0:01

This next case is very interesting

0:04

and, um, I'll withhold some of the history.

0:08

Uh, but I'll tell you that they were a pretty sick inpatient

0:12

when they got their CT scan.

0:15

And you can tell you that even without looking at the scout,

0:18

this is a defibrillator, uh, pad on the patient.

0:20

You know that there's been a sternotomy of some kind,

0:23

and the lungs are showing probably some abnormalities,

0:27

maybe aspiration, some edema.

0:30

Um, but I want to direct your attention

0:32

to the coronary arteries.

0:34

And you can see here that the LAD,

0:35

without even going off axial images, looks occluded.

0:39

And more importantly,

0:42

the ventricular looks very abnormal.

0:44

So the, uh, a normal ventricle should

0:46

taper towards the apex.

0:48

Just you can probably ignore the fact

0:49

that they had a mitral valve repair for now.

0:51

Um, but as you look at this case, um, I want you to trace

0:54

that LED down and then do a practice run at making your

1:00

long and short axis views.

1:02

And without even going much off of my, uh, normal views

1:05

and nice incidental view, the RCA here,

1:07

there's the left main circumflex.

1:09

But, um, look at the abnormal remodeling

1:13

of the left ventricle apex here.

1:14

So ventricles should have tapering of the myocardium,

1:19

but this is far more than we're used to seeing,

1:21

so we can turn on average intensity projection.

1:24

Again, I like about an eight millimeter mip,

1:26

but I don't think you need any, uh, special reformatting

1:29

to recognize the abnormality here.

1:31

So this is a very diluted ventricle

1:34

and there is a very irregular outpouching,

1:40

and this to me looks like a pseudo aneurysm.

1:42

It's got a narrow neck and a relatively wide body.

1:45

It's got a thin rim holding in the contrast,

1:48

and there's different densities here.

1:50

So if we're lucky, we find this at the time of scanning

1:54

and even grab a delayed image, uh, which just shows

1:57

that this does a pacify late.

1:59

Uh, you also might be lucky enough to get some motion.

2:02

Uh, here's just a partial cardiac cycle,

2:05

but I'm just gonna, um, play through that if I can.

2:09

Nope, not enough dynamic info, so we'll just ignore that.

2:12

But the fact is, regardless of what you see,

2:14

you see a dilated ventricular aneurysm.

2:16

And if I were to describe this aneurysm,

2:18

I would use my segmental anatomy.

2:20

And so I would know that the, uh, pseudo aneurysm

2:22

and likely fistulization into the right ventricle,

2:25

um, is at the mid-level.

2:27

And then I also have a dilated anterior and apical

2:32

and inferior wall segments.

2:33

And if I look here at the apex, it's really the anterior,

2:35

the lateral, the inferior and the septal.

2:37

So it's a basically an aneurysmal, um, left ventricle

2:41

with a pseudo aneurysm

2:42

and fistulization from the left into the right ventricles,

2:45

which can happen from mis,

2:47

and you have the cause of it right on the images.

2:48

That's the LED occlusion.

2:50

So in summary, um, this is a cataracts five with occlusion

2:55

of the LAD and it's a native LAD.

2:57

And then I'd add another, um,

2:58

Summary impression point

3:00

to talk about the ventricular aneurysm and the fistula,

3:03

and definitely give a phone call.

3:05

This is a really, uh, feared complication

3:07

of a myocardial infarction.

3:08

So myocardial contained rupture

3:11

and pseudo aneurysm with fistula.