0:00

Okay, this patient came in for an emergency scan, uh,

0:04

as part of their inpatient admission.

0:05

It was a elevated troponin value,

0:08

but situation where there was ambiguity wasn't

0:11

yet a cardiac cath,

0:13

but it seemed like a, something

0:15

to help clarify the diagnosis.

0:16

And you can see out sclerosis definitely confirmed.

0:19

Um, I'll just move over to the CT angiogram phases

0:23

and point out a few things.

0:25

One of them is that, um,

0:27

the extensive ACL sclerosis had some areas of, of stenosis.

0:30

Here's your LED. Um,

0:32

the circumflex is a relatively small vessel.

0:35

Here's that dominant right coronary artery

0:38

and, uh, a lot of stenosis there.

0:40

Um, so not a surprise that there's obstructive disease.

0:43

Um, but one of the things we like to do in the acute

0:46

and the emergency setting is look at a multi-phase, uh,

0:49

view, which we've talked about on a few of the cases.

0:52

So again, if you're gonna look at the myocardium

0:55

and the valves, it's good to get into a true cardiac plane.

0:59

I can see here that it's very noisy. That's intentional.

1:01

We're saving radiation. We don't really need these,

1:03

they're just kind of collateral benefit.

1:04

So we're gonna look at an average intensity projection.

1:07

I like eight millimeters.

1:08

And let's look at the wall motion since we now know there's

1:11

stenosis and it's an acute setting,

1:12

so there's very good chance that

1:14

that's causing a wall motion abnormality.

1:16

And so I'm just gonna play this movie for you.

1:18

Uh, and one thing I notice here is that the, um,

1:21

anterior lethal lid, mitral valve, uh,

1:25

functions very normally on this, uh,

1:27

three chamber cine view,

1:28

but the inferior papillary muscle doesn't move.

1:32

And what you're seeing here,

1:33

and I'll show you that on the, uh, um, short axis view

1:36

as well, is that when you have supply

1:39

to the inferior wall compromised,

1:40

and we know there's an RCA stenosis,

1:42

maybe even occlusion here, um, you can have a,

1:45

something called ischemic mitral regurgitation.

1:47

And that was known by an echo echocardiogram, uh,

1:50

that followed the ct.

1:51

Um, but the papillary muscle can become

1:54

dysfunctional because it's ischemic.

1:55

And so this is ischemic mitral regurgitation.

1:58

You can see the left atriums enlarging.

2:00

If I looked at the lungs, you might see regional edema,

2:03

but very important to pick this up

2:05

because, uh, ischemic mitral regurgitation is different than

2:08

degenerative mitral regurgitation.

2:10

And you can also see here

2:11

that there's maybe some hypo

2:12

enhancement of the inferior wall there.

2:14

Um, and there's definitely some

2:16

hypokinesis in the inferior wall.

2:18

The papillary muscles have a much smaller blood supply,

2:21

but it stems from the same regional territory.

2:23

So anterior was just fine,

2:25

but the posterior papillary muscle, not

2:27

so much ischemic mitral regurgitation.