0:00

Okay, so let's take another case.

0:02

This is another preoperative exam.

0:04

So patient where they're planning an aortic surgery.

0:07

Um, as you can see, there's a kind

0:09

of a bulbous aortic root here,

0:11

and I believe this was followed by echocardiography

0:13

and seen to be aneurysmal.

0:15

Anything over 4.5 centimeters, 4.2 actually in the root,

0:18

but an aortic root aneurysm over five can

0:21

certainly be considered for surgery.

0:23

So, uh, again, preoperative clearance, uh,

0:25

make sure there's not concomitant atherosclerosis.

0:27

Um, so let's just do our image check.

0:29

Good quality atrial appendage fills.

0:32

No significant breathing artifacts,

0:35

well opacified coverage of the anatomy needed.

0:38

Boom. And we won't be worrying about incidentals

0:40

and that kind of stuff in this course, but, uh,

0:42

of course we do widen a full field view

0:44

and reconstruct that check.

0:46

So, um, again, I'll do the RCA first,

0:48

so just following this RCA,

0:50

and if you are confident in that, there's not much plaque

0:53

axials are usually gonna be enough to get you there.

0:55

In this case, I don't see anything other than some

0:57

non-obstructive plaque.

0:59

So, uh, certainly it's a ca reds at least one.

1:02

And I guess I also should say we always

1:04

start with a calcium score.

1:05

So we, we know that there is, uh, a fair amount

1:08

of calcified plaque at certain segments here.

1:10

Um, we also know that it's nice to just remember

1:13

that the LED had some plaque and some of it was subtle,

1:16

because if you have a high good ification of the, uh, LAD,

1:19

you might, uh, mask that peripheral calcium with your,

1:22

uh, contrast bolus.

1:24

So LAD, and it comes off the left main.

1:26

I'm really quickly just going to make sure

1:28

that I'm not missing some vertically oriented plaque.

1:31

I'm not, and I'm gonna follow this, uh, LAD down.

1:36

So I see some partially calcified plaque, which is

1:40

where we should describe it,

1:41

that a lipid rich plaque is okay.

1:42

If it's a lot, then we start to worry about vulnerability.

1:45

Um, what I'm catching my eye on is this diag.

1:47

So the LAD proper is gonna be bridged for a segment.

1:50

Um, let's tuck for just a moment about bridges.

1:53

This is, uh, the coronary artery diving into the myocardium.

1:57

It's actually exceedingly common to have a bridge.

1:59

Uh, some CT studies show 70% CAT studies show 30%.

2:04

The reason we are higher is we see the myocardium causing

2:07

the compression, whereas an invasive angiogram, uh,

2:10

is continued upon a significant

2:12

compression to demonstrate this.

2:13

But if I do see this, I like to do a little bit of a,

2:15

if I have it, uh, look through systole.

2:17

I don't see much in the way of significant compression.

2:19

You might see a, a catheterized describe this

2:22

as milking angiographically,

2:24

but, um, this one's not the worst.

2:26

So, uh, moving on, we have, beyond that, the,

2:30

the vessel does, uh,

2:31

stay in the myocardium for quite a while.

2:33

If I were reporting this, I would give a length

2:35

of the first bridge,

2:36

and I would say it's, you know, two,

2:38

three millimeters deep about a 21 millimeter segment.

2:41

There's a, I think a second bridge here,

2:44

18 millimeters there.

2:45

And, uh, three millimeters.

2:47

Unless you have a very deep bridge

2:49

and there's a lot of compression,

2:50

we tend not to worry about it.

2:52

Rarely if every other cause of chest pain has been excluded,

2:55

it's a really deep bridge medical treatment.

2:57

And even in rare, rare

2:58

Cases, surgery can be considered.

3:00

Um, there's some special catheterizations you can do with,

3:03

uh, special like challenges like acetylcholine

3:05

to see if it's really a significant bridge,

3:07

small association with a site of coronary dissection.

3:10

If, if you are acutely presenting

3:12

and you don't see plaque, um, we tend not

3:14

to get atherosclerosis within the bridge segments.

3:17

And the reason we don't worry as much about a bridge,

3:20

even if it is compressing in systole, is that we know

3:23

that most coronary blood flow happens in diastole.

3:25

So your aortic valve closes, there's a little bit of, uh,

3:29

pressure head buildup, and that's

3:30

what peruses your coronary arteries.

3:32

In fact, one of the reasons we don't give nitroglycerin

3:35

to patients getting a coronary CT

3:37

with critical aortic stenosis is we know they depend on high

3:41

systemic arterial, uh, mean pressures to drive

3:44

that coronary perfusion.

3:45

And you offload that when you give nitroglycerin.

3:47

So, because those patients need the high pressures,

3:50

because there's not much blood flow forward

3:52

through the aortic valve, uh, think of your TAVR patients.

3:55

We see a lot of these, we don't give them nitroglycerin.

3:57

So the reason that we, again,

3:59

don't worry about bridges is coronary flows mostly in

4:01

diastole Anyway, so, um, long story short though, I see

4:05

that large diagonal and I, uh, my ire is raised

4:09

because I don't like the view of that that I'm getting.

4:11

So let's do some advanced visualization here.

4:14

So do I see a touch of motion? Yes, but not the worst.

4:18

Um, an artifact should not persist on multiple, uh,

4:21

phases of the cardiac cycle.

4:23

Uh, I'm gonna mip this,

4:24

but it's a low density plaque, so I can see that I'm,

4:27

I might, uh, be at risk of missing something if I, uh,

4:30

use the maximum intensity projection, the MIP view.

4:34

So there is some plaque in that diag,

4:35

and it's not a small diag, so I'm on the hook.

4:37

It's a two millimeter vessel

4:40

and just give you that overview again.

4:42

So, and this looks like an early, uh,

4:44

obtuse marginal by the way.

4:45

So I, I don't think I'd call that a trifurcation,

4:47

but some might in the, in the cath lab,

4:49

if it's ambiguous like that, I could see it go either way.

4:51

So yeah, I'm a little worried about

4:53

that plaque there in the diagonal.

4:55

Sometimes the diagonal has lots of branches

4:58

and that could actually be considered a variant

5:01

of a dual LAD system.

5:02

You can certainly have that. Uh, okay,

5:04

so Diagon gonna come back to, uh, this is a large, uh,

5:08

early obtuse marginal has a bridge segment as well.

5:11

This person may have some HCM

5:13

or just hypertrophy that can cause more bridging.

5:15

Um, here's the, so bridging just,

5:17

it's the vessel being in the myocardium.

5:19

It's either laying 180 degrees or more,

5:22

and it's within the, the myocardium.

5:24

It's a nondominant circumflex.

5:25

There's another obtuse marginal with a bridge.

5:28

Let's just, uh, give a MIP to reveal that.

5:30

But see bridging here, little subtle bridging there.

5:35

So a fair amount of bridges,

5:36

and there's that plaque that just, I can't make go away.

5:39

So I'm worried here, but it doesn't look severe.

5:41

I think at worst case, I'm talking about a moderate

5:44

stenosis, and I think that's what we called here.

5:47

Let's do another test.

5:48

In this case, our worst stenosis is a moderate stenosis,

5:51

and it's in a branch of the LED in a large branch.

5:55

But, uh, nonetheless it's not

5:57

Proximal, uh, LED or left main.

5:59

Um, so it's pretty reasonable to just stick on the train

6:02

of a non-invasive testing.

6:05

So a logical thing to do if you have a good image set is,

6:07

uh, F-F-R-C-T Here is that vessel.

6:11

And while does that stick out with a color scheme

6:13

that the vendor uses, so only one vessel,

6:16

the one we were worried about is that large diagonal branch

6:19

and, uh, very focal trans lesional gradient.

6:23

And it's fairly proximal.

6:24

We know that's a two and a half millimeter vessel.

6:26

That's certainly within the realm

6:27

of stenting if it's chosen to go that way.

6:30

Um, and no other disease.

6:32

So it's the other thing you get with, uh, one of these, uh,

6:34

adjunct tests is a second look.

6:36

So occasionally, like on the first case,

6:38

something more distal pops up

6:40

or an o opposite side vessel that we were distracted from.

6:43

So there's a bit of a core lab effect

6:45

and a bit of a second reader effect on these, um,

6:47

which when you have a lot of disease often, uh, welcome.

6:52

All right, so the angiography was performed

6:54

and I'm just gonna give you this selected view.

6:56

And the angiography did agree.

6:59

This is probably a dual LAD system

7:00

just 'cause of all the branches.

7:02

Uh, I'll point out that the LAD is here on this view.

7:05

Catheter goes left. There's your aneurysmal sinus

7:07

of El Salva left main, which looked fine to them.

7:10

LAD comes down, wraps around the apex,

7:12

and it's this big diagonal slash dual l LED D branch.

7:15

So at this site here, there's that stenosis,

7:18

and you can see it was considered about 80%.

7:21

Uh, the decision was made to just offer a bypass to

7:23

that one vessel, um, if the surgeon chose to,

7:26

when they were gonna go in and fix the aneurysm.

7:28

So, nice correlation here.