0:01

Yes.

0:01

Hi everybody, and thank you for joining us today

0:03

for week seven Office Hours.

0:05

Um, just a reminder, if you have a question, you can ask Dr.

0:09

Fontes directly or you can put your question in the chat

0:12

and we'll call on you or use the hand raising emoji

0:15

and we will call you on you that way.

0:17

So, Dr. Fontes, whenever you're ready.

0:21

Wonderful. Okay, so we'll do the same thing as, uh,

0:25

last week where, um, I'm happy

0:28

to answer questions you have about the cases.

0:31

We don't have to go in any particular order,

0:33

whichever case you guys felt was the most troublesome

0:37

or you had the most questions on, let me know

0:40

and I can pull it up.

0:42

Uh, if you know you don't have any questions

0:44

or anything, then we can kind of go

0:46

through each individual case

0:48

and kind of point out some of like the tips, tricks,

0:51

findings or,

0:53

or anything that we can do for approaching these to kind

0:56

of review, uh, the cases.

0:58

So you can put it on the comments on the chat

1:02

if you have a particular question

1:05

or you know, any other comment, question, concern

1:08

that you have regarding these cases.

1:10

So, um, Flo is yours.

1:14

I have the or recon sharing in case you guys have questions.

1:18

So percent. Okay. I don't see any questions in the chat.

1:23

I haven't heard from anybody, so we'll start with case one.

1:27

Okay. So this was kind of like an interesting case.

1:31

Um, this is done on a young male, 17 years old

1:35

with a prior history of Kawasaki disease

1:39

and he'd been having symptoms.

1:42

So they wanted to see if he had evidence

1:46

of evaluation of, uh,

1:48

or involvement of the Kawasaki disease.

1:51

And they had attempted to look at his coronaries

1:53

with an echocardiogram,

1:55

but they couldn't find a sense of, so since he wanted

1:58

to join the military, they wanted

1:59

to make sure he didn't have evidence of the disease so

2:02

that he could join up and, and serve.

2:04

This is how we, we have this unique case.

2:07

Uh, so what I'll do is, you know, kinda review the findings

2:11

that we have and like in all cases, I usually like to

2:15

line things up in a double bleed chamber view and,

2:18

and review the images in an anatomical orientation

2:21

like we would here.

2:22

We can see that he's got a left vein that's gonna bifurcate

2:26

and as we go through it, you can see

2:27

that he's got very healthy coronary arteries for,

2:31

for his age and expected normal anatomy distribution.

2:36

It's when we get to the right coronary artery here near the

2:39

mid RCA that we have evidence of this aneurysm

2:42

of the coronary artery, which we can often see in patients

2:46

who have, uh, Kawasaki disease.

2:48

Right now, transthoracic echo echocardiogram,

2:52

as you can imagine, is gonna have a difficulty

2:54

evaluating this particular finding just given the

2:57

limitations and the distance, right?

2:59

You can see here on your axi image how far away from,

3:03

from the chest wall we are for that aneurysm.

3:06

And even here on the 3D you can see the, the angulation,

3:10

the orientation

3:12

and the limitations of echocardiography to be able.

3:15

Now this aneurysm is oftentimes a very interesting findings,

3:19

which in this particular case you can kind of illustrate

3:23

and see some of those, uh, interesting

3:25

and CT characteristics that we see.

3:28

So in, in coronary artery aneurysms from Kawasaki disease,

3:32

right, you can have coronary artery calcifications,

3:36

which should be in your differential for patients

3:39

who have positive calcium score, if they're of a young age,

3:42

particularly, uh, under 35 or children

3:46

or even 17 year olds who have non gated CT scans

3:50

of the chest and you see calcifications in this particular

3:52

age group, this should be in your differential.

3:55

Other things include luminal stenosis like narrowing within

3:58

the vessel and you can kind of see a lot of these

4:02

luminal stenosis that come with it.

4:04

And obviously the thrombosis in some cases that can develop

4:08

or a lot of these plaque formation that

4:10

that that can be seen.

4:12

The thing for you to understand with these aneurysms

4:15

that are major prognostic markers of future events has a lot

4:20

to do with the size of the aneurysm

4:23

and the, the identification of it,

4:26

meaning treating it meaning if they identify this at the

4:29

time of his diagnosis and the the hand

4:32

and he got treatment for it with aspirin at higher doses

4:36

and the likelihood of future cardiovascular events is lower

4:40

in pediatric patients,

4:41

if they can't see on echo echocardiogram,

4:43

there's always a reluctant to get a coronary CT

4:45

because of risk of radiation

4:47

and two, their risk of lie non-diagnostic imaging.

4:51

But a lot of the times nowadays there's a lot of data

4:55

how you can use volumetric scanners

4:57

or like white detector row scanners as well as, you know,

5:02

dual source scanners to be able to minimize the imaging, uh,

5:06

radiation dosing,

5:08

but also get high diagnostic imaging from the

5:10

pediatric population.

5:11

This will often come into play.

5:13

The other thing that you need to realize that a lot

5:16

of the events are often associated with the size

5:19

of the aneurysm and these aneurysms tend

5:22

to be based on c SPOs for for the artery.

5:26

So for that you probably need

5:29

to identify the right coronary artery itself,

5:32

and what you do is you measure the dimensions

5:34

of the native vessel, meaning the non affected vessel

5:37

and see what that diameter is before and

5:40

after the, the aneurysm.

5:42

'cause that will give you your baseline number, the size

5:44

of the aneurysm at its widest diameters.

5:47

You do that and then you compare how far from, you know,

5:51

the average dimension of these two segments.

5:54

It is, uh, how do you differentiate

5:57

fistulas from coronary artery Camaro fistulas.

6:00

That's a very important, uh, question

6:02

and you know, it has to do with the force of that, uh,

6:06

of the vessel and more importantly the emptying location.

6:09

But we can talk about that here short.

6:11

In this particular case,

6:13

if you have a coronary artery aneurysm

6:16

that is five standard deviations from the average

6:19

of these two, that tends to be a, a, a, a significant risk

6:23

for future mace events.

6:25

So in your feedback for that, I put that in the report

6:28

for most of you where it is important for you to develop

6:31

that does the location of the aneurysm matter.

6:34

It really does not predict future events,

6:37

but it's important to recognize that once you have it,

6:40

if this persists years

6:42

after that, the risk of developing future, uh,

6:45

complications increases.

6:47

So that's why identifying deans in young

6:49

adults is important.

6:50

So that's the main teaching point for,

6:53

for this particular case.

6:55

Do you guys have questions

6:56

or concerns about this particular case?

7:02

No. Okay.

7:04

Now for coronary fistulas

7:06

or coronary Camaro fistulas, a lot of it has to do

7:10

with the size of the vessel, right?

7:12

So a fistula connecting one coronary artery

7:15

to the other will just be more

7:17

of a no significant chunk low assessment to get coronaries,

7:21

uh, to get coronary steel syndrome is less likely when you

7:26

have coronary artery can mirror fistulas.

7:28

Those can be quite large while torches in quite significant

7:31

given the flow differential

7:33

or the pressure difference between the two chambers

7:35

and the regurgit nature in a way of the flow of here.

7:39

So that's one of the things that, that you can do.

7:42

And obviously the course, uh, cardiac CT can definitely help

7:45

to think you gotta understand with cardiac ct,

7:47

and I'll emphasize again, is you're gonna take images for,

7:50

uh, at the end of DIA

7:53

or near the end of dia,

7:54

meaning the coronary arteries will already be filled

7:58

and not be filled in right in an antegrade fashion.

8:01

So you won't be able to tell how how that is.

8:04

Okay, very good.

8:06

Next question, case number two,

8:10

can we in d myocarditis or endocrine endocarditis you can

8:15

because you'll be able to see vegetations in the valve.

8:18

As long as the vegetations are

8:20

above half a millimeter in diameter, you should be able

8:23

to see them usually are thickening in that

8:26

myocarditis and cardiac ct.

8:28

I don't think you're gonna have the sensitivity

8:30

nor the specificity as you do with cardiac MRI

8:33

to be able to detect that.

8:34

On myocarditis, you'll be able to see areas

8:37

of prior infarction, particularly a large infarction

8:40

or in the case of an acute myocardial

8:42

infarction, you'll be able to do that.

8:43

But plain myocarditis of cardiac ct, there are particles

8:47

that exist in literature, but they're nowhere near the,

8:50

the sensitivity specificity as you would for, for, um,

8:54

for a cardiac valve.

8:56

So that, that's that. Very good, but good questions.

9:00

Next case is we're looking at this particular case

9:03

and this is the case of spontaneous coronary

9:05

artery dissection.

9:07

And I wanted to kind of go over this particular case

9:10

because a lot of folks, uh, had difficulty

9:13

with this particular case.

9:15

In fact, we select, we handpicked this case

9:17

because this was the exact same clinical scenario

9:20

that we were asked of ourselves when we were

9:22

evaluating this patient.

9:23

Like where is the abnormality

9:26

and was there any evidence of a dissection

9:28

or any type of abnormality?

9:31

So in this particular case, I strongly encourage you

9:34

to use the double oblique orientation to find the anatomy

9:37

of the arteries and more importantly, where the vessels are.

9:40

A lot of folks had difficulty tracking the circumflex

9:43

and instead that the circumflex was

9:45

obstructed or not visualized.

9:46

So I wanted to take time to first visualize the arteries

9:49

that are there certain place.

9:51

And here you can see that the Lester conflicts originates

9:54

here and you have an early separation

9:56

of the distal Lester conflicts, a left atrial branch

10:00

and a rather large

10:01

and prominent Optus marginal branch

10:03

you can actually see here.

10:05

So there were a couple of reports

10:06

that had like the Optus marginals chronically updated,

10:09

not visualized, that's not the case.

10:12

You can actually see those vessels and,

10:14

and see them, how prominent they are

10:16

and particularly how much territory they cover

10:19

along the lateral wall.

10:21

Another vessel that was the most missed,

10:24

this one was the actual nomenclature

10:26

of the LAD and its diagonals.

10:28

So in this particular case, I would encourage you to

10:31

MIP things, uh, bring your MIB thickness

10:34

to about three millimeters

10:36

and try to find those vessel branches as best as you can.

10:39

Right? In this particular case you can see one

10:41

of the diagonals comes here.

10:43

There's another short diagonal that quickly splits from

10:47

that diagonal right.

10:48

You can see that the LAD continues down into the in

10:51

treatment group, but you have essentially two diagonal

10:54

grants of vessels that kind of come around and wrap the LAD.

10:58

There was case reports I had.

10:59

The visual LED is chronically included.

11:01

Again, you can actually visualize the vessels quite well

11:04

in this particular case.

11:05

Once you've identified the anatomy, I strongly encourage you

11:09

to kind of see if the vessel diameter stay the same.

11:12

And you can see that there's an abrupt termination

11:14

and gradual increase in some of these diagonal vessels

11:17

that seem to be a little bit more outside of, of the normal.

11:21

So we're gonna do is trying to

11:24

separate this bifurcation point of the vessel.

11:26

So anytime you have a branch vessel bifurcation

11:29

or anything in this particular scenario

11:31

where the vessels are lined up like this

11:33

and you're wanting to see these three vessels together,

11:36

I strongly encourage you to kind of put your cursor

11:38

and your cross planes right directly lower end

11:40

and kinda put your cross hair where it aligns this way.

11:44

This will eventually give you this view

11:46

and it is in this particular view

11:48

that you can actually visualize in this diagonal vessel an

11:51

unusual wall thickening.

11:53

See here how you can actually visualize it

11:55

and you can actually follow that entire

11:58

wall thickening, right?

12:00

Kind of like a healed hematoma all the way down

12:05

into that diagonal vessel before it resolve, right?

12:08

See how the finding becomes as I as obvious as before.

12:12

But that kind of leads us into the findings of that.

12:15

What is that? And this is a lot actually a very vascular fat

12:18

stranding from a heel

12:20

that's instantaneous coronary artery dissection.

12:22

You see that there's no plaque

12:24

or stenosis in the remaining of the coronary arteries

12:27

as well as some of these intriguing findings.

12:30

So when you look at this and you know, we

12:33

provided you with a nice table on the case discussion about

12:37

what are some of the CT findings

12:39

that suggest spontaneous coronary art artery dissection.

12:43

A lot of it has to be the abrupt changes in

12:45

the luminal stensis.

12:46

If there's a dissection flap, an intramural hematoma tends

12:50

to be very intriguing, particularly

12:52

with high attenuation on non-contrast ct.

12:56

The luminal occlusion, again, persistence

12:58

of the luminal occlusion versus evidence

13:01

of an intramural hematoma, this intravascular fat stranding

13:05

as you can see on this case.

13:06

And more importantly, any type of tapered luminal stenosis.

13:11

So in this particular case, not only did we provide you

13:14

that imaging finding to go with it, you can actually see it,

13:18

uh, better on the,

13:20

or on the double leak reconstruction for how a lot

13:23

of this vessel in the long axis

13:26

and kind of manifest some of those disease.

13:29

In addition to that, we

13:31

provided you a plaque analysis to be able to do that.

13:33

So if you wanted to do that

13:36

and you go to the cardiac, you can actually select your, uh,

13:41

cfl l uh, your LAD pro multiplanar

13:45

and it'll ask you to click on the vessel of interest.

13:47

So in this particular case, you just come into this vessel

13:51

of interest, which ends up being this

13:52

particular vessel, right?

13:54

And then recon what it'll do is I'll track it, right?

13:57

See, you can now see this vessel being tracked

14:00

and you'll be able to generate

14:02

questions about the the plaque itself

14:05

and this, you know, so you can kind of see here.

14:07

You can also change the location of

14:09

where your plaque analysis is, right?

14:12

So you can put it here where you can see that abnormality

14:14

that we were discussing.

14:16

And in it you can actually assess the, the type of condition

14:20

that that, that you have as far as like

14:23

what the analysis needs to be, right?

14:25

So you can go to this curve, multiplanar, et cetera.

14:29

You can do the completion tracking.

14:31

More importantly here, uh,

14:34

you can actually do the assessment

14:36

for, or the plaque, right?

14:37

You can see this type of assessments here on thresholds

14:42

and it will be able to provide you the,

14:45

the things that you want.

14:46

So if you go to deletion, right,

14:48

it'll show you embedded geometry territory thing, et cetera.

14:53

You right click on the plaque and you hit plaque analysis.

14:56

There are two ways to do the plaque analysis on the recon

15:01

and a lot of it has to do

15:02

with whether the outer ring or not.

15:04

So you can change your threshold, right?

15:08

Or this, in this particularly, you can edit your color map

15:11

and I usually like the template too

15:13

because it simplifies this into low attenuation plaque, kind

15:17

of this fibro added plaque,

15:19

and then obviously the non non, uh, adipose plaque.

15:22

And then it's in this format

15:24

and you're able to kind of visualize

15:27

then the plaque composition of,

15:29

of this lesion in particular.

15:31

And that's why we're able to kind of see,

15:33

so you can see here how some of those findings

15:36

that we're previously discussing,

15:38

in particular the volume of that.

15:40

And you can see here on, on this particular image tool

15:42

as we're scrolling through, uh, how you can identify the,

15:47

the disease itself from, from this, right?

15:51

So you can scroll through

15:52

and you can see the entire harbor phase strand in,

15:55

in the paravascular fat.

15:58

So in this particular case, we also

16:01

provided you with the cardiac MRI

16:03

with the OR double BL orientation

16:05

where you can actually see the CPR vessels follow along

16:08

that same territory

16:10

and invasive angiogram that kind of shows you the occlusion

16:14

that they had before and more importantly,

16:16

what that vessel looks like.

16:17

So I encourage you to kind of review this case in detail

16:20

and see if you're able to kind of replicate these analysis

16:23

or for your own, uh, you know, review and future cases.

16:29

Any questions about spontaneous coronary dissections in

16:31

this, in this, in this particular case?

16:35

No. Okay, very good.

16:36

So what we'll do is we'll move on to case number three

16:40

and in case number three, uh, we're gonna have

16:46

an evaluation of of anomalous coronary arteries.

16:50

And this is very important when it comes to this

16:53

a**l coronary arteries really need to be categorized really

16:58

based on their course, meaning the subtypes are, uh, as

17:02

as it fault, right?

17:04

You're essentially, and my advice

17:05

to you is when you're looking at an OMA coronary artery,

17:09

you're gonna want to align the origins

17:11

of the coronary arteries along the aortic root.

17:14

You're gonna create this essential short axis view,

17:17

this essential short axis view of the aorta.

17:22

It's going to allow you

17:23

to detect which vessels originate from which coronary sinus

17:27

gus and more importantly the course.

17:29

If the ano coronary course is anterior to the pulmonic valve

17:33

or the pulmonic artery that tends, that is

17:36

to be a pulmonic r uh, course, if the course is

17:40

between the aorta and the pulmonary artery,

17:42

it would be here.

17:43

And we have cases of this

17:45

that would be considered an intra arterial if it tends

17:48

to be soft, again, subpulmonic it courses

17:51

between the pulmonary artery,

17:53

but at the level of the pulmonic valve rather than intra

17:56

arterially often referred to also as a transseptal course.

17:59

You see more this way.

18:01

And then obviously like in this case you have a retro aortic

18:04

course where it tends to follow behind the aorta.

18:07

So how it kind of rums around comes to be.

18:10

And then of course sometimes you have retro cardiac cause

18:12

where it'll come all along the posterior wall

18:16

of the heart improving the right a,

18:17

the left atrium rather than just the aorta.

18:20

So those are the important kind of nomenclature

18:22

that you need to know to be able

18:24

to describe this coronary arteries.

18:26

In addition to that, we also provide you with a lot

18:29

of information for like,

18:31

how do you essentially look at these vessels once you

18:34

identify the, the course.

18:36

Once you identify the course, you have to identify

18:38

where some of the high risk features.

18:39

So there's evidence of like acute angulation

18:42

or shared osteo of the, uh, of the aortic root.

18:47

If you have evidence of significant narrowing,

18:50

meaning it's slit like,

18:51

and it's characteristic, uh, how long is

18:54

that slit like orientation is in an oval shape,

18:57

is there a slit like shape?

18:58

How long is that narrowing length?

19:02

And more importantly the angulation.

19:04

If you look at this vessel

19:06

and if you were to draw the angulation

19:08

for which this artery is originating,

19:11

if you follow this angulation,

19:13

meaning you draw an angle line between

19:16

where this vessel originates, right?

19:19

And then where this vessel would be, we can see how that

19:24

angulation tends to be local, right?

19:27

So from the ote of this to the OTE of the next

19:31

reference vessel, you can see how

19:33

that angulation could be assessed.

19:35

So it's important for you to kinda be able to, uh,

19:38

to provide that information it's acute

19:41

that we care about that are important.

19:43

And more importantly, familiarize yourself with some

19:46

of the high risk, uh, characteristics for,

19:49

for these vessels.

19:51

So in this particular case, you know,

19:53

the vessel does have a separate osteo,

19:55

it has a non-acute angle take off.

19:58

It is above the aortic valve at the aortic valve re

20:02

and it follows a retro aortic force.

20:04

It has a normal diameter

20:06

and there's no evidence of vessel narrowing.

20:08

So in my report, in your report, you should put

20:10

that there is, uh, anomalous coronary,

20:13

but there's no high risk findings and that's important.

20:15

You wanna make sure that anytime you have anomalous coronary

20:19

artery, you're able to define

20:21

what is a, a high risk finding.

20:23

Okay, questions, concerns about the, uh, case three

20:28

and the initial findings for this?

20:32

No. Okay,

20:34

so now since we're talking about coronary arteries,

20:37

anomalous anomalies, we'll continue on the, on the topic

20:41

of like, okay, so now we're able

20:42

to define the anatomy which we have,

20:45

but now let's talk about other high risk features.

20:47

What are some of the other things that we need

20:50

to include in our report when we're talking about this

20:52

coronary anatomy?

20:54

So in this particular case, one of the things

20:56

that you wanna be able to discuss is the type

20:59

of osteo that you have.

21:01

So the osteo type

21:02

of the coronary anatomy needs to be discussed.

21:05

An almost coronary arteries can originate from their own

21:08

separate osteo, meaning they have their own connection

21:11

to the aorta directly,

21:13

or they can originate from a shared osteo,

21:16

meaning they both originate from the same osteo

21:18

or they can occur as a side branch or a branch vessel.

21:22

More importantly, after you do that, you have

21:24

to look at the proximal morphology of that vessel

21:27

as it continues to course in itself.

21:29

Is the morphology rounded, non compressed vessel

21:33

or if it's surrounded by different interactions

21:36

with the surrounding structures, is there an no appearance,

21:39

which is a less than 50% narrowing,

21:41

or more importantly a slit like orifice

21:44

or a slit like narrowing,

21:45

which indicates a greater than 50% stenosis in an

21:48

obstructive anatomy, right?

21:51

The other thing that you do is you have

21:53

to mention if there's evidence of the length of narrowing,

21:55

usually how long is the narrowing the distance from the

21:59

proximal take up toward the be begin, the beginning

22:01

of the narrow and continuous.

22:03

And last but not least, if there's any evidence

22:06

of intramural location, meaning this applies mostly

22:09

to the arteries that tend to be intraarterial,

22:11

particularly along the aorta in the sense

22:14

that an intramural location suggests

22:16

that the proximal course

22:17

of the anomal vessel is within the aortic wall.

22:20

And that can be challenging process.

22:21

Sometimes we talked about the angle of takeoff

22:26

and usually it's acute if it's less than 45 degrees,

22:29

which is what we really care about versus non-acute in this

22:32

particular case, acute angulation clearly not present in

22:36

degrees, almost perpendicular is like 95 degrees.

22:39

And then more importantly, where the vessel itself takes off

22:43

in relation to the aortic valve commiss, is it above

22:45

or below the aortic valve commiss?

22:47

So in this 28-year-old male who has a coronary ct,

22:51

yes you find an anomalous coronary artery,

22:53

particularly the left main

22:55

and the distal LAD is anom, you be be concerned.

22:59

But this left vein really doesn't have any

23:01

of this high risk findings.

23:02

It's got retro aortic course,

23:04

but doesn't have, uh, a, uh, you know,

23:08

branch vessel osteum.

23:09

It doesn't have narrowing in the proximal segment,

23:12

it's retro aortic, uh,

23:14

distal LAD does have a pre pulmonic course.

23:17

I want, I wanna make sure you guys were able to see

23:20

that you can follow this pre pulmonic course of the LED D.

23:24

See how the vis LAD kind of tends

23:26

to come here more importantly.

23:29

And then, uh, you can actually see the lack of takeoff angle

23:33

and the comm line, meaning this vessel comes clearly

23:37

above the commercial line for the aortic valve.

23:40

So again, these are things

23:41

that you want include into your nomenclature for your report

23:44

and more importantly, get into the habit of being able

23:46

to consistently discuss

23:48

and more importantly, summarizing when there are high risk

23:51

findings or not high risk findings.

23:53

Very good questions about this case, no.

23:59

Okay, now what we're gonna do is the last case.

24:02

And this one really is one of those cases

24:05

where you're going want to be able to describe

24:08

and see some of the high risk findings

24:11

for anonymous coronary partner.

24:13

Well, since we're talking about coronary arteries,

24:15

we're gonna want to again,

24:16

get into the habit of being consistent.

24:18

We're gonna, we're double orientation to the older group

24:22

as we are here.

24:24

You're gonna wanna look at this vessel

24:26

and you're gonna wanna see things different.

24:28

Now you can see that in this right coronary artery,

24:31

there is an interesting finding.

24:34

The right coronary artery definitely has an anomalous force

24:37

and it has already evidence of what looks

24:39

to be a very acute angle takeoff.

24:42

You have evidence of not only

24:44

that there's an intra arterial course,

24:47

which is very important.

24:49

The orifice itself, if we look at it here

24:52

as it originates from the vessel, it, you can see

24:55

that it's kind of slit like and it's nature.

24:57

You're, you're gonna be able to see how that orifice here,

25:02

uh, tends to be very narrow.

25:04

So you can see it right here where,

25:06

where your narrowing becomes significantly tight.

25:10

So you can see the narrowing of the arteries stenosis here.

25:15

More importantly, we be able to kind of assess how long

25:18

that narrowing tends to be,

25:20

and more importantly how significant it's right.

25:23

So here we are, we have that information here

25:26

when we have the ability to kinda see how things, okay,

25:34

so there's that perfect.

25:40

And then you can see

25:41

that in this particular case we're interested in seeing

25:44

how long this narrowing is.

25:46

So how do you assess the length of narrowing?

25:47

Well, that can be very simple.

25:49

It ends up being a measure of like

25:51

where you see the narrowing to

25:52

where the vessel becomes normal again.

25:55

But once you have identified that length of narrowing,

25:57

you begin a starting point, which tends is here

26:01

with your cause here, here you tend to go to the location

26:05

where the vessel ends up being.

26:10

I suspect that it's probably around here.

26:12

Just make sure that your cross hair is matched

26:14

and you can see that it, it's you does.

26:17

So that's kinda the,

26:19

the narrowing length that you need to have.

26:21

Again, it's important for you to understand what are some

26:24

of the high risk findings associated

26:26

and this is what we're gonna talk about next.

26:28

First one is the approximate proximal vessel morphology.

26:31

There's a slit line orifice, like what we saw

26:34

that indicates a greater of 50% narrowing.

26:37

And the odd ratio that you're going to need some sort

26:39

of vascularization for this is hot.

26:42

In addition to that, the length

26:43

of narrowing when this is more than five millimeters in

26:46

length, again, that also increases the likelihood

26:48

that the symptoms and the need

26:50

for vascularization is going to be tired.

26:53

Again, an interrater location is important,

26:56

but the most important thing about an interrater location,

26:58

it tends to be the most common co common, uh,

27:02

common anatomical variant that's associated

27:04

with postmortem sudden cardiac death,

27:07

in particularly when it involves the anomalous left knee.

27:11

So if you have an anomalous right coronary artery like this,

27:13

I could tell you as a cardiologist, I'm less inclined

27:16

to believe that this is gonna be a heart risk finding in the

27:20

sense that while it may lead to angina, surgical replacement

27:23

or repair of this is not likely going to reduce the risk

27:27

of cardiac death.

27:28

Meaning that the myocardium at risk is never going

27:31

to be sufficiently in farted for that to case.

27:34

And there's a lot of retrospective data for,

27:36

for multiple case series showing

27:38

that anomalous right coronary arteries, particularly

27:40

with an intradural course, even the spinal responding,

27:44

but they're associated with the likelihood

27:46

that you're gonna quote vascularization.

27:48

It does not mitigate

27:49

or lower your risk of future cardiovascular,

27:52

sudden cardiac death, particularly with exercise.

27:55

Now last but not least again, that the acute takeoff angle,

27:59

the length of narrowing, all those things contribute to

28:03

how much, uh, the risk of future events

28:06

and more likelihood, the likelihood

28:07

that you're gonna need revascularization from

28:09

this is present.

28:11

Okay, so that's kind of the cases that we had for this week.

28:15

Any questions, any other concerns?

28:17

You know, you guys are here.

28:18

I'm, I'm here for you to answer any of these questions and,

28:22

and help you with, you know, tracking this. Anything

28:26

Dr. Fontanez? My

28:27

apologize, uh, my apologies.

28:29

We did have a couple questions in the chat.

28:31

Were those addressed already?

28:33

Yeah, I saw the differentiation of coronary fistulas

28:36

and MyCard and endocarditis.

28:38

I haven't seen any others.

28:40

Terrific. Thank you.

28:44

No, nothing else.

28:46

I don't see any other ones coming through the chat.

28:49

Very good. Any other questions? Any other concerns?

28:52

Make sure you can track these.

28:53

'cause the next set of cases, I assume we have seen continue

28:57

to go along this path and some of the higher risk findings,

29:00

but these are important things.

29:03

What do you say for recommendation?

29:04

I think this is very important

29:06

and one of the things that I usually tend to do

29:08

for recommendations for this is if there is evidence

29:11

of high risk findings,

29:13

like there is usually the recommendation is to do further

29:17

functional assessment and we get into this argument

29:20

and until, like what is the best test

29:22

to assess if there's ischemia or not with this?

29:26

Uh, usually it depends.

29:29

I tend to prefer either a stress echocardiogram, you know,

29:32

scatter rats does not remain for anos.

29:35

So for omas coronary system, the high degree of stenosis,

29:39

this is a cadra exemption,

29:41

meaning CAD cataracts does not apply for this.

29:43

Uh, so if you put CAD rats,

29:45

you put the cadra D for exemption.

29:48

So you know, if you have,

29:49

like if you look at the case reports for these,

29:52

you'll notice that we don't use cataracts,

29:54

we just say there's anomalous

29:55

and it's got this high risk features

29:57

and when we have other disease in the a d risk respond

30:01

stenosis in the LAD et cetera.

30:02

But we don't use CAD rats when these these are present.

30:06

And that's based on the recent CAD rats recommendations

30:09

or the actual further re-certification for this.

30:12

If you see something like this with high risk features,

30:15

I always recommend a functional assessment

30:17

and you know, stress echocardiogram is one,

30:20

if they have good echo images, uh, stress MRI

30:24

with dobutamine or vasodilation important,

30:28

but again, you wanna be able

30:29

to see increased contractility in the ventricle,

30:32

particularly blood flow through the aorta to be able

30:34

to accurately assess.

30:36

Sometimes what we end up doing is the case

30:38

is still challenging.

30:39

We use intravascular ultrasound

30:42

or optimal coherent topography

30:45

of the coronary vessel while we give a dobutamine infusion

30:49

to see if the increase in contractility,

30:51

in in heart rate are associated with a narrowing

30:55

or worsening narrowing

30:56

or pollution of this branch vessel that needs to,

30:59

but again, a lot

31:00

of these vessels end up being ischemic or not.

31:02

You medically treat, you send to the surgeons

31:04

and sometimes they don't end up doing much high risk

31:08

for these, meaning you can repair it for the symptoms,

31:11

but this is not likely going

31:13

to result in quote unquote the risk of sudden cardiac death.

31:16

You may still feel it, but you're not

31:18

gonna likely die from it.

31:19

You have a left main 50% of patients

31:22

with an anomalous left main

31:24

that cause anterior course whether they have ischemia

31:27

or not have sudden cardiac death.

31:29

So usually those we tend

31:31

to re revascularize regardless of symptoms.

31:33

Does that make sense?

31:40

We don't do stents for anomal coronaries

31:42

because they like get pre, they get compressed,

31:45

meaning the pressure in the coronary artery

31:48

and their location of the orta particular,

31:50

if their intramural tends to be higher

31:53

than the stent patency.

31:55

So the stents don't, don't, um, expand well in addition to

31:59

that, the vessel itself is abnormal, so the risk

32:02

of dissection or injury

32:04

to the vessel is significantly higher.

32:06

So they're not normal ordinance, but good question.

32:13

Very good. Anything else?

32:20

Okay, well if that's the case then uh, you think

32:24

of anything else, let court know.

32:25

I'm happy to answer questions throughout the week,

32:27

but if not, then I will see you next week, same time,

32:30

same place, and we have more cases to go.

32:33

You wait, it's only the, the uphill,

32:35

the real uphill begins soon.

32:37

So

32:39

Yes. Great. Thank you again

32:40

Dr.

32:42

Um, and just to let everybody know this is being recorded

32:44

and I'll be sharing the raw footage here in the next couple

32:47

of hours, so check your email for that.

32:50

Thanks everyone. Have a good evening.

32:52

You too. Take care.