0:01

Okay, this next case is unique in that it was, um, done

0:05

in part to look at the coronary arteries.

0:07

Um, in that every TAVR scan, uh,

0:10

gets a look at coronary arteries, but it already had a cath.

0:12

So I just wanted to show you, um, a late sequela

0:15

of ischemic heart disease, difficult scan.

0:18

Um, not really, uh, important that we look

0:21

through all the coronary arteries,

0:22

but, um, we can look through the bypass graft anatomy.

0:26

This is not even gated, this part.

0:28

And you can see there's a vi bypass

0:29

graft going to the saphenous.

0:31

There's the lima, which is very disease, very hard to see.

0:36

REMA is not used. And then here's a right sided bypass graft

0:39

and a native occluded RCA.

0:41

Um, but what you notice on this delayed non-G gated series

0:44

is hypoperfusion of the myocardium.

0:47

So there's a couple ways to look at profusion.

0:49

We talked about the ischemic cascade,

0:51

um, and you even see thinning here.

0:52

So I'm gonna, um, briefly look at the myocardial function.

0:57

So we have a multi-phase exam here.

0:59

And the first thing I notice when I'm looking at the

1:02

ventricle is I'm not looking at thin cuts for the arteries,

1:04

but rather thickening the image

1:06

to make it easier on the eyes to see sub endocardial

1:09

or transmural infarcts.

1:10

Now this here is a multi-phase exam.

1:13

If I'm gonna measure wall thicknesses,

1:15

I'm gonna make sure I'm an end diastole.

1:17

And the first thing I could do is just draw a quick line.

1:19

That's a very large ventricle.

1:20

So if you look at echo normative databases, um, up

1:24

to about six millimeters for a tall man,

1:27

and I think 5.4 for a tall woman is about top normal.

1:30

This is seven. So there's nowhere near any, uh, normal here.

1:32

This is a, a dilated ventricle,

1:34

could be from a number of reasons.

1:36

In this case, I think it's probably due

1:37

to aortic valve disease as well as, uh,

1:40

ischemic heart disease.

1:41

And the reason I I'm suggesting ischemia is you've got a

1:44

bypass graft and you have some hypo enhancement.

1:48

And you've noticed here I've made an average intensity

1:49

projected eight millimeter image tight window within level.

1:53

And that kind of highlights this first pass rest perfusion.

1:56

Uh, and you can see a couple

1:57

of sub endocardial abnormalities.

1:59

And as you remember, the epicardial coronary

2:01

artis flow from outer to inner.

2:03

Um, and so the distal pressure head, the ischemic wavefront,

2:07

is worst at the inner layer.

2:08

That's why you get sub endocardial abnormalities.

2:10

This is your first pass.

2:12

So, um, you could indeed look at a delayed image and do this

2:16

and, and see that it's more profound.

2:19

Um, or you could go back

2:20

and look at your functional information

2:22

and look at how well does the heart contract.

2:24

And so when I look at this wall motion,

2:29

it's not quite a normal amount.

2:31

And I also wanted to point out in the distal apical segment

2:35

here, there's thinning and maybe perhaps kinesis.

2:37

And there was an LED territory insult, uh, at some point.

2:41

So, um, we don't necessarily need, uh, to look at

2:45

that on every scan if it's known by echocardiogram.

2:47

But when you have a limited echocardiogram

2:50

or it's complimentary

2:51

or you're just the first to know,

2:52

finding sequela ischemia is important.

2:55

Uh, you can even see the anterior

2:56

septal wall is thinning here. That's the LED

2:58

Territory. Uh, important

2:59

pertinent negatives that I mentioned,

3:01

if I see those findings are, um,

3:03

is there a calcified aneurysm?

3:05

Is there dyskinesis?

3:06

Is there thrombus within the ventricle

3:08

or really any part of the heart?

3:09

But every, uh, cardiac CT is a chance to roll out thrombus.

3:13

It's far easier than on an echo echocardiogram if you're

3:15

lucky enough to have that with a ct.

3:17

Just make sure if you need to,

3:19

to sort out mixing artifact from delay with a delayed image.

3:22

So here's a rapid scan immediately following the first scan.

3:25

And then what we do for our, uh,

3:27

structural heart scans is just always

3:28

include a delayed series.

3:30

So here's that. So a lot more equilibrium phase,

3:32

but if there were any question of mixing artifact,

3:34

it'd certainly be sorted out by one to two minutes.

3:37

This is actually a nice look at the myocardial

3:39

hypoperfusion here.

3:40

Let me just give you another look at the, uh, subin cardium.

3:43

So again, I'm thickening my view so

3:46

that I'd sort out the noise.

3:47

And you can see that fatty metaplasia and hypoperfusion

3:50

and the basal infra septal

3:52

and then the interseptal walls, so sequelae

3:55

of ischemic heart disease

3:57

and look at that little papillary

3:58

muscle, uh, poking in there.

4:00

So when you see calcification in a papillary muscle,

4:02

it's nearly always from ischemic heart disease.

4:05

So, uh, just something else to pay attention to.