0:01

Okay, so this next case is an interesting

0:03

and emerging use of CT and C-T-F-F-R.

0:06

This is a preoperative, uh, patient.

0:10

They have a thoracic dissection, thoracic aortic aneurysm,

0:13

and there's even talk about doing

0:16

a transcatheter aortic valve replacement.

0:18

You can see the type A dissection,

0:20

which is ironically chronic.

0:22

Um, that's a complex case, uh, already,

0:25

but, um, TAVR was being considered.

0:26

And so, um, what we've found from our, um,

0:30

advanced heart valve team is that they have asked us

0:34

to always evaluate the coronary arteries.

0:37

The pretest risk in these patients is higher,

0:39

but we know from many studies

0:40

that the yield is actually high in TAVR patients

0:44

because about half of patients, um,

0:48

that are TAVR candidates, which tend towards the elderly

0:51

and the interoperable, um,

0:52

do not have significant stenosis and they all get angiograms.

0:55

So, uh, a few studies since then,

0:58

including some internal looks, we had show the same

1:01

that we can clear people with CT at least some of the time

1:04

and spare that extra angiogram.

1:07

So, uh, here we are

1:08

and we now know there's a lot of, um,

1:10

calcific coronary art sclerosis,

1:12

some bulky mitral annular calcifications, just

1:14

as a curiosity, and we know they have calc in

1:17

their, uh, aortic valve.

1:18

That's why they're here for TAVR evaluation.

1:20

So, first things first, look at the RCA.

1:23

Um, so we bake this into every TAVR acquisition.

1:25

This patient also got a chest, ab pelvis, CTA.

1:28

We also, um, have learned you can send for the, uh,

1:33

C-T-F-F-R when needed.

1:34

There's some papers on that,

1:36

and it's successful more often than we would think

1:39

'cause the, you can't obviously give

1:40

nitroglycerin to these patients.

1:42

Um, and then the, the final thought is it's a lower bar.

1:46

We just want to decide whether you're cathing early

1:48

or just day of procedure.

1:49

So it's okay if we're not quite as precise.

1:52

It's more of a triage tool, um, which is comforting

1:55

'cause these are much higher risk elderly patients.

1:58

I believe this patient is 87.

2:00

Um, and the problem here is it's not negative,

2:03

which is all we're really aiming for.

2:05

Um, it's kind of got a moderate stenosis here.

2:07

And we also know that the stenosis won't be quite

2:09

as apparent without nitroglycerin.

2:11

So there's a propensity to slightly under call.

2:13

So we read a little more conservatively.

2:16

And so this patient was called to have a, um,

2:20

moderate stenosis in that I think circumflex, uh,

2:23

the lesion in question.

2:25

Uh, so this is, uh, another one

2:26

where there's a trans lesional gradient.

2:28

It's mild and it's distal,

2:29

and they're really looking for proximal things

2:32

in our circumflex lesion in question.

2:34

My question was right here

2:35

where it's gray, too small of a vessel.

2:38

And so that's another teaching point to remember

2:40

with C-T-F-F-R, is that you have to have a lesion of, uh,

2:44

certain diameter.

2:45

And we know that it performs best in, in fact,

2:47

they give you this caveat page, uh, uh,

2:49

when they put it's a 1.8 millimeter vessel or larger,

2:53

or they just have to decline it.

2:55

And, um, it performs best when nitroglycerin is onboard,

2:58

which is contraindicated in people

3:00

with critical aortic stenosis.

3:02

So, challenging use of C-T-F-F-R, it was a good try.

3:06

We were so close to having a vessel big enough to analyze,

3:08

but it just didn't make it so not a great yield.