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Alright, next case.

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This is a patient in their seventies

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and they came for a preoperative, uh, screening test.

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They have mitral valve disease.

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You can see the left atrium's huge.

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So that would go along with several causes.

0:13

And even without going into the classic three chamber view,

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look at that mitral prolapse.

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So, um, we know why they're here.

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We'll quickly just show you a calcium score

0:20

to see whether there's any athero.

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And so often you can see this in, in this age,

0:25

especially in women, you might not have any

0:26

plaque, but this patient does.

0:28

So we have some degree of atherosclerosis

0:30

before we even start looking.

0:31

Um, I'll flip over to my small field of view image.

0:35

And now I'm going to just sharpen up that RCA.

0:40

Sometimes I like to just jump right to a cv.

0:42

I hadn't seen anything yet and, um, there wasn't a ton

0:45

of calcium in the RCA.

0:47

So this looks pretty good.

0:48

I'm just gonna look at this second lesion, uh,

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a second, uh, view here.

0:52

But, um, basically, uh, RCA looks pretty clear to me.

0:55

I don't need to go much further than that here.

0:58

Uh, let's jump right to the left.

0:59

Main, not gonna read it in mip,

1:01

but I am gonna overview it in there.

1:03

So left main looks pretty free of disease actually.

1:05

Uh, it's a long left main.

1:07

Um, but then when you get to the LAD

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and um, that's where the things, uh, get a little trickier

1:12

because we have a tubular calcified stenosis.

1:16

We do know that tubular

1:18

or circumferential calcium can be a cause

1:20

of false negatives, uh, and false positives

1:23

because it, it can encroach, there's some blooming.

1:25

Um, and one of the things that you can do

1:27

to mitigate the blooming, uh, is a, be aware of it.

1:30

B you can, uh, do some windowing.

1:33

Um, newer scanners

1:34

with higher resolution are coming out as we speak.

1:38

Um, that'll have less blooming, uh,

1:40

but they're not gonna be widely available, uh,

1:42

for a a few years at least.

1:44

And of course they're a little bit expensive, uh,

1:47

as new technology tends to be.

1:48

So we, we know we have a propensity to overcall this

1:52

and this really does not look terrible.

1:54

So I think it's still on the order of probably mild,

1:57

but I, I'm a little concerned, uh,

1:59

and we don't wanna miss something going to the

2:01

or, um, so mild,

2:05

but, uh, a little bit uncomfortable at that LED.

2:08

Um, now let's look at the circumflex

2:10

that there was a fair amount of disease.

2:13

When I see this happen where I see noncalcified plaque,

2:16

and I know it's a little bit hard,

2:17

but just to zoom in, so there's

2:19

noncalcified plaque shouldn't bloom.

2:21

So that's already a red flag

2:22

and that's the more active plaque, if you will.

2:25

There's a lot more to the plaque analysis than just that.

2:27

But I think the, the key thing would be

2:29

to know it's more likely you over call calcified plaque

2:32

and more likely

2:33

that the noncalcified lesions are more accurately viewed.

2:37

So that's already a moderate

2:38

and it's in the fairly proximal circumflex.

2:41

And then I see a second lesion here and that's bothering me.

2:44

So I'm just gonna, um, put my cursor on that, turn on it

2:47

and lay it out a little better.

2:49

Get a second, uh, plane.

2:51

By the way, you've seen me read pretty much exclusively off

2:53

of NPRs here, which is how we do our daily work.

2:56

It's nice to get the curve plane reformats, but these are

2:58

Not artifacts by the way.

3:00

I see that the plaque is not gonna change

3:02

with different phases.

3:04

If we call this in a too marginal branch, uh,

3:07

it's an intermediate size.

3:09

I I backtracked that first branch.

3:11

Uh, the, the circumflex gave rise to,

3:13

that's also a significant there.

3:14

So, uh, small vessel, but not nothing.

3:17

And we read for sensitivity.

3:19

The, the surgeon that's about to go

3:20

to the OR here doesn't want me to brush things off.

3:23

They'd rather do a few too many cats than miss disease

3:26

or have perioperative myocardial infarctions.

3:28

Other things I think about when I'm reading a preoperative

3:30

case, they're gonna do a mitral valve surgery.

3:32

So they're gonna do a lot of stitches along the annulus.

3:35

Lemme just give you that plane real quick by the way.

3:37

So I'm gonna go into my short axis view,

3:39

and when I'm looking at a a mitral valve, I want

3:43

to get into the three chamber view.

3:45

We talked about that in the, the lecture part of the course.

3:48

And you can see this prolapse.

3:49

So this is actually probably a degenerative

3:51

barlow type mitral valve.

3:53

Um, and so in the three chamber view, uh,

3:55

which I show you here, um, that's

3:57

how you would measure prolapse.

3:59

And this one's so clear you don't need a ruler.

4:01

But, um, if you draw a line along the mitral, uh, annulus

4:04

and anything that goes further than two millimeters, uh,

4:07

would be considered prolapse.

4:08

This is almost a centimeter.

4:09

And I can see incomplete coaptation, uh, here.

4:12

So we would obviously look

4:14

through the entire cardiac cycle if we had it, we do.

4:18

So you can, you can see here there's P two prolapse,

4:21

so it's a two and P two.

4:23

There's three, uh, scallops.

4:24

These are the middle, the most common,

4:26

and P two is the most common to have prolapse.

4:27

You can see there's not complete computation.

4:29

So this is free mitral regurge in the atrium

4:32

and probably the ventricle are dilating.

4:34

We don't have to get too much into it,

4:35

but a sick ventricle, um, or a stress ventricle will dilate.

4:38

No woman should have a 76 mil.

4:40

In fact, no man should either.

4:41

So this is above the threshold for any person of any height.

4:44

So we know that the ventricle and the atrium are dilating.

4:47

Um, so it's time for surgery.

4:49

We, we knew that that's why they're here.

4:51

Um, and again, we called uh, a marginal branch

4:54

and I'm a little worried about this circumflex

4:58

and I'm believing that the LAD is probably,

5:00

uh, going to be negative.

5:02

Again, we don't send every case, in fact,

5:04

we only send about nine 10% of cases

5:06

to the vendor for analysis.

5:08

But here's the F-F-R-C-T, um, which, uh,

5:11

does confirm disease in that marginal branch, um,

5:15

as well as in the sar.

5:16

So right where we worried, um, we also see that that area

5:19

that caught my eye in the LED, nothing big.

5:21

I need to go back into a second look at this distal,

5:24

probably not gonna worry too much about a distal lesion.

5:26

And then the right coronary artery here, it's kind

5:28

of an intermediate lesion right on the border of positive.

5:31

So not negative, uh, but not positive.

5:35

Uh, and conveniently we have very clear disease elsewhere.

5:38

Um, so we can go on and look at the invasive angiogram.

5:42

Okay, so here's the invasive coronary angiogram.

5:45

Um, this is a left sided view. Catheter goes left.

5:49

Um, this is the LAD coming down along the

5:54

right side of your screen. And this is the

5:56

Circumflex proper and the obtuse

5:58

marginal, let's just freeze that.

5:59

I, uh, interventional cardiologist can view these in real

6:02

time, but I'm not that smart, I guess.

6:04

So you have a significant stenosis,

6:07

I bet it's at least moderate in the description.

6:10

And then I think you also have one here,

6:11

but things have overlapped

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and that's a known phenomenon on the cath lab.

6:15

So you can see what the, the cath lab will do is try

6:18

to take some different angulations so they can kind

6:20

of clear this distal stuff.

6:22

Um, but a lot of overlap there.

6:24

Another view kind of laying things out.

6:27

So again, the LED wrapping

6:28

around the apex like most LEDs do, which means

6:31

that's your circumflex.

6:32

So it's coming up and then down.

6:34

Um, let's give another, okay, this is good for left main.

6:37

And so this is an interesting view. The, uh, l coddle.

6:40

So this is the LED.

6:41

So think of it like looking at A MRI

6:43

or a CT for the myocardium.

6:45

This is the ventricle looking in short axis.

6:47

So the apex is here, base is here.

6:50

LAD is on the septal side.

6:52

So these are your, uh, obtuse marginals and your circumflex.

6:56

As you can see here, there's that circ lesion,

6:57

kind of like an apple core.

6:59

Uh, and no, we're not gonna see the other one

7:01

that well, but okay, here it is.

7:02

So now it's laid out. So this looks

7:03

to me like a significant lesion in that of tooth marginal.

7:07

Um, I'm also curious 'cause the RCA,

7:09

I think we weren't terribly worried

7:11

based on the F-F-R-F-F-R uh,

7:15

said it was borderline not even quite threshold.

7:18

That's a tight stenosis.

7:19

So I think the CT angiogram

7:21

and the the cath are correct here

7:23

and it'd be hard to argue

7:24

with this being anything but significant.

7:25

And they even went on and got two views.

7:27

Um, and there you have it.

7:28

So this is pretty tight

7:29

and there was not a lot of time between these two tests.

7:31

So I don't think there was progression of disease.

7:33

The CT happened less than two weeks apart.

7:38

Um, and just to, uh, complete our thoughts here,

7:41

let's look at what the official report said.

7:44

So again, kind of we did see it, it just didn't look

7:47

as bad physiologically, um, which can also happen.

7:51

I guess the other thing to talk about is depending on the

7:53

amount of myocardium supplied

7:55

and the, this is predicting what a stress

7:57

of the vessel would look like.

7:58

Uh, but I don't know anyone

8:00

that would do anything further than just do the treatment

8:02

with a tight stenosis.

8:03

So this was officially read as proximal LED oh,

8:07

actually tubular 50% RCA 90% in its mid third.

8:11

So that's this, uh, lesion right here.

8:15

And the oh tooth marginal was

8:17

what we were most worried about.

8:18

These red vessels here, 70% in the mid third

8:22

and first marginal, they called it a tubular 50%.

8:26

The decision was made to

8:30

revascularize since they were going in

8:31

to do the mitral valve do a, a bypass surgery at the time.

8:35

So in summary, this is a, uh, complex disease, obtuse,

8:39

marginal, and RCA under call by C-T-F-F-R.