0:01

The next case is, um, a fairly young gentleman

0:04

who had already had a stenting procedure.

0:06

And you can see that stent right here in the LED.

0:09

And, um, rather than worry too much about the coronaries,

0:12

I wanted to talk more about the myocardium.

0:14

So it was known, I believe,

0:15

that this patient had an occlusion.

0:17

Let's go back and just review

0:20

the myocardial segmental anatomy.

0:22

If you take these axial dataset

0:25

and you put your cursor in the middle

0:27

of the mitral valve plane and then go parallel

0:29

to the interventricular septum on this axial image,

0:32

you'll create the two chamber view.

0:34

And on this view, you wanna go perpendicular

0:37

to the long axis.

0:38

So that green plane is defined here.

0:40

This is your short axis.

0:42

And then if I find the middle of the, um, right ventricle

0:45

and bisect the acute margin, this view resulting, um,

0:49

defines the true four chamber.

0:52

And if I take it up to the basal level

0:54

and bisect the left ventricular outflow tract,

0:58

I would define the three chamber.

0:59

But no matter which long axis view I look at,

1:02

I see the apex vial, and I don't like what I see.

1:04

And what I'm seeing here is a

1:08

hypokinetic left ventricular apex and a thrombus.

1:11

So the most common cardiac mass is thrombus,

1:13

and the most common cardiac disease is

1:15

ischemic heart disease.

1:16

So really not a shock.

1:17

Um, but the apex can be close to the echocardiography probe

1:21

and too close to the chest wall, to the point

1:23

where you can miss that due to artifacts.

1:24

So you might wanna warn if you're the first to know,

1:27

because the echocardiogram can be done differently

1:29

or more carefully to look at the apex.

1:32

Um, but also, uh,

1:33

if I wanna look at the

1:34

myocardial function, I can help out here.

1:37

And so I might go to an eight millimeter average NPR,

1:40

and I would mention that the mid to apical, uh,

1:44

interseptal walls as well as the,

1:47

I can just look at each one and kind

1:48

of do it like a checklist, really.

1:50

The anterior, the lateral, the inferior,

1:52

and the septal, uh, walls

1:53

of the apical segment are hypokinetic.

1:56

So I have this noncalcified thrombus,

1:59

and I have regional abnormality in the, uh,

2:02

territory of the LED.

2:03

And if you remember, I just glossed through it,

2:05

but there was an LED stent.

2:06

So this is not, uh, a shock that it fits the territory.

2:10

Uh, but important to note this complication.

2:12

Say you're not sure if there's mixing artifact.

2:14

This is well defined, and, uh, I'll stop the syn

2:16

and just show you here that's sharply de marketed.

2:18

I can always just do a delayed image and see that persists.

2:21

So one to two minutes is all you need.

2:23

Um, if you check the images and find them, uh, great.

2:26

If you don't, then you would just wanna make sure you

2:30

add that to your protocol.

2:32

And I'm second guessing.

2:33

Oh yeah, there might actually

2:36

just be extensive atheroma and not a stent.

2:38

I can't remember whether this person had a,

2:40

a stent that was occluded.

2:42

In fact, it was not a stent, it was just tram track calcium.

2:44

So I, what I was showing you, there was stenosis

2:47

and, uh, extensive on of plaque.

2:49

The dis LLAD is probably occluded,

2:51

but there's certainly not, uh, a stent,

2:53

but rather just a, a fair amount of plaque important

2:56

to make a phone call if you do

2:58

Find this and you're the first to know.

3:00

Uh, and the other interesting thing about this patient is

3:03

that there is a, uh, uh, lot of disease in the RCA.

3:07

And I believe when we sorted out the wall motion, uh,

3:11

we looked and we went through segment by segment,

3:14

and we noticed a little bit of lateral wall, uh,

3:17

hypokinesis and thinning too.

3:19

So really, uh,

3:20

the most profound abnormalities in the LED territory.

3:22

But you also have, uh, this lateral wall finding,

3:26

which would suggest, uh, circumflex disease.

3:28

And as you can see, the proximal circumflex,

3:31

we'll show this jump to real quickly.

3:33

Circumflex has its share of disease as well.

3:36

So again, important sequela of infarction, uh,

3:39

thrombus formation.