0:00

So the fractional flow reserve was performed,

0:03

and the question was mid LAD.

0:05

And what we see here is that there's a gradual transition

0:10

around that stenosis that I had.

0:11

My biggest question, um,

0:13

and you can see the branch here

0:14

that was that large diagonal.

0:16

Um, but there is a more distal lesion.

0:19

So, uh, this one doesn't reach significance, this 0.85,

0:23

but this one certainly does, and I can see a focal lesion.

0:25

So I might do a second look at that distal lesion,

0:28

which I actually hadn't really noticed as much.

0:30

Um, and you can see here on this view,

0:33

this particular vendor gives you a plot

0:34

that tells you the gray zone is 0.75 to 0.8,

0:38

and, um, positive is below that for sure.

0:41

Anything below 0.8 could be positive.

0:42

These distal things with like a nothing,

0:44

no one's gonna stent that anyway.

0:46

It's too small. Uh,

0:47

but there is an open question here about the distal ID

0:50

with a focal lesion, a focal transition,

0:52

and those focal trans greatness tend to be, uh,

0:54

the ones we worry about.

0:56

So let's see what the invasive coronary

0:58

angiogram showed here.

1:00

Okay, so here's the invasive angiogram.

1:02

Um, here's a selective left-sided injection.

1:04

The catheter's pointing left.

1:05

I can see the left sinus of El Salva, the spines on the,

1:08

the left side of the image.

1:09

And you can imagine that if, uh, we had a wider field

1:12

of view, you'd see the apex coming off to the right here.

1:14

So, uh, I just think of the,

1:15

where, where the heart would live.

1:17

I don't really think as much about memorizing the degrees

1:19

of rotation for these, uh, views.

1:21

But we can see here is, um, the, the left main

1:25

and bifurcates.

1:26

Uh, there's probably a tiny, uh, trifurcation that I'm,

1:28

yeah, it's kind of a small vessel.

1:30

Uh, I'm gonna change views here

1:32

to get a little different injection.

1:34

Um, and then I'm gonna follow this down.

1:36

So these are the, this is the LED wrapping around the apex.

1:39

We kind of have some overlap of diagonals

1:42

and septal perforators and then the obtuse marginals.

1:45

So what the interventional cardiologist did would

1:47

just lay this out a little differently.

1:48

So these ones coming off at a right angle

1:51

are septal perforators.

1:52

The diagonals come off at an oblique angle

1:54

and the area of concern was about right here.

1:58

So that was a positive FFR.

2:01

Um, the CT was, uh, had a concern, a little higher up.

2:04

Um, but, uh, the, the bottom line in this, uh, report is

2:09

that the, uh, interventionalists, as you probably see

2:13

with your own eyes, um, thought there is a stenosis

2:16

and they thought it's about 40, uh, percent, um,

2:19

and apically almost 50%.

2:21

So in the moderate range.

2:23

Um, and I believe that

2:24

because this was a pre-op, oh, they did another test here,

2:27

something called the DFR as we talked about.

2:29

Um, and they ran that

2:31

and it was above threshold, so it was negative.

2:33

So, so this case is nice.

2:34

We have a CT that was successful

2:37

and then it was a very high calcium burden

2:39

we could see through the lumen.

2:40

We picked up some questions.

2:42

Um, it was intermediate,

2:43

so it was a little more complex than just negative

2:45

or positive catheter angiogram confirmed

2:48

that we have an intermediate lesion to the point

2:51

where even the interventionalist wasn't sure.

2:53

So, uh, and the way they go about doing

2:55

that is placing a wire, uh,

2:58

and doing some measurements with a special tool.

2:59

So they put the wire right across the lesion in question,

3:02

investigated it and confirmed it was not worth treating.

3:05

Patient went to surgery and did fine.