0:00

So this next case is interesting.

0:03

Middle-aged patient was an inpatient admitted in part

0:07

for chest pain at one of our hospitals

0:09

that does not have a cath lab.

0:11

So, uh, very reasonable first test to do.

0:14

And what we see here is that there is a sclerosis

0:19

and not the best of image quality you

0:21

can imagine on an inpatient.

0:22

Uh, maybe not the best of enhancement,

0:25

but uh, let's try to clear what we can.

0:28

You can see how they're a larger patient too.

0:30

So in addition to the bolus being not the ideal bolus, um,

0:34

it's still coming in the contrast, but it's also late.

0:36

So I wonder if there was a Val Salva type maneuver.

0:39

Um, but I think it's gonna be, uh, diagnostic for me.

0:43

So yeah, I see some plaque

0:45

and there's probably not anything significant in the uh,

0:50

RCA so far.

0:52

I have to be careful which phase it is tortuous,

0:54

like just like the last case.

0:56

But, um, maybe a slight limitation on the RCA,

0:59

but I don't think it's fully non valuable.

1:02

Mm. Yeah, I think we can probably say it's, uh,

1:05

with not supreme confidence,

1:07

but that there's nothing obviously severe.

1:09

Uh, remember if you have a hospital at a cath lab,

1:11

you're at least making a triage decision similar like the,

1:13

the TAVR patient where we wanna make it.

1:15

Just broad strokes, do you need to go further or not?

1:19

LED actually looks pretty good to me, as does the left main,

1:24

and of course we're gonna check that in one more view.

1:26

Looks good. So that brings us to the circumflex

1:29

and while this is gonna be a tough, uh, valve just

1:32

'cause of the tortuosity, the calcium,

1:36

but non-dominant vessel

1:40

and I just don't see that very well down here.

1:43

Sure. Wish I had a less noisy set of images.

1:47

Don't know if I can confidently say that's negative.

1:50

Um, but a lot of resource use

1:52

to grab a calf just to confirm.

1:54

So we wanna augment, I think I'd have

1:57

to call this moderate actually, just based on the amount

1:59

of plaque and the borderline narrowing here

2:02

in this circumflex.

2:03

So, uh, I'm gonna call it circ moderate.

2:06

And uh, next thing I think would either do a second test,

2:10

like a, maybe a nuclear profusion test

2:13

or perhaps A-C-T-F-F-R.

2:15

And of course we have that.

2:17

Um, interestingly, they just couldn't do this

2:21

'cause of motion or maybe the noise.

2:23

There's some clear thresholds the, the vendor sets.

2:26

So that's fine. It wasn't a question in my mind.

2:28

Um, LED is cleared fine. Um, circumflex is cleared.

2:32

So yes, there's some mild abnormalities

2:34

and that was the area I was most concerned.

2:35

I really thought that was moderate. I think it still is,

2:38

it's just it's not predicted

2:39

to be significant and that's all they needed.

2:41

They just wanted a, uh, con in a non-dominant vessel anyway,

2:44

you would have a hard time pursuing just that.

2:47

But this is a adding a modicum of confidence

2:50

that this is a negative study.