CVM Grand Rounds- January 7, 2026

Name: CVM Grand Rounds- January 7, 2026
Uploaded: 2026-01-07T20:31:41.95Z
Duration: 1 h 4 min 12 s

January 07, 2026

Information

ID: 13721
To Cite: DCA Citation Guide

Download Transcript

08:11K. Very good. Okay.
08:13K. Welcome, everybody. We'll just
08:14kinda kick things off.
08:18Hi. And happy New Year.
08:22Uh-huh.
08:23Let's go here.
08:25Just running through,
08:26the upcoming schedule. Still kinda
08:28working out a few kinks
08:29on the upcoming month. Doctor
08:31Adiran will be speaking to
08:32us, on the new guidelines
08:34and then some faculty research
08:36meetings, and then Miles Shen
08:37will be doing a structural
08:38case conference.
08:40And then we'll get out
08:41as we finalize these last
08:42few details of spring semester,
08:43we'll also get out the
08:44whole semester schedule so you
08:46guys have a heads up
08:47and then can plan accordingly.
08:49And then I will hand
08:50things off to doctor Fau
08:51who will introduce doctor Khan.
08:53Thank you.
09:01Thanks, Katherine.
09:02It's my great pleasure
09:04to introduce doctor Ali Khan
09:06as today's cardiovascular medicine grand
09:08round speaker.
09:10Ali is a native of
09:11Virginia and did his undergraduate
09:13work at the University of
09:14Virginia where he was a
09:15chemistry major, which I was
09:17quite surprised
09:18to find out.
09:19Not surprisingly,
09:20he won the Merck Award
09:22for being the top chemistry
09:24student
09:25in the undergrad program there.
09:27He also won a teaching
09:29award for undergraduate chemistry.
09:32He stayed at the University
09:33of Virginia to do his
09:35MD PhD
09:36work
09:38as a PhD student. His
09:40work focused on the structure
09:41of gap junction channels
09:43in the context of myocardial
09:45infarction.
09:47He then, came to Yale
09:49for his internal medicine residency,
09:51where he worked with Rachel
09:53Lampert looking at the effects
09:55of atrial fibrillation and atrial
09:56fibrillation treatments
09:58on athlete performance.
10:00And then, of course, he
10:01stayed for his cardiology fellowship.
10:04And interestingly,
10:06is working with, Joel Butterwick
10:08from the Department of Pharmacology
10:11on the molecular structure
10:13of this is hard for
10:15me as an interventionist to
10:16say. Okay?
10:17Human cardiac rapid delayed rectifier
10:20potassium channels
10:22bound to class three antiarrhythmics
10:25to understand,
10:26the functional effects of antiarrhythmics
10:28and perhaps
10:29to design antiarrhythmics
10:31as well.
10:32So,
10:33without further ado, Ali, thank
10:35you very much, and we're
10:36looking forward to your discussion.
10:51Thanks, doctor Pha, for that
10:52kind introduction. Thank you for
10:54everyone
10:55attending our clinical grand rounds
10:57case presentation.
10:58Today, our case comes from
10:59the Connecticut VA health care
11:01system.
11:03I'll be presenting a real
11:05really interesting and
11:07unusual case of an enlarging
11:09left ventricular aneurysm.
11:11In addition, we're also gonna
11:13have,
11:14experts joining us today, which
11:15will also be teaching us
11:17on the various nuances
11:18in terms of the imaging,
11:20and we'll also discuss surgical
11:21management.
11:23Our learning objectives today include
11:26to review the imaging findings
11:29of LV apical aneurysms with
11:31echo CT and MRI.
11:33We'll also discuss the management,
11:36and discuss the management of
11:37LV aneurysms.
11:41Now this is a case
11:41that spans a little over
11:43two and a half years.
11:44So to orient everyone to
11:45the presentation,
11:46I'll be focusing on three
11:48periods. First, the initial hospitalization,
11:51then the outpatient management, which
11:53was primarily in the VA
11:54system, and then surgical management,
11:56which was a joint effort
11:57between the West Haven VA
11:59and Yale New Haven Hospital.
12:04So our case,
12:06goes to February twenty twenty
12:07three.
12:08This our patient is a
12:09sixty six year old female
12:10veteran
12:11with a three day history
12:13of fatigue and unwitnessed fall
12:15and also with chest pain
12:16two days prior who presented
12:18as an EMS STEMI activation
12:20from an outside hospital.
12:22Her past medical history has
12:24multiple cardiovascular risk factors, including
12:26diabetes, hyperlipidemia,
12:28chronic kidney disease, and active
12:29smoking,
12:31as well as,
12:34pulmonary nodules, bipolar disorder, and
12:36PTSD.
12:36She does not have any
12:38prior cardiac surgeries nor does
12:39she have a family history
12:40of heart disease at baseline.
12:42She's an she's independent and
12:44able to perform all of
12:45her ADLs.
12:47This is her presenting EKG,
12:51which shows ST elevations into
12:53anterolateral
12:53inferior leads
12:55suggestive
12:56of an extensive infarct.
13:00Her physical exam was significant
13:02for Raul's
13:04and weak peripheral pulses. She
13:05was hypotensive,
13:06requiring presser support. Her initial
13:08laboratory workup showed markedly elevated
13:11high sensitivity troponins,
13:13elevate BNP, lactic acid, AST,
13:16and acute
13:17kidney injury all concerning for
13:19cardiogenic shock. In addition, in
13:22the emergency room, she had
13:23a point of care ultrasound
13:24that showed severe apical a
13:26kinesis and possible thrombus
13:28at the LV apex.
13:31The cath lab was activated.
13:32Here's a coronary angiogram
13:35of the left coronary arteries
13:37system.
13:38And,
13:41and I want you to
13:41appreciate that she had total
13:43occlusion of the proximal left
13:44anterior descending artery.
13:47Here's now a a caudal
13:49shot of the left system,
13:50which, you can appreciate it
13:52a little better.
13:55And, again, seeing that where
13:57there should be a branch
13:58for the left anterior descending
13:59artery is a big occlusion.
14:04There's no significant stenosis in
14:06any other vessel.
14:09She also had no collateral
14:10flow coming to this region,
14:12this region of the heart.
14:14The interventionalist
14:15at the outside hospital
14:17attempted balloon angioplasty,
14:19but were unsuccessful.
14:21She
14:22had an intra aortic balloon
14:23pump that was placed, and
14:24then she was transferred here
14:25to Yale.
14:29For NPA, she was admitted
14:30to the cardiothoracic ICU service
14:31on pressors
14:32and evaluated by our heart
14:34failure team for advanced therapies.
14:36She had a Swan Ganz
14:37catheter placed, a mixed venous
14:39o two saturation,
14:41was in the normal race
14:42likely corresponding to a missed
14:44cardiogenic and distributed shock picture.
14:48Her initial echo showed an
14:51estimated ejection fraction of thirty
14:53five percent
14:55with apical a and anterior
14:56a kinesis consistent with her
14:58LAD infarct and a large
14:59mural thrombus measuring three point
15:01one by one point two
15:02centimeters.
15:05She had a fairly prolonged
15:06hospital course.
15:09And the first couple of
15:10days, she developed Pseudomonas, Bacteremia,
15:12coli, UTI,
15:13requiring IV antibiotics.
15:16She was difficult to wean
15:17off oppressors.
15:20She was extubated day five.
15:21And given the persistent
15:23shock,
15:25repeat coronary angiogram was again
15:28performed and just redemonstrated
15:30the occluded LAD
15:32not amenable to PCI.
15:36She started to have atrial
15:37fibrillation with RVR, also had
15:39a high PVC burden started
15:40on amiodarone,
15:42started to improve after
15:44a week and had her
15:46balloon pump removed on day
15:47eight of her hospitalization.
15:49Her pressers were weaned off,
15:51and she was transitioned to
15:52oral antibiotics on day ten.
15:55Advanced therapies in the setting
15:57of the her recovery and
15:58infection was then deferred to
16:00the outpatient setting.
16:03Two weeks since she had
16:04a repeated echo, showed that
16:05her EF was relatively unchanged
16:08with the kinesis of the
16:09LED teratarpy,
16:11and then showed this mural
16:13thrombus measuring four point four
16:15centimeters by one point one
16:16centimeters.
16:18On day eighteen, she was
16:20discharged from the hospital on
16:21aspirin, eliquis,
16:23and amiodarone to a rehab
16:24facility and to follow-up with
16:26the v, VA cardiology team.
16:29We were unable to start
16:30GDMT due to hypotension.
16:36Now in rehab, she was
16:37then seen by doctor Charles
16:39Phillips in the Newington VA
16:40Cardiology Clinic.
16:42Over the next several months,
16:43she had symptoms of mild
16:44dyspnea class you know, NYHA
16:47class two
16:49classification.
16:52She was requiring Midadrine for
16:53hypotension, which made which along
16:55with her kidney function made
16:56GDMT difficult to titrate.
17:01She had a series of
17:02echocardiograms
17:03then during this period.
17:06The first one, which was
17:08two months
17:09after she was discharged,
17:11showed,
17:13an unchanged ejection fraction around
17:15thirty five percent, but there
17:16were signs of apical remodeling
17:18as the entire apex was
17:19not aneurysmal.
17:21However, there was no signs
17:23of LV thrombus.
17:25And what I have shown
17:26here is the noncontrasted
17:27images,
17:29and the different apical views
17:31and then under it, the
17:32corresponding contrast images.
17:34Now get
17:36despite,
17:37given the evidence of the
17:38continued remodeling, shared decision making
17:40with the patient,
17:43Her it was decided to
17:44continue her anticoagulation.
17:47She then had another echocardiogram.
17:50This is now seven months
17:51post her hospitalization for consideration
17:53of a primary prevention ICD.
17:56Her EF was unchanged, but
17:58the apical aneurysm of prearrant
17:59increased in size. Now measuring
18:00three point eight by three
18:02point one centimeters
18:03on her, compared to five
18:05months prior.
18:07There still continued to be
18:09no signs of contrast, but
18:10of note, contrast wasn't used
18:11in this particular,
18:13study.
18:17Given these findings, I just
18:18wanna take a moment to
18:19sort of review,
18:21LV aneurysms.
18:23They most commonly occur after
18:25a transmural,
18:27my acute myocardial infarction,
18:30due to LV remodeling. In
18:31this process,
18:32the infarction
18:34leads
18:36to fibrosis of the necrotic
18:38tissue.
18:39The infarcted myocardial myocardial undergoes
18:42thinning
18:43and loses contractility.
18:45The wall stress against this
18:47this thin wall
18:48undergoes dilation reading through this
18:50classical aneurysm bulging.
18:54Depending on the degree of
18:55aneurysm formation,
18:57several complications can arise.
19:00It can decrease the
19:03LV ejection fraction and lead
19:04to heart failure symptoms.
19:07Due to blood pooling and
19:08stasis in the aneurysmal segment,
19:10thrombus can form.
19:13The
19:14dilation and lack of contractility
19:16to the scarred segment
19:18can lead to myocardial,
19:20to mitral valve dysfunction.
19:22And then certainly because of
19:24the heavy scar burn, this
19:26this region can be a
19:27substrate for ventricular arrhythmias.
19:30Fortunately, the incidence of LV
19:32aneurysm has greatly decreased,
19:34over
19:35the over the past few
19:36decades. In thrombolytic era, incidence
19:38was measured for as low
19:39seventeen up to nineteen percent.
19:42And now in the current
19:43PCI era,
19:45is about is less than
19:46five percent.
19:50Management is
19:51of these aneurysms is dictated
19:54by complications.
19:56So here's sort of a
19:58chart that I adapted.
20:01If you have heart failure
20:03symptoms and LV dysfunction,
20:05you're gonna elect for guide
20:07you know, guideline directed medical
20:09therapy. Certainly, if there's
20:11revascularization
20:13or ischemic territory that can
20:14be revascularized, you would consider
20:16PCI or CABG.
20:20If there's mitral regurgitation, you
20:21can try medical management, reduce
20:23the afterload with ACE inhibitors
20:26or ARBs.
20:28If
20:29there's if there's evidence of
20:30thromboembolism,
20:32vitamin k antagonists or DOACs,
20:35can be used. And if
20:36certainly, if there's ventricular arrhythmias,
20:38aneurythmic drug therapy or ablation
20:40should be considered and in
20:41appropriate patients that meet indications,
20:44an ICD placed.
20:46Now if these sort these
20:48measures fail,
20:50that's when we have to
20:51start considering surgical repair of
20:53the aneurysm.
20:55And what do our guidelines
20:56say about surgical managements?
21:00These are the really the
21:02two most recent guidelines, the
21:03STEMI guidelines that comment on
21:05it. On the left is
21:06the two thousand four STEMI
21:07guidelines,
21:08which gives a, class two
21:09a recommendation
21:11for
21:12surgical aneuryscectomy
21:14if there's intractable ventricular tachyarrhythmias
21:17or pump failure refractory to
21:20medical or catheter based therapies.
21:22The more recent two thousand
21:23thirteen STEMI guidelines, they don't
21:25give a formal recommendation,
21:27but the they make a
21:28statement to consider repair for
21:30treatment of heart failure,
21:31ventricular arrhythmia is not a
21:33minimal to drugs or ablation,
21:35or recurrent thromboembolism
21:37despite appropriate,
21:39anticoagulation
21:40therapy.
21:45Now given all this in
21:46mind, let's go back to
21:47our case.
21:50Now for about
21:52the next,
21:53year and a half, the
21:54patient was, was continued to
21:56be seen in clinic.
21:58Her symptoms
21:59were really unchanged.
22:01Still mild dyspnea, NYHA class
22:03two.
22:05She received a primary prevention
22:06ICD for unrecovered ejection fraction,
22:10And we were also able
22:11to get her started on
22:12minimal g d n t
22:13therapy due to improvement in
22:15her blood pressure.
22:16And then given really lack
22:17of symptoms and lack of
22:19these complications that, I mentioned
22:21serial imaging
22:23of the of, the aneurysm
22:25was discontinued.
22:28She had a repeat echo
22:30in October twenty twenty four.
22:31Now we're about a year
22:32and a half after her
22:33hospitalization.
22:36Unfortunately, the aneurysm continued to
22:37grow in size. It was
22:38now measured to be three
22:39point nine over four point
22:41six centimeters
22:42with contrast.
22:45And now
22:46despite being on anticoagulation,
22:48it was discovered that she
22:50had a large mural thrombus.
22:53So this is just so
22:54you can have an appreciation
22:55for,
22:58the aneurysm. And now I'm
22:59gonna show you the parasternal
23:00long view with contrast.
23:03And you can see sort
23:04of this,
23:06this aneurysm,
23:08black
23:10and the contrasted images.
23:12And then lastly,
23:13it was discovered she has
23:14a VSD.
23:15A ventricular septal defect,
23:18was also present.
23:21Fortunately, at least the, there
23:22wasn't any significant,
23:24change to her mitral regurgitation.
23:28And
23:30now I'm gonna just take
23:31a minute just to talk
23:32about the echo imigings of
23:33LV aneurysm and thrombus.
23:35Echo is the first line
23:36imaging modality
23:39for LV thrombus. It,
23:42can help distinguish
23:45sorry. First line imaging modality
23:46for LV aneurysms and thrombus.
23:50It can distinguish between true
23:52versus pseudoaneurysms.
23:54And one of the one
23:55of the key ways it
23:55can do that is by
23:56looking at the internal neck
23:58diameter versus the sac diameter
24:00ratio.
24:01Typically,
24:03when the ratio is point
24:05five to one,
24:07meaning a sort of a
24:09larger
24:10neck, then this corresponds
24:12to a,
24:14true aneurysm
24:15versus a pseudo aneurysm or
24:16false aneurysm where this ratio
24:17is less than point five.
24:19Certainly and when I say
24:20pseudo aneurysm, it means sort
24:22of complete rupture of the
24:23wall
24:24of of the LV wall
24:27and,
24:29blood contents going into filling
24:30the pericardial space.
24:33Now in terms of thrombus
24:34identification with echo,
24:37where it's not as strong
24:39as other imaging mortalities
24:40is its sensitivity and a
24:42definite thrombus. With no contrast,
24:44the sensitivity is thirty seven
24:45percent.
24:46With contrast, that increases to
24:48sixty four percent.
24:50And then the specificity
24:52of
24:53but the specificity
24:54is comparable to that of
24:56cardiac MRI
24:57where with contrast to ease
24:59of a ninety nine percent
25:07The difficulties of doing imaging
25:09of LV aneurysms and thrombus
25:10with echo,
25:13first, it's difficult to compare
25:15the aneurysm size
25:17and thrombus
25:18on echo.
25:21Echo can underestimate the aneurysm
25:24size mostly due to foreshortening,
25:26which can miss the true
25:27LV apex or the thrombus.
25:31It should be, you know,
25:33it should be considered to
25:35per because of the increased
25:36sensitivity, the study should be
25:37performed with contrast.
25:39And then volumetric imaging of
25:41the aneurysm
25:42could can also be helpful
25:43in these cases.
25:46Now
25:50so what I have here
25:52and just to so you
25:53can appreciate that point is
25:55that we have these echo
25:56images.
25:57And the first ones are
25:58images in twenty twenty three
25:59and then in twenty twenty
26:00five
26:02in the same apical views.
26:04And what you can hopefully
26:06appreciate
26:06is that it's it's really
26:08difficult to tell,
26:10changes
26:12between the sizes, you know,
26:13over this two year period.
26:16You know, if you're just
26:17looking qualitatively, sometimes it can
26:19look unchanged.
26:26Now aside from her cardiac
26:28care, the patient was also
26:29getting worked up for pulmonary
26:31nodules,
26:32and she received a low
26:33dose CT scan
26:34that showed that the aneurysm
26:36size has almost doubled in
26:38dimensions compared to our prior
26:39echo, which raised a lot
26:40of concern.
26:41So I'm gonna ask, doctor
26:43Philip Mora,
26:45to discuss these,
26:47these findings in detail. And,
26:49also, he's gonna give us
26:50his expertise on the role
26:51of CT and imaging for
26:53these cases.
27:01So we generally don't read
27:03low dose CTs,
27:05but,
27:06you know, it's a not
27:07that it's not it's not
27:08a cardiac dedicated study, so
27:10there's no contrast.
27:12So it's hard to take
27:13a lot away from it.
27:14But
27:15surprisingly enough, if you if
27:16you if you put effort,
27:18you can get a lot
27:19of information. And I think
27:20we were able to get
27:21a nice piece of information
27:23here. You know, you see
27:24here, we have reconstructed for
27:26you in the sagittal, the
27:28coronal, and the axial views.
27:30You see this bulging,
27:33apex,
27:34that
27:36expands outside of the regular
27:37contours
27:39of the myocardium, you know,
27:40extending even
27:42below the the diaphragm,
27:43and nicely enough. You can
27:45use the ICD as, as
27:47a reference,
27:49for where that might be,
27:51even though we essentially have
27:52no contrast at images.
27:54And then,
27:55if you click,
27:57can you go forward one?
28:00So this is the twenty
28:02twenty five one that we
28:03just looked at. But if
28:04you compare it with the
28:05same,
28:07acquisition that was done
28:09a year prior,
28:11you can appreciate at least
28:13visually,
28:14you know, the extension of
28:16the bulging,
28:17apex, you know, below the
28:19the ICD and the diaphragm
28:21seemed less substantial.
28:23Now,
28:23the the,
28:25the left lateral,
28:26left to right dimensions appear
28:28about the same size. But
28:30if you look at
28:31the cranial to caudal dimensions
28:33and the anterior to posterior,
28:35dimensions,
28:36they look a bit enlarged.
28:38And we're actually able to,
28:40do a little bit of,
28:42use a tool where we
28:43kind of try to get
28:44a,
28:45a really a really poor
28:46man's assessment of volume.
28:49But interestingly enough,
28:51if you actually if you
28:52look at the aneurysm
28:54on the right, the one
28:55from a year prior, where
28:57we got an estimation of
28:58about thirty six,
29:00forty five cc's,
29:02if you compare that to
29:03the echo done about the
29:05same time
29:06where that bulge had a
29:08spherical radius
29:09of about two point one,
29:11two point two,
29:15centimeters,
29:16it actually pairs up, relatively
29:18well in terms of volume.
29:20If you use that,
29:22mathematically, you get about thirty
29:23eight, ml.
29:25So that was kinda interesting
29:27to to note. But, you
29:28know, it's not a dedicated
29:29study, but it it raised
29:30definitely raised concern that there
29:32might be,
29:33there might have there there
29:34had been some, interval increase
29:36in size over the course
29:38of a year.
29:40And then, you know, generally
29:41speaking,
29:43you know, for assessment of
29:44aneurysm of the LV and
29:47or thrombus,
29:48your your go to is
29:49a cardiac MRI.
29:51You have higher, spatial resolution,
29:54as well as tissue,
29:56differentiation with what you can
29:57do in in cardiac MRI.
29:59But it is
30:00reasonable to to pursue a
30:02CT, particularly if you can't,
30:04can't conduct a cardiac MRI
30:06in a patient.
30:07And that we find in
30:08the guidelines,
30:09both in US and Europe.
30:12And, you know, not only
30:13can we do a volumetric
30:14analysis,
30:15but with the, with CT,
30:17we can also do delayed
30:18enhancement imaging as well.
30:20So, you know, not just
30:22the arterial phase but if
30:23you image in, you know,
30:24between five or ten minutes,
30:25depending on your protocol in
30:27your lab,
30:28you're able to see enhancement,
30:31a delayed enhancement,
30:32in where there is actually
30:34still
30:35myocardium, where would be the
30:36case of a of an
30:37aneurysm.
30:38And if there if it
30:39is, in fact, a pseudoaneurysm,
30:41generally,
30:42it's a much lower density,
30:45structure,
30:45and so that can be
30:46used to differentiate one of
30:48the two.
30:51Thank you, doctor Moore. I'll
30:52just keep it. I'll just
30:53keep it there. And,
30:58now
30:59back to back to the
31:00case, we have this,
31:02given this rapid enlargement.
31:05She was then admitted to
31:06the VA,
31:07for CT surgery evaluation.
31:10But despite these imaging changes,
31:14she still did not have
31:15any progression of symptoms.
31:19She was, switched
31:20in the setting of this,
31:26she had evidence of,
31:28given the evidence of thrombus,
31:30she was switched
31:31from apixaban to Coumadin for,
31:33DOAC failure. And now we
31:35obtained a cardiac MRI to
31:37really care to fully characterize
31:38this aneurysm to help us
31:39move forward in how to
31:40manage it. And I'm gonna
31:41ask doctor,
31:43Emmanuel Quintoy to comment on
31:44the MRI findings.
31:46Alright. So,
31:49so I would say,
31:50the indication for cardiac MRI
31:52in this kind of patient
31:53would
31:54definitely be to differentiate
31:57between,
31:58a true aneurysm
31:59and a pseudo aneurysm, which
32:01is a critical,
32:04this,
32:05determination to make because the
32:07pseudo aneurysm, it's,
32:09urgent. It require, like, urgent
32:11repair because it could become,
32:13like, a catastrophe
32:15due to the high risk
32:16of rupture.
32:17So,
32:18like, Ali already mentioned,
32:21echo is the,
32:22imaging mod first imaging modality,
32:25but,
32:27the
32:27specificity of echo is limited.
32:30And that's where where Kedac
32:32MRI comes in to make
32:33that important,
32:35distinction.
32:36So,
32:37in terms of Kedac MRI,
32:39we do a lot of,
32:41sequence in order to,
32:43make determination
32:44of,
32:45what's the exact,
32:48pathology is.
32:50And, we typically start with
32:51the cine images. So as
32:53you can see, this is
32:54a
32:57poor image quality, and this
32:59it's poor image quality for
33:00this particular case because this
33:02patient already have an ICD.
33:04Patient with ICD,
33:06they it tends to limit
33:08what kind of sequence,
33:10we can do, and,
33:12it affects,
33:13the image quality. So the
33:14image quality is degraded in
33:16this particular picture. So this
33:18is typically not what we
33:19get for most of our
33:20cardiac MRI.
33:22But what is showing here
33:23in this, senior images is
33:25just the, long axis view.
33:28And,
33:28we can see the sac
33:30coming from the inferior, epicoinfluorateral
33:33wall.
33:34Just looking at this in
33:35the images, it's hard to
33:36tell. Is this pseudo aneurysm?
33:38Is this aneurysm?
33:39So,
33:41we rely on,
33:42dedicated,
33:44MRI sequence,
33:45called the, delayed enhancement imaging,
33:48which is what is shown
33:50in this,
33:50slide.
33:53Like echo, we look at
33:55we look at similar,
33:56features just like echo.
33:59Like Ali already mentioned, we
34:00look at, the neck,
34:03of the,
34:04sac.
34:05So less than fifty percent
34:06means it's narrow.
34:09So that suggests you do
34:10aneurysm. If it's more than
34:11that, that suggests aneurysm.
34:14Also, we look at,
34:17the location.
34:18So,
34:20a sac in the anterior
34:21or,
34:22apex,
34:23most likely aneurysm. If it's
34:25inferior, then it's most likely,
34:28pseudo aneurysm.
34:30And then we also look
34:31at,
34:32abrupt cutoff.
34:34So between,
34:37we look at the boundary
34:38between the LV
34:39and the sac. So is
34:41there, like, an abrupt cutoff
34:42between
34:43the myocardium
34:44and the sac? So if
34:45there's an abrupt cutoff, then
34:47it suggests that there's probably
34:49a rupture there.
34:50Right?
34:52If there's no rupture, it
34:53kind of tapers into the
34:55sac.
34:56If you look if you
34:57use that, you probably say
34:58this is probably a pseudo
34:59aneurysm because it suggests that
35:01there's an abrupt cutoff between
35:03if you look at the,
35:05infra lateral wall and the
35:06beginning of the sacs, it
35:08looks like I didn't couldn't
35:09really appreciate any tapering there.
35:12So and that tells you,
35:14the limitation. It tells the
35:16limitation of all these,
35:18features.
35:19Right? So where MRI actually
35:21stands out is in the
35:23tissue characterization.
35:25So we can actually look
35:26at the tissue and can
35:27tell exactly what we,
35:29dealing with.
35:30And that is what is
35:31shown in the zoom out,
35:33image,
35:33on the right.
35:35So,
35:36if you wanna put your
35:38cursor there. So the the
35:40dark part no. The dark
35:42part yeah. So that's a
35:43thrombus.
35:44So we use a dedicated,
35:47MRI image with,
35:50called a long TI image
35:51to look at, thrombus with
35:53actually have very high sensitivity
35:55and specificity.
35:56So that tells you that's
35:57a thrombus.
35:58And then next after that,
36:00you see the white line.
36:02So that white line actually
36:03is the infected myocardium.
36:07So that tells you there
36:08is, like, a a dead
36:09myocardial tissue there. And then
36:11after that is that
36:13dark line. So that's the
36:14pericardium.
36:15So this is actually the
36:17most specific way
36:19to diagnose to differentiate it
36:21from,
36:22pseudo aneurysm.
36:23If it was a pseudo
36:24aneurysm, we're not gonna have
36:26that
36:27white line. So because there's
36:29no there's no myocardial tissue
36:30there. So all we're gonna
36:32have is just a pericardial
36:33tissue,
36:34which most time is going
36:36to be,
36:37enhanced
36:38because it's inflamed.
36:39So this actually, I think
36:41it's,
36:42puts the question to bed
36:44in in terms of whether
36:45this is, aneurysm or pseudo
36:47aneurysm.
36:49Next slide.
36:51So,
36:52I guess this also was
36:54acquired just to,
36:57look at the,
36:59thrombus burden.
37:00It's still the,
37:02delayed enhancement imaging.
37:04And what it's showing here
37:05is just short axis stacks
37:07from,
37:08like, the base to the
37:09apex of the heart. And
37:11as you can see from
37:13the from the base of
37:14the ape once we start
37:15getting to the mid portion,
37:16we start seeing thrombosis in
37:18the
37:19anterior septal wall,
37:21number two.
37:23Like, you can see thrombosis
37:24lying there. And as you
37:25move down from two, three
37:29down to seven, then you
37:30can start seeing additional thrombores
37:32more
37:33towards the,
37:34latter the epicolateral wall. So
37:36it just give you, like,
37:38an assessment of,
37:39the thrombores burden. So I
37:41think this is just an
37:42additional
37:45information that,
37:46MRI can give in this,
37:48patient.
37:50And I think you have
37:51a slide. Okay. So this
37:52is just,
37:54teaching points that, Alias highlighted
37:56as far as,
37:58role of cardiac MRI,
37:59in this kind of patient.
38:01So as, shown in previous
38:03slide, it provides the best
38:04issue characterization.
38:05It's the most,
38:07specific
38:08imaging modality to differentiate between,
38:11true aneurysm and pseudo aneurysm.
38:14It's the gold standard for
38:15thrombus imaging.
38:17So the sensitivity,
38:18I believe, is from the
38:20traditional delayed enhancement imaging with,
38:23new,
38:24modality new new sequences, the
38:27long TI, I think the
38:28sensitivity
38:29for
38:29of MRIs
38:31in the high 90s.
38:32So like ninety studies are
38:34up to like ninety eight,
38:35ninety eight, ninety nine percent.
38:37And the specificity is in
38:38the high 90s.
38:40So gold standard for thrombus
38:41imaging, gold standard for volumetric
38:43analysis,
38:44and it can also provide,
38:46three d anatomical details similar
38:48to CT. We typically don't
38:49acquire a three d dataset,
38:51but it's something that we
38:52can do if, needed on
38:53MRI.
38:54Thanks.
38:57Thanks, doctor Kintoy.
39:01Now we'll go back to
39:03our case. With all these
39:04imaging findings, we then discussed
39:06this,
39:07the patient was then discussed
39:09in our weekly,
39:11VA heart meeting, which is
39:13really one of the highlights
39:14of being a cardiology fellow
39:15here.
39:16It's an interdisciplinary
39:17conference with cardiology
39:19and CT surgery attendings and
39:20fellows spending really all aspects
39:22of cardiovascular
39:23care.
39:25Given that there this aneurysm
39:28has continued to enlarge
39:29and that there was increasing
39:31clot burden despite being on
39:33anticoagulation,
39:34surgical repair
39:35was recommended.
39:39The patient came to YNH
39:41for
39:42left ventricular restoration surgery by
39:44doctor Roland Ossie. Fortunately, doctor
39:46Ossie has a case today.
39:48He was unable to join
39:49us
39:50to go over the nuances
39:52of the surgery, and I
39:52will do my best to
39:53do justice to what really
39:55was an incredible surgery. That's
39:57for all your security.
40:05Now the goals of the
40:07surgery are outlined here. This
40:08as you can,
40:11the principle of addressing a
40:12large
40:13LV aneurysm are as follows.
40:15First, enter the infarcted nonviable
40:18tissue.
40:18This way, we're not damaging
40:20the viable tissue.
40:22And the capsule
40:24of the aneurysm is actually
40:25quite
40:26while it's thin, it's quite,
40:28it's relatively tough material.
40:31This area, as you can
40:32see, it will become when
40:34this patient,
40:35goes under bypass,
40:37it will become compressed. And
40:38this all this compressed collapsed
40:40tissue is all aneurysm, measuring
40:42about fifteen centimeters.
40:47The
40:50now as you can see
40:51in the fall, while,
40:52you know, we're gonna
40:54we're gonna while we reconstruct
40:56this, we're gonna also actually
40:57keep this collapsed tissue because
40:59it can serve as extra
41:00tissue for the the surgery.
41:02And, typically, the approach is
41:04to enter through the middle
41:04of the scar.
41:07Here, you see the team
41:08entering the infarcted tissue.
41:11You get a sense of
41:12how tough this tissue can
41:14become, but also how thin
41:15it is,
41:17relative to normal LV muscle
41:19the the normal LV.
41:21In the case upon
41:22when they entered the LV
41:24cavity,
41:25there was a large amount
41:26of old clot,
41:28which is you which is
41:30this, like, yellow and fiberness
41:32material,
41:33which is consistent with long
41:34standing clot as opposed to
41:36fresh clot, which would be
41:37more red and less well
41:38organized.
41:42And now after
41:44removing the tissue, rather than
41:45removing the aneurysmal tissue, its
41:47capsular can be used as
41:48the end as I mentioned,
41:49at the end of the
41:50case to reinforce closure
41:52of the incision in the
41:53LV.
41:56The photo on the left
41:57shows the aneurysm, which has
41:59been opened up,
42:00and multiple black sutures are
42:02there to retract the wall
42:03of the the walls of
42:05the aneurysm and keep it
42:06open, providing
42:08exposure to the surgeons.
42:09The white tissue, as you
42:11see, that's all scar.
42:15The suction is is is
42:17inside the true LV cavity,
42:20and you can see the
42:20mitral valve and the trabeculations
42:23of the LV. And one
42:24thing to notice is that
42:25these trabeculations are gone,
42:28in the aneurysms
42:29in the aneurysmal segment.
42:33Also, to highlight the picture
42:34on the right, you can
42:35shows the small ventricular septal
42:37defect that will also need
42:39to be closed when the
42:40aneurysm is patched.
42:46Now one of the most
42:47important parts of the operation
42:49is to recreate
42:50this new LV cavity with
42:52the appropriate geometry.
42:55And to do this, though,
42:57we're gonna be placing a
42:58they're gonna place a patch
43:00at the mouth of the
43:01aneurysm sac. In this case,
43:03it's a big area, and
43:04there's different ways,
43:06after talking with doctor Austin
43:07and doctor Pelletier that there
43:08are to do this.
43:10In this case, a bovine
43:11pericardium was used along with
43:15felt,
43:16felt, pledge
43:19it to reinforce the closure.
43:23And sutures are placed in
43:24a circumferential
43:25manner
43:26around the neck of the
43:27aneurysm and then pass through
43:29the patch.
43:31The most important thing is
43:33to ensure the LV cavity
43:35is not too small.
43:37In
43:38some cases, they,
43:40they would actually
43:41fill a balloon with saline
43:43that's in that's
43:45that's to the right size
43:46based on body surface area
43:48and,
43:51use that to sort of
43:52give you the right geometry
43:53of the LV and the
43:54size. In this case, the
43:56aneurysm was so large and
43:58it wasn't needed.
44:00The picture on the right
44:01shows the
44:03the patch repair,
44:04and now the repair is
44:06gonna be reinforced
44:07with the aneurysmal tissue on
44:09top of it.
44:12That that's why it doesn't
44:14just close the aneurysm because,
44:16you know, you can imagine
44:17if you do pick the
44:18edges where the belt is
44:19and and you close,
44:21but they create a l
44:22b cavity that's too small.
44:24So that's why they use
44:25this patch
44:26to allow,
44:27you know, not preload.
44:30So for the vision, they
44:30still don't have there.
44:36So this is the completed
44:38restoration,
44:39and the results were excellent.
44:41Here I have the
44:44the presurgery and post op
44:46TES.
44:48As a little difficult to
44:50appreciate, but the the LVEF
44:52is tremendously improved, probably to
44:53forty to forty five percent,
44:55and there was no evidence
44:56of thrombus.
44:59In terms of the VSD
45:00shunt, as you can see,
45:01presurgery, there was a a
45:02shunt that's no longer a
45:03a shunt going from left
45:05to right flow.
45:08And then in terms of
45:09the mitral valve
45:11apparatus,
45:11the patient continued to have
45:13stable MR,
45:15meaning that it was,
45:16intact.
45:18Were the corners reshot
45:21the LIV
45:22occlusion was left?
45:25We reshot them when she
45:26originally presented. They haven't
45:29they were reshot in planning
45:30for the procedure.
45:33But,
45:33good question.
45:35Surgery.
45:43The patient had an uncomplicated
45:45post op course.
45:46She came in. She was
45:47transferred to CTICU on epinephrine
45:50and norepinephrine.
45:51But within four days, was
45:52weaned off pressers and extubated.
45:54She was transferred to the
45:55floor on day post op
45:56day four.
45:57And then with the and
45:59post op day seven, she
46:00was discharged on apixaban
46:02and aspirin.
46:04And
46:05overall, the patient's doing quite
46:06well.
46:07Doctor Phillips just saw recently,
46:09she still has this mild
46:10dyspnea that's unchanged.
46:12And
46:13we have this is her
46:14echo,
46:16TT, transthoracic echo, one month
46:18post op,
46:20showing
46:21that her EF is still
46:23maintaining a forty to forty
46:24five percent,
46:26without any signs of
46:28no signs of LV thrombus
46:32and then trace mitral regurgitation.
46:36So with that, I would
46:37like
46:38to conclude.
46:40LV aneurysms are a possible
46:42complication of transmural myocardial infarctions.
46:46Echocardiography
46:47is the first line imaging
46:49modality,
46:50but less sensitive than CT
46:52and MRI, especially for assessing
46:54aneurysm size and thrombus burden.
46:58CT and MRI provide the
46:59most accurate assessment of of
47:01aneurysm size and thrombus
47:05burden.
47:06As for this case, surgery
47:07should be considered
47:09if patients have a concomitant
47:10cardiac surgery for significant valve
47:12disease
47:13or bypass
47:15coronary bypass surgery.
47:17Ventricular arrhythmia is unresponsive
47:20to,
47:21medical or ablation therapies, refractory
47:24heart failure despite medical therapy,
47:26and as for this case,
47:27increasing thrombosis burden despite appropriate
47:30anticoagulation.
47:31And what I hope I've
47:32demonstrated is that this case
47:34highlights the importance of multidisciplinary
47:36cardiac teams and the management
47:38complex LV aneurysms.
47:42I'd like to acknowledge all
47:43it's
47:44because because it took such
47:45a large team for this
47:46case, I'd like to acknowledge
47:47really everyone that helped put
47:48this case presentation together.
47:51Doctor Charles Phillips,
47:53who's the patient's primary cardiologist
47:55and was, my mentor for
47:57this presentation.
47:59Appreciate doctor Sugang, doctor Mora,
48:02and doctor
48:03Akintoy's,
48:05guidance on the imaging,
48:07and then, doctor Roland Ossie,
48:10doctor Palatir,
48:11and doctor Williams for their
48:13input on the surgery.
48:15Certainly, we have an excellent
48:17VA.
48:20Our VA Connect health system
48:21is excellent. It's one of
48:22the highlights of being a
48:23fellow here,
48:25and it's really rich to
48:26see the collaboration between
48:29them and Yale New Haven
48:30Hospital.
48:31And I like to also
48:32acknowledge the continued support of
48:33the cardiology fellowship program over
48:35the last three years.
48:37And with that, we'll be
48:38happy to take any questions.
48:46Okay. Fantastic
48:48job.
48:49Thanks.
48:50And probably Steve or others,
48:51if I can identify what
48:52my questions are gonna be
48:54or kind of the focus.
48:55So I'm very interested in
48:56in kind of just,
48:58first of all, excellent result,
49:00great,
49:01technical and and surgical,
49:03decision making and collaboration. It's
49:04fantastic.
49:06But I'm I'm very curious
49:07at the initial presentation,
49:12whether coronary artery bypass graft,
49:16surgery was considered and
49:18whether, you know, there's some
49:20suggestion that maybe there was
49:21infarct expansion that could have
49:22been preventable, and, obviously, VSD
49:24occurred afterwards
49:25that could have been preventable,
49:27you know, leaving this patient,
49:29you know,
49:30under revascularized,
49:31I guess. And I'm just
49:32curious from Steve or anyone
49:34or Charles Charles or anyone
49:35who was there at the
49:36time whether
49:37that conversation happened and what
49:39your thoughts about that, was
49:41and
49:41and whether viability imaging or
49:43anything came into play.
49:48So I'll I'll dodge it
49:49a little bit and say
49:50that I wasn't there. Because
49:52so this patient presented the
49:54Saint Mary's in Waterbury and
49:55that was transferred to Yale,
49:56and I don't know who
49:57the operator was here
49:59who tried to open it
50:00or made the decision to
50:01leave it closed.
50:03But I think
50:04that reading through the chart,
50:05the consensus was that it
50:07was a late presentation infarct
50:09and whatever was done was
50:10done, and it was already
50:11infarcted. There was a large
50:12thrombus burden in the apex
50:13already. The apex was thinned
50:15out. And I I think
50:17they made the decision to
50:18not push the issue in
50:19terms of revascularization.
50:21And as you saw from,
50:23the stills that Ali presented,
50:25but if you look at
50:26the angiograms, you'd really never
50:27visualize the distal LED.
50:29And so I think that
50:30was not a big part
50:32of the consideration.
50:34So, you know, I think
50:36when she came to Saint
50:37Mary's,
50:39they were able to get
50:40a wire across it. They
50:40actually ballooned it, but there
50:42was no flow ever restored.
50:44And,
50:45I don't remember I don't
50:46think they did any intracoronary
50:48imaging, which would have been
50:49very interesting to see,
50:52but they decided to leave
50:53it be at that point.
50:54And then when she came
50:56to Yale,
50:57the findings were unchanged.
50:59So it's a good point,
51:00except I think the the
51:01the conclusion was that it
51:02was just a late presentation
51:04infarct, and it was all
51:05out of the barn.
51:11Two comments. One is the
51:13the inability to,
51:15expand
51:16GDMT
51:18in a way reflects the
51:19fact that there is, you
51:21know, obviously,
51:22in a,
51:24flow going it's like MR.
51:25It's like flow is going
51:25in the opposite direction. Right?
51:27So you're using the the
51:28the aneurysm is becoming a
51:30receptacle
51:31for, you know, no for
51:33non forward flow,
51:34and that's decreasing, you know,
51:36obviously,
51:37useful cardiac output and and
51:39actually
51:40and reducing the opportunity to
51:42start things. So I think,
51:44even though the patient didn't
51:45have refractory heart failure, I
51:47would argue that the inability
51:48to to move,
51:50GDMT forward,
51:53you know,
51:54with an early indication
51:56that this patient would you
51:57know, that this was affecting
51:58their their, their output and
52:00and, obviously, increasing wall stress
52:02and all that from that.
52:03The the third option, which
52:04is maybe I'd love to
52:06hear Matt talk about this
52:07a bit around the different
52:08the evolution of this technique
52:10and how it's, you know,
52:11it's really a tremendously interesting
52:13story spanning fifty years, I
52:14think, plus
52:16and others. But but, you
52:17know,
52:18we're gonna have Dan Bercoff
52:20here in a few weeks,
52:21months. I can't remember, Catherine.
52:24And THT and, is down
52:26around the corner and CRF,
52:28the the the,
52:30that conference finished. But there's
52:32a lot of interest to,
52:34renewed interest in,
52:36both surgical as well as
52:37percutaneous devices,
52:40that can be placed to
52:41reduce expansion
52:43of these of these aneurysms
52:45in patients with true you
52:46know, with severe aneurysms with
52:47this, but also just people
52:48with very large LVs post
52:50infarct.
52:53So it's just something that
52:54to keep on the radar.
52:55And, Dan, I'm sure we'll
52:56talk about that when he
52:56comes. If you wanna talk
52:58about the surgical
53:00Yeah. I'm I'm far from
53:01an expert in this, but
53:02I can remember watching on,
53:04PBS,
53:05doctor Batista in Brazil. They
53:07they did a whole hour
53:08long special with
53:10how his,
53:11aneurysm reduction surgery was,
53:14working miracles for these patients
53:16in Brazil.
53:17He, he worked in an
53:18ICU where there weren't a
53:20lot of,
53:21good ways to monitor patients.
53:23And I remember he looked
53:24at the camera and held
53:25up
53:26a held up a,
53:28urinary catheter Foley receptacle and
53:30said, this is my monitor.
53:33So,
53:34anyway,
53:35it became a very hot,
53:37popular
53:38operation
53:39when I was a general
53:40surgery resident. Even as a
53:41fellow, I can remember at
53:43Duke. Eric, you were there
53:44too. The the
53:46there would be two or
53:46three
53:49door operations on the schedule
53:51every month, and,
53:52you know, we'd probably do
53:54one or two a year
53:54here now.
53:56My recollection is that there
53:58was a,
53:59a big trial that did
54:00not show any benefit for
54:01the procedure, and it just
54:03kinda
54:04went away at that point.
54:05So,
54:07I think that the indications
54:10remain murky.
54:12This patient, it seemed like
54:13you guys decided to tackle
54:16this because of increasing clot
54:17burden and
54:19risk of stroke. I think
54:20the indication for refractory heart
54:22failure is,
54:24you know, not as reliable,
54:25whether you're actually gonna make
54:27people better or not, whether
54:28it's worth
54:30the risk we impose by
54:31doing this complex operation,
54:34is unknown, and that's why
54:35so few of them are
54:36down.
54:38So any other
54:39comments on that issue?
54:42Oh, I think it
54:44send it around. Start this
54:46way and go around.
54:47Yeah. I think for us
54:49in our multidisciplinary
54:51conference, she was presented a
54:53number of times and the
54:54whole question was,
54:55what are the indications? What
54:56are the real indications? She
54:58hadn't had a thromboembolic event,
54:59it's impressive as the echoes
55:01are. She hadn't had any
55:03arrhythmias, she had an ICD,
55:04which we could interrogate and
55:06see she had no,
55:08arrhythmias.
55:08And,
55:10you know, we actually were
55:11able to advance her heart
55:12failure therapy a little bit
55:14over time.
55:15So we had a pretty
55:16vigorous debate about whether it
55:17was worthwhile to proceed with
55:19it, quite honestly.
55:20And, Roland felt strongly that,
55:23you know, the anatomy was
55:24favorable and he could
55:26improve things. And so I
55:28think he was the big
55:29force kind of moving forward
55:31with surgery. And in retrospect,
55:33it was the right choice.
55:34She's done very well. So
55:35but it was a hot
55:36topic of debate, to say
55:37the least.
55:43Jeff?
55:45Terrific
55:46presentation.
55:49So I have a couple
55:50comments. One is a little
55:52bit old school, which maybe
55:54is a lot of my
55:55comments these days, and and,
55:57the other
55:58maybe not so.
56:00The the question
56:01one is question. One is
56:03not. The question is
56:05the one term that I
56:07never heard you mention in
56:09the entire
56:11presentation
56:12was dyskinesis.
56:13And so the reason I
56:15said that's an old school
56:17concept, and
56:18those of you who have
56:20been around for
56:21a little while know that
56:23we used to make a
56:24big distinction between a segment
56:26that was frankly disconnected
56:28and one that was just
56:30a large akinetic segment.
56:32I I do believe
56:34there's less of a deal
56:36made out of that distinction
56:37anymore, but but we used
56:39to say that disconnect segments
56:41were less likely to develop
56:43big thrombi
56:44because they are still moving
56:46even if they're moving in
56:47the wrong direction.
56:48Whereas a large a kinetic
56:50segment is just let's just
56:51not moving when it's there.
56:53And I was looking carefully.
56:54Maybe Lisa can comment. I
56:55was looking carefully at all
56:57the echoes going through, and
56:58it wasn't until the very
57:00last two thousand five echo
57:02that I that was sort
57:04of a presurgical
57:06echo that that I thought
57:08I saw
57:09frank dyskinesis.
57:10So is that something that
57:12we pay any attention to
57:13anymore? Is it something that
57:15we should still be using
57:17as a distinction
57:20for moving forward?
57:25So,
57:28when we call something that's
57:29aneurysmal, that it already
57:32includes the connotation that it
57:33is disconnected.
57:34It can be akinetic,
57:36but, it's usually,
57:38disconnected.
57:40But we do use dyskinesis,
57:43on its own,
57:45even if there isn't an
57:46aneurysm. So we we still
57:47use those,
57:50terminology of dyskinesis.
57:53Not old school. Yeah.
57:57The the non old school.
57:58Comment.
58:01A little bit about
58:02the alpha biology of the
58:04spark expansion.
58:06And this is not a
58:07question, but just kind of
58:09a comment towards the future
58:10a little bit is that,
58:12you know, a lot of
58:12people,
58:14are really interested in what
58:16actually causes this adverse remodeling.
58:18And is there any are
58:20there any early
58:22molecular
58:23intervention interventions
58:24that could occur in order
58:26to
58:27forestall that or prevent it?
58:29And, you know, I I
58:30can't
58:31make a comment without mentioning
58:33the word inflammation. So there's
58:34a lot of,
58:36interesting inflammatory cells that
58:39take residence in the area
58:40of the infarct and the
58:41peri infarct area that are
58:43producing soluble factors
58:45that probably promote this adverse
58:47remodeling and how to
58:49affect that and prevent that.
58:51So that that's just a
58:52comment sort of looking towards
58:53the future,
58:55because I think we still
58:56don't know as much about
58:58that as we as we
58:59would like.
59:09I mean, Emmanuel and
59:11Please. I just wanna make
59:12one comment. I'm Charles Phillip.
59:14I was the her primary
59:15provider since two thousand and
59:16twenty three, and I wanna
59:17commend Ali for doing a
59:19great job summarizing her case
59:21over the period of time.
59:23You know, despite having two
59:24mechanical complications from an MI,
59:26both the BSD and the
59:28aneurysm,
59:29she
59:32heart failure symptoms, angina symptoms,
59:34and even arrhythmia.
59:37So it's surprising that
59:39despite these favorable,
59:44favorable,
59:45symptoms,
59:46her aneurysm was getting bigger
59:48on this the imaging modalities
59:51as well as the cloud
59:52burn despite being on low
59:53dose g d m p
59:54therapy and anticoagulation.
59:56So, I'm
59:57fortunate to work,
59:58at the VA where we
59:59had multiple discussions as doctor
01:00:01Pfau alluded to, discussing her
01:00:03case at length, reviewing her
01:00:05cases, reviewing her imaging, and
01:00:06rereviewing
01:00:07new imaging,
01:00:08discussing with in a multidisciplinary
01:00:10approach with,
01:00:12our,
01:00:13imaging staff, our surgeons, our
01:00:15intangential, and general cardiologists.
01:00:17And,
01:00:18we were able to collect
01:00:19it. We make a decision
01:00:20that hopefully will lead to
01:00:21a good outcome in her
01:00:22future.
01:00:24I know the veteran is
01:00:25very appreciative of the time
01:00:26spent in her care, discussion
01:00:27of her care,
01:00:29and she keeps,
01:00:32thanking all all the support
01:00:33that was given both at
01:00:34the VA and Yale in
01:00:35terms of her overall outcome
01:00:37and overall
01:00:41care. Yeah.
01:00:42So another question, actually. I
01:00:43just wanted to make a
01:00:44comment about,
01:00:46the LV remodeling,
01:00:47in this patient.
01:00:49I believe one of the
01:00:51reason
01:00:52from talking to Ali, one
01:00:53of the reason
01:00:55why,
01:00:57they also decide to do
01:00:58surgery in this case was
01:00:59because the,
01:01:01aneurysm was rapidly progressing,
01:01:03which is which is not
01:01:05maybe probably the rate of
01:01:07of,
01:01:09of remodeling was probably exceed
01:01:11what we expect for most
01:01:12aneurysm.
01:01:13We tend to see rapid
01:01:14progression for pseudo aneurysm,
01:01:16maybe less rapid for aneurysm.
01:01:18But this case, it was
01:01:19rapidly,
01:01:21progressing.
01:01:22I guess,
01:01:23the theory I have in
01:01:25this case was, the patient
01:01:27also had a VSD.
01:01:28So the VSD,
01:01:30in this case,
01:01:31VSD tends to cause,
01:01:33volume overload on the left
01:01:35side.
01:01:36So I believe the volume
01:01:38overload on the left side,
01:01:39it's probably what is also
01:01:41driving the rapid regression of,
01:01:44the aneurysm size in this
01:01:45patient.
01:01:50Another thing.
01:01:55Yeah.
01:01:57Yeah. So maybe just a
01:01:58couple comments, and then, again,
01:02:00thank you. I mean, it's
01:02:01just for for the trainees.
01:02:03I mean, this is a
01:02:04great case because you don't
01:02:05see this very often. There's
01:02:06many reasons why you don't
01:02:06see this very often, but
01:02:07I can tell you that,
01:02:10when, you know,
01:02:12when when I was training,
01:02:13we saw much more of
01:02:14this, and this was actually,
01:02:17you know, a very hot
01:02:19topic within the surgical and
01:02:21cardiovascular
01:02:22communities
01:02:23around around how to optimize
01:02:26approaches to these patients. I
01:02:27think prevention,
01:02:29as well as better
01:02:32earlier presentation and evaluation
01:02:35and and and restoration of
01:02:37of coronary flow, I think,
01:02:38has made a big difference
01:02:39in in this.
01:02:41You know, there
01:02:44there is a distinction I
01:02:45also would like to leave
01:02:46people with,
01:02:47between
01:02:48kind of this aneurysmal
01:02:51and
01:02:52the kind of surgical ventricular
01:02:55restoration or SVR or door
01:02:57type procedures that were and
01:02:59are still at some in
01:03:00some places,
01:03:01performed,
01:03:02which are really looking to
01:03:04kind of
01:03:05reduce the ventricular
01:03:07size to promote,
01:03:10forward flow and improved outcomes
01:03:11in heart failure patients, which
01:03:13were tested in in, you
01:03:15know, one of our one
01:03:16of my trials many, many
01:03:17years back. Publishers, like, in
01:03:18two thousand nine. It's dated
01:03:20now. But but, which didn't
01:03:22show an advantage.
01:03:23Hazard ratio was one of
01:03:25of, of of that procedure
01:03:27for kinda
01:03:28akinetic
01:03:29large ventricles.
01:03:31But I think this is
01:03:32a different situation, and these
01:03:33patients were serve certainly not
01:03:35randomized
01:03:36in in our trials because
01:03:37of of the size of
01:03:38this ventricle.
01:03:39But I think a very,
01:03:40very interesting congratulations.
01:03:42Wonderful job. And, congratulations to
01:03:44Charles for keeping this patient,
01:03:47doing so well and for
01:03:48Roland and and and the
01:03:49whole team for for their
01:03:51care. So
01:03:52Thanks, everyone.