0:01

Next case is a 60 something year old patient who, um,

0:05

had some symptoms, thought to be an a**l equivalent,

0:08

uh, no known disease.

0:10

I'll just start with a quick run through the calcium score.

0:14

Now we have known disease, we have no atherosclerosis,

0:17

but really no info about the the stenosis,

0:19

but I can already tell this is gonna be a pretty much

0:21

of a haul to get through.

0:23

So we look at the RCA

0:25

and immediately see a lot of dense proximal calcium.

0:28

Not thrilled about that.

0:30

Um, and we know that calcium can be a limitation.

0:34

Tortuosity as well, uh, sure looks significant to me.

0:39

Um, and then we may need to evaluate these, um,

0:45

with a grain of salt,

0:46

just knowing that they're so calcified.

0:48

But the rest of the vessel looks pretty good.

0:50

Uh, I'll strip away the, uh, chest wall just

0:52

to show you the tortuosity.

0:54

And as you look at the, um,

0:59

proximal RCA, you can see the,

1:00

the challenge here we're up against with

1:02

between calcium and tortuosity.

1:05

It's puts it as it in a difficult spot for the eye to, uh,

1:08

discern left main looks.

1:10

Okay. Uh, you can see it's got some plaque, but not a lot.

1:13

And then this LED, um, already right here, I don't know

1:18

how I'm gonna say anything,

1:19

but it's got, uh, something, uh,

1:22

of potential significance in the mid segment.

1:26

It's not an easy case, uh, on several counts.

1:29

Um, there's a bit of calcium blooming, there's some motion,

1:33

but I'm thinking that if the next step is a calf,

1:37

that would be totally fine with me.

1:39

And knowing we might still be over calling,

1:41

but I can already see, like for instance, uh,

1:44

here there's a, a moderate stenosis, so

1:46

that's probably gonna be it.

1:47

So I'm worried about the prox RCA,

1:49

I'm worried about the mid LAD

1:51

and maybe even the proximal LAD.

1:52

Uh, there's a probably an A ramus

1:54

or an early OM that's branching.

1:56

Maybe this would be actually a good one to term a dual LED

1:59

because it's branching and it follows the course of an LED.

2:02

So probably a dual LED

2:03

with potentially significant stenosis here.

2:05

That calcified plaque. I'm just gonna center my cursor

2:08

so it makes me more confident when I have calcified

2:10

and noncalcified plaque.

2:11

And I certainly do here.

2:13

And then I'm just gonna run the circumflex

2:15

and don't like what I'm seeing right there.

2:18

I can see that being downgraded though.

2:20

But these oms are also not the prettiest.

2:24

There's a little bit of disease,

2:26

smaller vessels, hard to say.

2:28

So at least two vessel disease.

2:30

Um, and uh, probably a dual LED system

2:34

and circumflex the oms, like especially right here is,

2:39

uh, where I'm most worried.

2:42

Uh, maybe moderate of two marginal little,

2:44

uh, disease there.

2:46

Let's move to the next test.

2:48

Uh, we're already here in the ct so we might as well try

2:51

for an fr this one, uh,

2:53

was declined on the RCA due to motion artifact.

2:56

Uh, unfortunate because I had a question there, but I'm

2:58

Pretty sure that's a calf worthy lesion right there.

3:01

And then you have positive values in the LED,

3:03

so even just one's enough, uh, with a symptomatic patient.

3:07

And um, the other two

3:09

or smaller vessels, I can imagine those being ignored.

3:12

Or as a pessimist,

3:13

you have multiple vessels in the C territory.

3:15

You've got a clear LED and a very broadly clear RCA.

3:18

So you're kind of in three vessel disease territory.

3:21

So now let's look at our catheterization.

3:26

Looks like they okay here their injection.

3:29

Oh, and that confirms, I think that's an RCA severe.

3:32

I'm sure they're gonna try it one more effort to.

3:34

Yeah, especially if I pause.

3:37

It's kind of a shelf like plaque. Yeah, right there.

3:40

So I think that's a true lesion.

3:42

Um, they're injecting the left,

3:44

and I think we were correct on the circumflex.

3:47

There's just some OM stuff, which is kind of distal

3:51

and there is a little overlap there.

3:54

Let's look here. LE.

3:55

Oh yeah, so multiple lesions in the LED and that diagonal

3:59

or a dual LED, whichever you want to call it.

4:01

So it was called as three vessel disease.

4:03

Severe calcified, long mid LED stenosis in series.

4:06

So serial stenosis always hemodynamically significant severe

4:09

calcified proximal rca, good

4:11

and severe stenosis in all branches

4:13

of a large trifurcated, high OM one.

4:15

So I didn't investigate the labeling there,

4:17

but uh, went for a cabbage

4:19

and I didn't mention

4:21

that there's a aortic valve replacement.

4:23

Uh, uh, so there must be some issue with,

4:26

and I could see already a little bit of sclerosis

4:28

of the aortic valve.

4:30

I think the, uh, aortic root looks big too.

4:32

So I can imagine that this being a combination

4:35

of things that leads to a surgery.

4:37

Uh, I will also point out, um,

4:39

if you're gonna look at the aortic valve,

4:40

you wanna look in short axis, I look at a couple phases.

4:44

Incomplete co-optation here.

4:45

So there's probably moderate aortic insufficiency.

4:48

There's never a point in diastole

4:50

where I'm finding the valve coapting.

4:52

So yeah, this is a very large, uh, uh,

4:56

incomplete co-optation aorta looks big too.

4:59

And it is. So it's a judgment, call it whether

5:01

to replace that.

5:03

But an interesting case of

5:04

what ended up in three vessel disease

5:06

and two indications for, uh, open heart surgery.