,

3:29

which helps you look at things like plaque ruptures,

3:31

vessel walls, uh,

3:33

and it's a pullback, so it's difficult to suss out.

3:36

If you can, um, imagine this just like a CT scan where the,

3:39

it only shows you the area around the lumen,

3:41

that can be a helpful feature.

3:44

Okay, so here's that invasive angiogram.

3:46

Looks like we started with a right-sided injection.

3:49

No surprise there, that's a patent vessel.

3:51

But pay attention here in the late views, you can see

3:54

brisk collaterals, retrograde filling that LED,

3:57

so severe stenosis or subtotal occlusion.

4:00

Um, so the cause of the CHF is no longer a mystery.

4:02

This is, uh, coronary disease.

4:05

Here's a catheter down the, uh, uh, circumflex,

4:08

and there's that LED subtotal occlusion

4:10

pretty dynamic process.

4:12

Um, you can see here that it,

4:13

it might have become a total occlusion in the day

4:16

between the, um, CT scan and the calf.

4:18

Uh, heart failure explained coronary diseases found, um,

4:22

and it's the lipid rich, highly active type of plaque.

4:26

We would also interpret a little differently if we knew

4:28

that there were elevated troponin values and whatnot.

4:30

But, uh, a CHF presentation due

4:33

to really proximal LED disease

4:35

with you're already watching a,

4:36

a successful stenting in progress.

4:38

And let's just check the final result.

4:41

So, cataracts four a, uh,

4:43

assuming it's an acute presentation,

4:44

it would be different management recommendations,

4:46

but a much more urgent catheterization if it's

4:49

an acute situation.

4:50

Beautiful result there with good stent.

4:53

So use of CT to clarify congestive heart failure, uh,

4:57

and rule in or out ischemic heart disease.

5:00

In this case in.