65. Case Report: Spontaneous Coronary Artery Dissection (SCAD) Requiring Heart Transplantation UCLA
Worldwide cardiovascular disease affects the lives of hundreds of millions dedicated cardio nerds everywhere are working hard to fight this global epidemic. These are their stories. Welcome back. Carter exists other than Dan thanks for joining us as we toured fellowship programs across the country as part of Cardi nerds case report series produced in collaboration with the American College of Cardiology fellows in training section, each episode will feature a cardiology fellowship program fellows from that program will present and teach about a fascinating case and share what makes their hearts. Flutter about their program. Each case discussion is followed by an e CPR segment from a content expert and a message from the program director. Before we dive in just remember, we are an independent educational platform. This podcast is not meant to be used for medical advice. 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Carter's welcome back to another fabulous discussion as part of our CNC our series. We are so privileged and honored to be joined by fellow colleagues from the UCLA cardiology fellowship training program are so thrilled to be joined by doctors, Hilary Shapiro, Ruth Show, and Jay Patel guys welcome to the show. So excited a heavy here really excited about today's case. Would you mind introducing yourself? Hey, everyone. My Name is Jade Patel. I'm a PG life five cardiology fellow at the University of California Los. Angeles I was born and raised in Chicago most of my schooling there. Before moving to the area for residency, I'm so excited to be through my fellowship now here in Sunny Southern California when not at work you previously would have found my wife and I spending time on one of our many hiking trails here in southern California or waiting in line for some delicious street Tacos. But more recently, you'll find a sitting at home training, our new puppy, a beautiful Bernadette doodle Mambo he guys thank you so much for having us on Cardio. nerds were really excited. Be Here I'm Hilary Shapiro, one of the final year cardiology fellows at. Ucla in one of our current chiefs along with Ruth I'm interested in advanced heart failure, cardiac transplant mechanical support outside a work I love to go to the beach or go hiking in Malibu or explore the restaurants in L. A. and even though in California I also left his skis. So in the winter I'm up in the Sierra Nevada mountains getting much snow time as I can. Hi everyone it's such a pleasure to be here as well. I am Ruth. I'M ONE OF THE THIRD YEAR CARDIOLOGY FELLOWS AT UCLA is in general cardiology with a focus on. Women's cardiovascular health and in my free time very busy with my rambunctious and very opinionated toddler who I've successfully trained to know the heart makes to sounds. Wow, ruth j hillary what a treat a treat to have you join us and I have a special shoutout from Jeff Su who has just been a great card entered supporter from the very inception. Definitely gives us great feedback along the way and he sends his love to you guys. We Love California shot to be fair to all the states but we do love the side we do love the beach. The sand and guys take us to your favorite place where I think as on the cook gets caught your favorite chill sess- or your favorite place to chill sash I? Don't know if we use that phrase out here. But yeah, there are a lot of great substitutes in L. A. as you probably know the weather is awesome year round. So I think most of us are outside on. Any Day off but you know when we're talking about a place to take you guys, we actually had hard times. There's so many awesome restaurants in L. A.. There's tons of good cuisine on the museum and culture offerings are also amazing and Ruth I bet that your daughter loves Disneyland is just thirty minutes away. Actually I love the Disneyland is just thirty minutes away hold the Disney cartoon. We're pulling out of VIC funches Oh. Let's be honest when people think about L. A. I'm pretty sure everyone thinks about palm trees and surfing, and we google some stats and found out we have seventy five miles of beaches to choose from from. La is so without the best link thing to do would be to head to the beach in Santa Monica and set up a bonfire social distance watch sunset roast marshmallows, and talk about this. Case guys I have to say I'm hoping this goes really well because I'd love to make friends and actually visit you guys actually go to the beach and take for a walk was Momo Right J. Yeah really. Cute Mobile. Yeah this is awesome. I love this place. We're so happy here we want to stay here forever but let's do what we love doing. We're having a child slash some say. WHAT SOME CARDIOLOGY Before we jump in a little bit of a quick disclaimer I recently went camping by a campfire marshmallows and then I touched the spit like where the marshmallows was thinking that it would be not hot. Fingers. So let's not do that while we do this even though we're going to be very engaged and yes, did get in the way of working that coronary catheter into the right for air to but. Let's start this case. Let's start. Are, so let's jump into it our patient as a forty nine year old healthy non smoking woman with no family history of heart disease who presented to one of our satellite community hospitals reporting intermittent chest pain for one day. She said the pain started while eating a meal but then progressive constant pain for thirty minutes, which is when she decided to come to the emergency room in the emergency room, her ekg showed entrance upto and lateral sti elevations with reciprocal inferior as depressions and yard team called cardiology because they were worried about acs caused by. Q-QUICK rupture. While J only forty nine years old and she has no risk factors for heart disease that one liner can really help set your framework for what to include in your differential diagnosis I mean the average age I am is in the United States is sixty five for a man seventy, two for women. But as we all know, the age range can be quite wide and she doesn't have any cardiac risk factors such as hypertension smoking, diabetes dyslipidemia, it doesn't mean. That atherosclerotic disease is off the table for her in fact, studies have shown that almost twenty percent of ACS patients younger than the age of fifty years old presenting with type one myocardial infarction have no traditional risk factors and more and more patients with no traditional risk factors are actually presenting to the hospital with stems while I, agree with the concern for plaque rupture with UN, the emergency department in the back of my mind I'm wondering if something else is. Going on yeah let's Point Ruth. You know if we even take a step back further to our chief complaints, which was just intermittent chest pain while eating in a young lowest woman without knowing what the US honor Ekg my I thought actually may not be acute coronary syndrome. The differential chest pain is really broad and some other dangerous things I hope they ruled out was we want to make sure we don't Miss section Soft Gel rupture or some. Sort of pulmonary embolism. Also, with the Association of pain to her meal, her symptoms could have also been chopped up to G I if if the year hasn't got any G. so it's a really important point because majority of women with SDS deal of chest pain non cardiac centers are way more common in women than men. So you'll also see a lot of female patients who are having a semi or an end semi that come in complaining things like fatigue. Nausea or neck pain, and they may never have any chest pain even if they're easy. G in an geographers slam dunk for a heart attack something else wearing me is that women are more likely to attribute their symptoms to non-cardiac issues. So they may think that they're having a GI problem instead of a heart problem and delay coming into the ER at all, and finally they do actually go to the ER or their primary care doctor's office with complain of these symptoms study showed that actually providers are also less likely to immediately think about ACS and women are less likely to. Get. An. EKG Inter opponent check when I go into the medical office, their access to prompt care in a correct diagnosis can be even more delayed. So you know it's really important to have a high suspicion for s and women, and Dr Carol Watson Are Awesome Program Director and director of the women's Heart Center. UCLA says that if a female patient reports, any exertion symptoms anywhere between her nose and her navel, you should always think about a cardiac issue some really glad that our patient went into the Er and I'm so glad that our community hospitals check that ekg so quickly. I was just GonNa. Take that. I. Barely settled into feature. You guys hit us without s geolocation. But. There's this is exactly our speed our pays and we love it and I just. I. Think this is such a common presentation even if we didn't have frank television sort of makes our job easier because we know what to do in that moment. But there are so many presentations with EKG isn't as profound and people present in different ways inside just glad. That you're contextualising the symptoms within the framework of patience you know in terms of both her age and her gender because he's a really important considerations, we've gotten into a few times in the podcast before like talk showed Galati in danger, and so this is a great start and for setting the stage for contextualising presentation in the framework of a patient who hostess. Yet and I'm I actually have a mentor who is one of our giant faculty in residency who's quite a senior professor at this point and she went into an emergency room with chest pain and she just tells the story of how she was totally not taken seriously as what have and the EC G wasn't even died genitals where this was but in easier g wasn't obtained. Rapidly, and then her husband like about like thirty minutes after she was already triage that she was a physician and all of a sudden run to arms. Let's get everything done I was like, Oh, you're one of ours type things and the guy got an e c g but the thing is you can't see a semi until you do any g reilly. Yeah you look. For it. So you know and she did well and everything ended up being great. But that's the actual issue. Right? You can't use your eyeball testing preconceived notion sometimes. Yeah that's absolutely correct and I think sometimes we also neglect realizing that the risk factors for cardiovascular disease is different than women as well. So since we're talking about cardiac issues, female patients, something else that. We should mention is the different risk factors for third grosses and women compared to men because there are some extra ones that you should be asking your female patients about, for example, diabetes smoking actually a maternal history of premature coronary artery disease. All increases the risk of cardiovascular events in women compared to men. We also know that a history of depression trauma or just general. Mental stress are also strong nontraditional risk factors for coronary artery disease in women and emerging area of research is actually looking at the gender differences in Gut microbiome and seeing how that plays into the development of CAD, and when it comes to hormonal effects. The balance of hormones with pre menopause is actually considered protective of the development of coronary artery disease but things changed. When you're in the menopause or post menopausal phase where you have the estrogen withdrawal that women experience, and that actually puts women at increased accelerated age related risk for cardiovascular disease. So there's been studies that looked at hormone replacement therapy and seeing if that mitigate, some of the high risk features that we're seeing in these menopause on postmenopausal women, but the randomized controlled trials didn't. Find benefit for each rt in preventing primary or secondary cardiovascular disease and actually had signs of potential harm. So currently, hormone replacement therapy isn't recommended and finally I think it's always important to take a moment to ask about obstetrics history. If she had children because studies have shown that even temporary things like just station diabetes or hypertensive disorders that revolve around just the pregnancy state. have been associated with an increased risk of future is heart failure strokes. So that was quite a detour but I think it was important one. Let's go back to our main question again, which was the concern for a pack rupture, and in the back of my mind, there is a concern for the Q. Pack Rupture but I'm also wondering if there's something else going on. I think that's an excellent detour. Ruth The you know you're asking great questions a agree that you know first and foremost most acutely we need to rule out in acute plaque rupture. But even if we think the patients having a cardiac issue rather than a Gi is or something else, we should also think about her other cardiac causes of chest pain when I hear about her easy g with St segment elevations in the interest central and lateral leads I'm definitely thinking about an interior. Am I am worried about a plaque rupture in the left anterior descending artery, the left main artery but as. We know there are other cardiac issues it can cause similar ekg changes. Other things I'm thinking about for her would include spontaneous artery dissection or skied coronary artery embolism a corner artery visas spasm or talk at sumo or stress cardiomyopathy and we are in. Kovic. So you've got to think about Myocarditis pericarditis as well. The awesome thing that I think about cardiology is the when there's a question about what exactly is going on with the patients coronaries we can take them to the Cath lab in June and geography and take a look so I hope we took our patient the Catholic next yeah, J.. Anxiously waiting. Don't Worry Hillary Ruth Dan and all you cardio nerds the Stomach Pager was definitely activated. The patient was loaded with aspirin anti-tiger before being taken straight up to the Catholic while every Catholic is a little bit different. Our strategy here was the first image what we assumed they send ekg was the non corporate vessel as tested. A culprit vessel is critically if not totally included and wouldn't take up. The majority of a case by I. Looking at the Non Culprit vessel, we can get an idea of what the coronary supply is to the rest of the heart and we go with a guide catheter for our culprit vessel. Now, if the patient had been unstable or engaging non culprit vessel took longer than, let's say a few minutes, we'd go straight for the presumed culprit vessel time as Myocardium as. As great j Yes, almost an interesting experience in talk at Suppo Cardiomyopathy, which classically looks like A. EKG. has totally normal corning arteries on geography you're totally right. Hillary. J Hillary Ed Ruth this is crazy gates and I'm really excited to hear about the NGOs but just to clarify for the audience in case you're not aware remember that the g not only diagnosis semi, but it actually helps us localized the semi and so what we talked about earlier, you know the s the elevations in the anterior leads with the reciprocal depressions in the fear leads really points to a proximal led Proxima left main situation rather than let's say a right coronary artery or circumflex situation, and basically when we approach these, it's Kinda crazy like cartoons hasn't done like an acs series yet which. I'm crazy but that's what we're doing. When we have patient chest pain we are looking at C G hungrily trying to figure out what's going on and when we sniff out Imia, we're trying to actually localize it a neurologist would with a focal abnormality anyways. But then just found that what Jay said lot of practitioners but they'll do is let's say they've identified that it's a left sided problem sale led or left circumflex they'll just go and quickly look at the right coronary artery first before they proceed with looking at the actual problem because they. Wanted to make sure they know what's going on in the right side before they intervene on the culprit lesion that they think it's going to be and most of the time the does point to the right direction. So that's just what j. you're totally right down. That's actually one of the reasons I. Love. Catholics is you know until you get that first image on the screen you can have guesses about where you're going to see. You're never really sure and also as you mentioned you diagnostic and treatment at the same time with the same procedure. So, tell us what did you find but he took the patient to the table of truth. Table. So here we go in the Cath Lab the opening shot was the non culprit, right coronary artery, which was large dominant vessel with a note disease. So that was reassuring next switched catheters to engage the left. System in the opening shot after the Cath team injected the contrast the immediately that there was a problem Kathy deserve on the Cardio nurse website and I definitely encourage you check them out but I can describe to you here. Now, the left corner system usually left artery that bifurcated into big healthy left anterior descending artery Anna left circumflex artery, and sometimes there's a Ramos areas artery in between the two. In our patient the left main artery looked a really long skinny sliver of a vessel with a small area of contrast feeling into what looked like a false looming. After that, we looked branches off the left main, a nice left circumflex artery was visualized but informally, there was no left anterior descending artery visualized at all. While description, you gave of the left main appearance in the lack of appearance of the led is very concerning when we talk about plaque rupture and what it looks like on an geography typically, we say that the artery appears abruptly included or ulcerated with contrasting not a long skinny sliver of a vessel with loss of distant branches, and then contrast into a possible false loom in like you said, with this angiographic appearance paired with her acute presentation, her female gender, Middle Age and basically. No traditional traditional risk factors I'm less concerned about a classic plaque rupture but I'm really concerned about her having scattered or spontaneous coronary artery dissection, and this would actually fit while with scattered because it's much more common in younger women with eighty to ninety percent of Scott cases occurring between ages late forties to early fifties and our patient. She's forty nine and she fits perfectly within this demographic. The prevalence though is really low. It's about four percent, but it's thought to be the underlying cause. Up to thirty five percent of all ACS cases in women, fifty years or younger, and the true prevalence is probably under represented in registry studies because it's hard to get an accurate diagnosis and there's recruitment methodology is is and things like that. So in terms of why Scott Develops, no one really knows why. But there's two leading theories that we should be aware of one is the inside out and the second one is the outside in theory. The inside one is where blood enters into. The sub optimal space from the true bloom and creates a dissection flap. The outside in is when a hematoma develops. Novo and this disrupts traversing micro vessels and causes a dissection. So in both cases, you have separation of the layers of the coronary artery similar to when we think of when we hear about eight dissection, the majority of Scott is thought to be from this outside in hypothesis because when they look with imaging, there's not really a communication between the true in the fos- looming. Yeah, absolutely earth you know just taking a couple more minutes to talk about the geographic appearances of skied. The most common thing we see is what we call a few stenosis without any abrupt changes in the caliber of the artery. Type Choose Guide in archies. However I think this looks more like a type one angiographic appearance, which is seen only in about thirty percent of skaggs cases where you get a really long filling defect from the intimacy section flat, and then there's a little pocket of extra contrast causing downwards file dissection in Arcades looking at pictures. It seems like the dissection starts at the distal left mean is where that contrast dating is in reassuringly she didn't have a healthy left circumflex artery healthy RCA, but this is not the case that you ever WanNa get. In the middle of the night, it's really rare. The prevalence of Scott is already very low and the prevalence of scadden involving the left main is even lower. So like less than one percent of all Scott Cases I just have to say one this has been awesome discussion hitting. So many of the main points and critical pearls will lead to scab but I'd like to speak directly to our audience I a so to our audience whatever you're doing right now whether it's exercising or driving the car or sitting on her desk not just. Pause the discussion right now and go to the blog post and take a look at these images because this is the most impressive angiogram I have ever seen. I show this to multiple people at work yesterday faculty who've been working forever, and this is just a a such an impressive image you look at I album started choking on my bonfires. Moore's it is that. Don't do that. and. Also drive safely do not look at this liar driving. Unless he could safely not not her. Doing If you're I'll. have to pull over. Our fans are very intelligent people. They know they know yet. Okay. Disclaimer for the lawyers you please pullover I safely. All right and also I gotta just add you have to see these pictures. Yeah. I totally agreeing with these are just really really really impressive pictures but also bringing it back to the patient really really critical pictures to see recognize and to learn from so and whoever was in the Cath Lab at this time I commend them for just whatever's going to happen next I'm sure whatever's next was was really really challenging and when you're confronted with an image like this, the sympathetic get wrapped up I all I'm sure and the other thing that I pointed out from this particular image if. You look at it as Jay so eloquently said, first of all, you could see some dice standing in the left main. You'd see that and second of all the Elliot's flush included, which means that there's like no flow into La D. and so for half you know it's very helpful to actually I learn how to identify the walls of the heart when you're learning calf and this isn't a Catholic at all. So I won't go into yet. But if you learn the walls, then you're gonNA learn what arteries go to those walls and then you're going to be able to see. Oh. Wow. There's an entire artery that's missing here. Only when you see, let's say in L. A., D. at an all of a sudden abrupt stop at Abrupt Inclusion, my twelve year old and my nine year old can pick out the lesions, but it's totally flesh secluded they can't, and that's because your eyes are drawn to inclusion. But if you have a flush seclusion where the artery never starts to begin with, it can be very challenging. So you really want to learn the walls than the arteries that go to those walls of the heart, and this has been such an incredible didactic but like with. A patient I'm really curious what the next steps are because the conventional teaching is if you see the section that you probably don't want to shoot more contrast because the pressure of the contrast going in itself injection can cause more trauma and injury caused further dissection propagation, and then secondly, you know we've got a critical left main stenosis from either dissection flap or the outside that's an encircling Truman and the led is gone. So I'd love to know right now what are the human dynamics and how do we support this patient? So that way we can figure out what to do moving forward. Dance. A perfect segue into what I was going to say next, you know the interventional team definitely was in a battle. At this point you know this is in the middle of the night they shoot this diagnostic angiogram not wanting to do harm on the patient unfortunately even with just contrast injection for the diagnostic the patient went downhill quickly she had cardiac arrest and she trickier fibrillation shortly afterwards, diagnostic and view grab the team. was able to defibrillator quickly with just one shot and he gave her intravenous Amiodarone for stabilization and Palace EP was placed for additional left ventricular support, Higher Level Mechanical Sport like Akmal and emerging cardiac surgery or not ready available at this hospital overnight given the patients amick and electrical instability. The Catholic team fell at her the was suffering enough from auction delivery and decided to attempt to rescue operation by opening up the artery. Man This poor lady you know we were just talking about it but treating Scott and trying to reverse guys scab just terrifying. You guys are absolutely right. Scott is what I would say a catch twenty two you risk propagating the dissection if you try to fix it with coronary stunting Perky Tina's interventions. But when there's no flow and the patient's chemo dynamically compensating quickly your hands are tied and you have to try something. So I think it really depends on how the patient presents and what the. Vessels are involved and by far and away the most common strategy just like with had alluded to earlier is conservative management. That is no re basketball station whatsoever over ninety five percent of patients who were treated conservatively had andrew graphic healing of the legions on repeat angiogram four to six weeks later. But even if you do choose a conservative treatment strategy, you need to monitor the patients in the hospital for several days. In case, the clinical course takes a turn for the worse and urgent bypass surgery if. Is the preferred method of re basketballers ation in clinically stable patients with. Or high risk dissection if the patient is clinically unstable such as in our lady than attempting park detainees, coronary interventions is reasonable. Yeah you know I think that sometimes management of these high risk cases also depends on the resources available at the hospital you're at I. Know we'll probably talk about this a little bit later but I know in our main academic hospital where lucky have echo in C. T. surgery available twenty, four seven but at our satellite centers or wherever we are absolutely you do whatever you can for the patients ruth. When you say a conservative management strategy, you meant giving the patient anti platelet therapy and Betablockers and Hepburn right to minimize myocardial workload maintain agency of the true Cornell Lemon trees associated from. Body legions, right. You're absolutely correct hillary in addition the use of thrombosis is generally not recommended because extension of dissection on her Hematoma have been reported with Ron, politic Houston Scott patients. So in addition to all the conservative therapies that you try, what else did you guys do for this patient? Jay. So once a wire was passing to the Ramos Intermediates Branch which I forgot to mention existed before intra vascular ultrasound was used to confirm visualize a large section flat in left main coronary artery with a significant amount of intramural hematoma. This is also really impressive video clip that can be Carter nerds website. Another plug for Ucla, is Dr Jonathan toews one of our interventional cardiologists who performs complex. Pf for closures alcohol mitral valve. Pisces was also one of the pioneers for injured Oscar ultrasound. He's a wealth of knowledge in a resource and always accessible president artesian conferences and interventional internal clock sessions. Going back to the case attempts at wiring led were successful only to the mid portion after which multiple wires were tried but all were unable to pass down to the disability. This didn't open up one large branch. Because the Ramos intermediates wire wise confirmed with Iras to true lament, the left main stent was delivered on this wire. However after stent expansion, there was no additional improvement in the flow through the led additionally, the left circumflex artery, which was previously nicely open. Peyton now closed likely as a result of dissection flat propagation. We're now four hours into the case in the middle of the night and the team was reaching its contrast and florals coppee limit. The decision was made to cease further attempts at revising the relation. I. See what you mean Ruth with Scott being a catch twenty two, the parking Tina's intervention strategy for dissections is really difficult. really commend our satellite. Interventional team for doing the best they could for this really sick lady. Getting into the true lumine of the dissecting arteries, the most important step, but it can be really. And interventionists reform chronic total exclusion interventions utilize strategy of actually creating dissection planes to bypass the chronically included area. A wire won't pass through it but in situations like this wiring incenting into an existing dissection plane through a false lumine could compromise all the branching festivals as well, which could just be disastrous intra vascular imaging stitches. I'VE S or Oct can help us confirm that the wire we pleased action the. Right position. So in the Truman, rather than falsely men, but this is also not really an easy task to perform because those imaging strategies need a wire as well and putting that imaging wire down to do the imaging can propagate the dissection as well. As you can tell, this was not a straightforward case. It seems Kinda heavy for a beach bonfire that how is the patient's heart function doing throughout this? This is exactly how we do our beach on fires. Heavy stuff in La. Yeah. The scattered the ACLU. La D. and the ARRHYTHMIC arrests really negatively affected her cardiac function, her post procedure transfer echocardiogram showed life tricky rejection fraction of twenty, two percent with ethical AK- nieces and anterior antra lateral hypo could ISA's which is all myocardial territory read expect to have problems with what we saw honoring geographic. There was no significant valvular disease. Jason how did Ucla Ronald Reagan, our main academic referral hospital get involved. Unfortunately the patient continue deteriorate clinically she sent up to the ICU on maximum. Pella support and team hopes she would cool off and stabilize. Impel. ouflows could not be weaned indicating that her heart wasn't strong enough to circulate blood on its own, and then she developed acute renal and liver failure probably from her low cardiac output a little later she went into ventricular fibrillation two more times. Basically, her heart was failing and it was causing all other organs search shutting down as well. Fortunately, they were able to contact Ronald Reagan Ucla expeditiously and get her over here for higher level of care. Jay that's something I. Love About Ucla our network is huge and we have hospitals and clinics all over southern California. I think we span like middle radius from our big academic center. So we're really to help a lot of people. We get to see some of the most complex cases in southern California I think right now ucla health is providing care all the way from San. Luis Obispo to Northern San Diego County. So spanning much of the seventy, five miles of beach front. The other great thing about this is that there's lots of clinical academic job opportunities for our fellows after graduation for those who want to stay within the UCLA health system. So going back to our case now that the patient is back in the mothership at Ronald Reagan what happened? That's in one of virtual conferences is that our satellites endings are able to participate in conferences and some are giving us talks to widening exposure to more community based cardiology and not just academic cardiology. anyways Ronald. Reagan. Ucla was contacted for higher level of care as I mentioned because our function was so poor are mobile Ecuador. Team went to the Outside Hospital Kanye late at her and placed her on va echo prior to transfer back to the mothership. I love our mobile team such an awesome innovation that we've had ucla for the past few years and they really do have the most high tech ambulance truck. I've ever seen. The Akron team is spearheaded by one of our see surgeons images saved a lot of lives in the greater southern California area were actually able to go and pick up patients at other hospitals who need Akmal or who are already on Echo. We can bring them back to ucla where we have this. Awesome twenty four, seven team. That's huge. We have CD surgeons, heart cardiologists in. Perfusion specialists, restaurant therapists, and ice universities who are all in Akron care can take care of these patients. I'm so impressed by the ability to offer mobile. Switch a tremendous. I they look like like ghostbusters into these like huge tax on income like into our other hospitals like scoop these. Recall Yeah exactly the. As we all know that they're support the heart right we can support takeover for cardiopulmonary system really that allow them ability immortality comes from the end organ injury and so yes, time is hard. But also time is kidney time is brain time is limited time has got time is your vascular tone, and so if we can sort of minimize time until we get these end organ injury, this common sort of a systemic inflammatory response release, your bachelor tone, I imagine that the outcomes would be better with all this very, very impressive. Yet, and I'll add it like really speaks to a system. This is what you're describing here is just incredible system where everybody is so important as part of the system, you know the people that ground that have that obviously, this case was pretty profound than you recognized shock and it's pretty cute. But like you know shock sometimes be challenging recognize as Ahmed said time is Oregon's diamonds everything time is life and so you can have the biggest system involved, but it really speaks to the network that you have set up over there with the ability to mobilize and then have these your multidisciplinary discussions on the go to develop. This is very impressive. Incredible. Yeah you're totally right. Usually health has a big footprint kind of all over southern California like Ruth said, and it's a really great of collaboration were a lot of our UCLA interventionalist. Just Ucla cardiologists work in the community hospitals. They also rotated Ronald Regan are mean little. You know some of the Times that we all know each other really well. So if anything happens, you're everyone's really well trained but if anything happens or someone's worried about a patient is just one phone call somebody always picks up, we can really help people and we've brought people over for ECM watch just 'cause they look unstable they might need mo but sometimes I was. Talking about this big backpacks, the Akmal actually bring all of their ECM equipment to the patient wherever they are I think they've even started on the sidewalk outside of a hospital and they can calculate the patient at where the piece is stabilize them get them into this giant ECM oh truck, and then translate back to UCLA to Kinda get tuned up and figure out what else to do. So it's awesome it. It's been a great learning experience for all of us. Hillary yes. That's pretty much exactly what happened to our outpatient? She was admitted to the CARDIOTHORACIC ICU at Ronald Reagan after being placed on the at the hospital she was intimated sedated started on crt to help her failing kidneys. Cardiac surgery didn't think she'd be a great candidate to take to the or unfortunately IC- cabbage or coronary artery bypass grafting, which is usually reserved for Scott patients who have Pi that's failed or situations that are considered extremely high risks such as left main dissections with ongoing like in our patient can actually. Be quite risky to perform especially due to technical concerns with suturing the fragile decided coronary artery tissue because of the spiral dissection down the patients L. A. D., I can't really see a clear target for a graft stall ID looking at the images which you can find on the cardio nerds website plus you already had a left main stint that required anti platelet therapy are though some of the reasons that cardiac surgery didn't think she was a good candidate for bypass. Jay, you're absolutely correct. Additionally, the patient had already significant myocardial ISCHEMIA. Probably, far ship from Elliot Being Essentially for over twenty four hours and she was still require maximum mechanical support with Akmal and Pella. So the possibility of the patients requiring a heart transplant was in the back of our minds with the lack of target for bypass surgery at her still critical state. The decision was made to proceed with an another temped for intervention to try to restore some flow to the led myocardium to stabiliser. We mechanical circulatory support as much as possible and start an expedited heart transplant evaluation she was taken. Back to the Cath lab the day after transferred to see if there was anything else done to help restore blood flow to led territory myocardium are caffeine at Ucla was able to wire down to the diesel led interested Alderson showed wire coursing in trilling approximately that the wire entered the dissection playing in the mid Elliott t, and then distantly the wire reenter into the true Ruben because the wire disallowed entered back into the woman three stents were placed across the length of the led from distal proximal to try and help restore led. You may be wondering what the risk is withstanding of the fossil. In this case, the wire traverse through the dissection clamp, but luckily reentered the true distantly. So they were able to connect the proximal true lemon to distant true with the three stunts. Place her post intervention angiogram showed improvement in led flow at our subtitle diagonal ranch's reappear she returned to the CARDIOTHORACIC ICU and slightly better condition and was successfully excavated the following day that's awesome. Jake, it's incredible that they were able to do such a great job on such a complicated and salvage flow to the diesel vessel. Just a quick question actually when. They. Go into the false looming reenter extended open do you risk losing the site branches come from the push of vessel immature traversing the false women? I think that is a risk and with this patient being as high risk as she was the team. Inpatient your team as well as the team were just trying to salvage whatever myocardium it could at this point while already having been expedited transplant evaluation being down on the back burner. That's amazing. I mean you know even if they sacrifice a small branch really recovering flow too much of the masses that can really awesome. Phenomenal. So after the Cath, a patient went back upstairs, the ICU she was actually decapitated from five days post procedure and the impels removed seven days post procedure. However, the patient continue to require significant financial support and repeat studies show that the LV ejection fraction didn't really improve enter kidney function also been proof so even. Though blood flow was restored to solve her heart tissue with the second angiogram. The team thought that a lot of permanent damage had already occurred and that are Reno and cardiac function probably would never recover therefore are cardiomyopathy and renal transplant teams who were already falling her from the start of our admission decided to conduct and complete expedited valuation for heart and Kidney Transplant for which she went successful dual heart transplant just twenty eight days after transferred to UCLA. That is incredible. Got Major Goose bump actions even though the fires hot I'm sweating a paradoxical. It's goosebumps reverse paradoxes but. What Jerry just looking at that situation. Like a reference to her annuals perversity for construction. GERIA-. Okay Telling me. Okay but I was I was like what I find it totally remarkable here is you know we said time is life and that's really true and I'm a pointed out that the organs you know suffer right away and here you have basically. Okay. So we understand why the heart can't come back. You know this as a lot of schemic time but then kidneys are very very sensitive to his but what it's Really Amazing, and the really again highlights the resuscitation effects of the team is that the brain is preserved like it's an unbelievable thing that you're seeing here that you know basically again, even after all of this, she is a candidate she's even a candidate for transplant, and then as actually able to transplant is just again speaks to the blood sweat and tears village that went into taking care of this patient. Yeah exactly Dan it really speaks to the coordinated care to get her transplant in less than a month but just taking a step back and looking at it from the patient's perspective I think this must have been terrifying. For, the patient and her family, she was a healthy person had one day of symptoms then found herself deteriorating so much that she needed not just one but two organs transplanted within a month and all this during the covid pandemic to. Yet it was a really really rapid courts and I think the family was scared when she first came over to Ronald Reagan on top of her health issues, she's actually a high school. Spanish teacher had recently become the primary breadwinner for her family because her husband lost his job tutor pandemic everything going on their situation with stressful. Yet Jay I'm sure that was really stressful and it reminds me that in addition to pregnancy extreme emotional stress and extreme physical stress have actually been identified as a trigger for skied in almost two thirds of cases I wonder if stress was just the big trigger for her initial scab developments, there are also case reports of vomiting leading to Scott as well. But I think you said that our patient had chest. Pain when she was eating, she wasn't throwing up. So probably it wasn't that you know it just goes to show that the triggers for Scott can be a lot of different things you need to take a great history look really carefully the angiographic images in the Catholic I think we said earlier early skied was very obvious but for a lot of patients with Corrado dissections, the findings are really subtle yes and You also said earlier how you know this patient like again, totally healthy in just gets just being this whole thing unfolds I actually saw not I would say similar case but a patient who is undergoing eeg is a while back many years ago with a patient was getting an easy d she was in her forties for just a work of Gerd and ended up having the F. and. Then, also an EC- G that showed a salvation entirely had left main dissection went to the Cath Lab. They couldn't fix it and then up getting bypass but was on a balloon pomp and unfortunately had complications related to the balloon pump lost a leg, and so this woman as actually having when I was a medical student, it's really seared in my mind I think this person all the. Time. I remember first last name and I remember being in the or watching the surgery and seeing like the open chest and then ultimately the next day the patient had go for a leg amputation all before she woke up and and then she wakes up basically again she was getting a work for Gerd and then ended up having his like just a devastating consequence actually followed her. Chart followed her for years because I always thought about her and while she at a different kind of outcome as this patient, she went to Rehab and basically really really worked what she had and I obviously never met her again but I would've loved meter and hear her story but it really left an imprint on me and again severe scat it could be really really really challenging to manage. Know like one what a nightmare to also to show you how much strength people can have in the worst of circumstances. Yeah our patient definitely had a lot of strength to get through all of this with everything going on with CODA pandemic. Thankfully, she lives in a home with great support network she had to rely were caregivers, her husband and her mother who were able to help post transplant. She also had an employer who really fantastic in accommodating through her hospital stay. So she was able to keep her insurance and was able to financially be okay. Those are all great factors studies. Show guarantee a good outcome after transplant is a huge surgery and it's a huge life change and we want our patients to have the best support to get them through this adjustment period help them take their medications and get to and from all of their follow appointments. Our transplant team here is very large and has a lot of fantastic social workers who do a great job of really figuring out how we can build individualize of fourteen for each patient that we transplant. Transplant is a deal I. Think sometimes we forget how monumental it is because we see so many transplant patients ucla. I'm going into advanced heart failure heart transplant. So I love this stuff, but I think this is probably a great time to maybe remind all the listeners that there's a lot of different reasons that we can actually transplant someone's heart not just end stage heart failure so you can do heart transplants for persistent Cardi genyk shock that can't be weaned from tropes or mechanical circulatory support our patients you can transplant for on true just end stage heart failures new. York Heart Association class for heart failure with symptoms that are refractory to optimal medical and surgical therapy including things like ads transplant for persistent anginal symptoms corner disease that just isn't amenable to vascular station. We transplanted people who've had life threatening recurrent arrhythmias like v. t storm that's unresponsive to all other modes of treatment, and then we would be congenital heart center here at UCLA, we do transplant for some of these specialized forms of cardiomyopathy. Isn Congenital heart diseases so. Luckily for a patient though it seems like when she got a new heart, her risk of developing skied or her history of developing Skadden, her I heart doesn't put her at any increased risk of developing Scott in her transplanted heart. So at least that's one less thing to worry about because I know that a lot of scab patients actually have some PTSD after the event worrying they're going to have another of spontaneous cornell already dissection the future I hope she's been doing well since this crazy month in the hospital how is she doing j? Yes she had a pretty smooth and pretty uneventful offered, of course instead now, the transplant kidney took a little bit of time to start working after transplant was just meant that she had a prolonged period of CRT postoperative -ly, but she actually is recently discharged from the hospital with normal heart and kidney function. It's a really great outcome for what was initially an devastating and rare diagnosis. When we look through the literature, we only find three or four other case reports of a patient with such significant scat that they needed a heart transplant. So this story really is one in a million. I'm so glad we were able to help her did you get a chance to see the pathology slides from the wanted her? I heard they were incredible. Oh Man pitcher really really is worth a thousand words. We have some great images from the planet hard that are on the coroner's website and definitely encourage everyone to check those out. But if you're driving, please pull over. I. Wasn't clear before, but you do have to check out these images because they are incredible. There's a gross pathology image that shows the infarct Admire Karya in the led territory while infected myocardium is, of course, not unique to this case or even scat in general is very fascinating for me to see what a gross specimen looks like after my Carl Infarction I personally never seen it before there's also a great radiographs. Of expanded heart showing extensive, stamping that took place all the way from the left main through the distant led, and finally my favorite image is incredible his pathology age of the led in Cross section, which shows a gigantic false limited and a smaller Truman and within that false lament, you can actually cease than Strut indentations although the of the diagnosis of scattered was clear even after the first shot in the Cath. Seeing this histo-pathological image really drove home for me magnitude of this section. You're so right Jay. Some of my favorite images that I've ever seen in my life are the Three d images of my children in my wife's belly and this image right here I mean, this is just This is Scott a shell. This is a New York. Thank you for sharing. Your. Let me rephrase that the the picture of by Kids Weiss Belly, a picture of my wife and this image that say. You definitely need to pull over and take a look at the images now. Yes I completely agree you know another thing that it really highlights is what you're missing on geography and I love geography. But remember that when you basically inject the die, the die is only going into the lumine that you're injecting into and so that's why skied we had talked about this on a previous episode, Scott Challenging to diagnose this case not so much. It was very very clear but sometimes, you just see a narrowing of the arteries and then fatten up again and they look like spasm or could even subtle and if it sometimes long enough, your may not even notice it. As a problem at to begin with, and so here you appreciate what that means that when you're seeing just the die you could imagine for example, in this picture that I'm looking at where if die we're going into the false lumine, you might get impression that that is the actual Truman by the die, these would fill out the entire hearty whereas the through limit is actually squashed to the side is really a flat it looks like a moon or a thumbnail or something like that. So definitely check out this image in kind of correlated to the Andrew aggravate that we saw earlier. Just looking at the sandwich it's like hair-raising in retrospect now that we've recorded and have the discussion realized that they they knew that they were in the false loom in and it was sort of control re entry incenting. But just thinking about what was going on in that moment, you know the patient is crashing organs are suffering in a life of a young otherwise healthy woman who has children is on the line and it's just like the. The methodology here, the technique, the level of minded thinking the teamwork are all just such a testament to the capabilities of the team, the experience and the expertise that goes into taking care of critically ill patient but being able to essentially use control steps to salvage as much profusion. Can you know I'm so excited to be an interventional cardiologist and is just such a amazing thing to see how experience and expertise can get you to that level. One to level about cardiology. Yeah I agree completely and you know I think that we are really lucky ucla to have this team that just functions a big unit in all kind of help each other out and those pathology images were incredible and one of the things I really love about. Is that another member of the care team is Dr Fish fine who he loves to teach, and he arranges these monthly sessions for the fellows just to teach them and let them see all these path specimens of patients, cardiac patients who recently had an autopsy or organs ex planted, and he does these combined sessions with the Pete's cardiology group as well as we get to see everything from tiny little baby hearts right up to huge dilated cardiomyopathy this whole the hearts score over the past slides Scott the case again and it really just like you said. Hammers home. Some of these teaching points also makes you realize that the learning continues even past the cath lab and into the pathology lab is well, he had. You're right Hillary though sessions are really priceless valuable I. Think we're really lucky to have dr fish buying at Ucla, and we also get to pick heart dissections every year to learn cardiac anatomy, which is always really fun to hang out with our fellows but anyway, I'm glad our patient did well, I made it home moving forward. Now what are some things that you guys council the patient on J. One of the biggest things we emphasized to our patient was the importance of eventually being screened for other arterial disease given a strong association between Scott and five muscular displeasure. It is crucial that patients damaging of the other large vascular beds evaluate for silent disease. The other skill beds most commonly involved, include the meals, the cradle vessels, and the LAX. We also council their patient on the importance of Cardiac Rehab, which will be part of our acute rehab. After this prolonged hospitalizations, there's a high burden of psychological distress among scattered patients. So proper surveillance going forward is also A. Imports to ensure a patient gets the treatment referrals. She needs. There is unfortunately a lot of fear and uncertainty for Scott patients who really worry about the recurrent cardiac events and other vascular issues in the future, and we want to provide not only medical but also psychosocial support to the best of our ability. Yeah. This was just a fascinating case lot of twists and turns, but you know I'm so glad that the patient had a happy outcome at the end I. Know Like we've said, I think one of the reasons that I love this case as it really highlights the collaborative nature of Ucla even from the Community Hospital or kind of affiliated hospitals to the CD surgery team, the team, Cath lab, the ICU, and then our transplant teams you know everyone's really at the top of their game and everyone's input is valued and everyone just pulled together to help patient. So Hillary Jay this case embody. So much of what I love about cardiology and really took us from an initial acute emergent presentation where life is on the line took us through although multiple teams that are involved in taking care of a patient at a specialized cardiovascular center with a specialized and capable heart team and really put the patient at the center you know with her particular circumstances and ended up with a phenomenal outcomes congratulations for you all in terms of being able to take care of patients. Such incredible way, and so I'd like to ask you guys at this point. One of the reasons you decided to pursue cardiology and what makes your heart flutter about Ucla. The reason I pursued cardiology I think is from even medical school days just understanding the cardiac physiology I. Think it's all answer that a lot of people give for this question, but it's something that was so intuitive on my math and physics background that it made sense and it was how I applied those things to medicine and I just really enjoyed cardiology back from early third year medical school days specifically UCLA I. I've enjoyed my time so much here from day one I've grown both emotionally and intellectually becoming a cardiology fellow definitely at a steep learning curve and I remember early on feeling like I was ready to handle the responsibility. However a program leadership and our senior fellows feel so comfortable that I won the week log boot camp to over procedures. Logistics was Super Clutch, and then we spent several weeks learning the basics of agriculture. We had backup senior fellow when we were on call and we were intentionally plays later additions to study for Insurance Medicine Boards, which was actually really nice for our wellness. Once things got more intense the faculty were patient thoughtful antiquated when it came to teaching us how to do procedures are running the see you. They made it possible to deliver effective care and help us gain experience our clinical training spread over four different hospitals, and with that comes in tax financial increase in the complexity and diversity of patients we see on a daily basis. From leaders and Chagas Cardiomyopathy County Hospital to Cath lab legends that are va to preeminent adult congenital attending that our university hospital we really are privileged to be here learning under the tutelage. Lastly and most importantly, I love this program because of the people, my co fellows program leadership are some of the kindest people I know there is no shortage of people willing to step up and fill in if you have an emergency. There's no shortage of people willing to give you valuable life advice whether it be about raising a puppy or any Kirsch eating I attending salary. The. Greatest Comfort training as Doug I can text any attending co fellow about something medical or non medical and get a genuinely insightful response. Yet, Jay I really agree with everything you say and you know for me I chose to do cardiology because I really just enjoyed the physiology with it. I. Actually went into medicine and went into residency thinking that I was going to be a primary care physician. It wasn't until I was an intern on you that I was like well, following more dynamics. is so cruel and just really exciting but I fought the idea of going into cardiology because I felt like I had defined this path of primary care for so long but ultimately when I was in third year resident I decided to do cardiology. So for those listeners who are still on the cost, it's definitely Ok to take time to think about what makes. Your heart flutter like on the says and I hope you do choose cardiology because it's really amazing and I hope you also consider applying to Ucla because there's two reasons that I love this program and one means the prophet training and to the people having four training sites was really important to me because I wanted variety not just in the patient population. But also styles practiced. So at Ucla, you encounter four different sets of attending within each cardiology specialty, and that really helps hone your skills and provide you with lifelong resources. It's also very helpful for the future too because you'll be more versatile being exposed to comprehensive set of healthcare systems and get an idea of what type of setting you would like to practice. And, the second reason is that people I think the educational environment here is so supportive and collaborative if a question or just can't get my brain to understand a concept like all those. ECHO boards studying questions. I. Have Right now all the attendance here will pause sit down and talk you through it and I think that type of collegial an engaging environment is so important when you're training to feel comfortable to ask questions and to feel prioritize in this hectic world cardiology training and like I said earlier I, have a toddler Two, and a half year old girl I started fellowship when she was still infant and Michael fellows have been nothing but supportive, they quickly jumped to cover me when daycare calls with emergencies. Sometimes daycare even calls during zoom calls on. Everyone's just jumping to help out and make me feel really supported. They cook US homemade meals and they make me feel like I'm doing it well as a mother and a cardiologist even though my internal imposter syndrome is very strong. I think you're doing a great job bruce. St. Attending Sarah also mazing as well. In addition to being master clinicians, they're also life mentors Dr Lori Kapoor Dr Yang Dr Wang, Dr Komo's Coppola Shapiro Bassett's everyone Dr, Watson, especially, our program director they have shared with me. So much of their wisdom, not just on cardiology, but also childcare options had a managed work life balance and how to know family build and career build at the same time. So this is hands down one of the most supportive imbalanced program. My daughter knows who I am and I don't feel like I missed her major milestones at all. Fake the everything you guys said I also have loved Ucla and been here since intern years did residency here as well. Back, in the day I actually Fi when I was in med school for I thought I was going to be a surgeon I did a C. surgery rotation visit. This is where I'm going I love procedures and I love creek care kind of acute care and that adrenaline rush and I think I realized that for me cardiology was the perfect mix really in cardiology can do anything. You can be a procedure less to doing these minimally invasive surgeries in the Cath Lab. You can if you want to be in clinical time via an outpatient, non invasive cardiologists into your own imaging and I, just love that like breadth of options of what I can do and I'm really excited to. Go into faith at heart transplant and you know be running Assisi you someday and getting procedures there and also seeing patients in clinic in still having that Nice Longitudinal relationship. Think UCLA's been really formative helping me figure out what I WANNA do and I have just a loved fellowship here I don't know about you guys. But when before I started fellowship, I was just convinced that this was going to be some sort of three year hazing process like either watch grey's anatomy or something, but it is actually been some of the best in happiest years of my life the training fantastic and I think over my three years a fallen in love with just about every cardiac sub specialty we. Have Dr Greg teaching about guideline, directive, medical hair, and advanced heart failure doctorship Kamara who actually now the editor in chief for Jackie. P, who comes in and sits down in his teaching us about VAT. In EP procedures, we have one of the best and oldest shuttle heart disease programs in the country here, which Abajo zone. News. Always happy to talk about his super complex procedures. We have specialists in Cardio, oncology cardiac obstetrics, advanced imaging, and world class preventive cardiology lipid allergy with Dr Carol. Watson as you guys have probably heard today, our Cath lab definitely never has a dull day. You know even though we have this incredible collection of really smart and famous attending teaching us. We're actually given a lot of autonomy to make big decisions care for our patients, which is something that I love and it's a way that I learn but I've really never felt unsupported. We have the cell phone numbers of just about every attending in the program and we call all of our famous cardiology attending by their first names, which was a huge shock for me after spending twelve years on the east coast. I've definitely called Masisi you attending two or three in the morning when I needed help with a tough case or the comes in patients but no matter what time I wake them up the attendance are always available. They're always happy to help and they are totally supportive. And then finally, just like what Ruth and Jay have said I think the culture of this program the people we work with religious makes it such a gem of a place. The emphasis here is on being a good cardiologists, but also just being a good well rounded person and we are encouraged everyday day to be efficient with our work and then just go home and be with our families, go to the beach or just make time to do whatever it is that we need to do to refill our cops recharge and be happy. I think people are really happy here and I think it shows both are great patient outcomes and also the lifelong friendships we make. Oh. My Gosh Hillary Ruth J has been nothing but a pleasure a pleasure I mean as we talked about the case are bonfire grew stronger. It was. Feeling it I'm pure cardiology greatness, and then as you talked about Ucla and all of your just a collegial is in the way you reflected on your mentors is just that we had to like really back from this fire. So named joining us this was an amazing I will say, and I can't wait to meet you guys in person you guys are just fantastic. Thank you so much for having us. We've really enjoyed this sin. We're happy to have you guys out in La anytime maybe in winter you should come in winter because our winters are probably better than yours I. Think. More temperate in winter here. Everyone I hope you guys enjoyed our case and now we have an e CPR segment with Dr Jonathan Toby Stocker Tobin is one of our interventional cardiologists lose pioneered a lot of procedures and technology and interventional cardiology. So we're really grateful for his time and his expert discussion bloom name this Johnson Cobras. The professor of medicine, cardiology at UCLA and the MEREDITHS director of interventional cardiology I very much enjoyed the case presentation and the enthusiasm of the fellows involved in the case and in the podcast. In the same format of presentation. I, guess I'm a PG wide forty-seven. The presenters covered most of the important issues of a spontaneous coronary artery dissection and I'll add a few comments from my experience of treating these patients. In the Cath Lab. When person presents this? You have to consider the diagnosis and especially the young person. Women were who have low risk of coronary artery disease who present with a stemming he or non stemming of the differential diagnosis of courses atherosclerosis. But in this population, you also have to consider other unusual causes myocardial infarction such as paradoxical embolism. So I will often ask if there's a history of migraine with aura prior to the catheterization because fifty percent of people who had my agreement or. I have a Payton Framing Valley, which could be the pathway for the paradoxical embolism to the coronaries. Coronary artery spasm is another consideration you really cannot distinguish and geographically it's rare that you see a double tracks of dissection and most of the time it's just that you see narrowed arteries usually more diffuse kind of presentation, but it's very difficult to distinguish that from atherosclerosis except for the. That it's a younger person without risk factors or woman I often give nitroglycerine into coronary before. I do any dimension to rule out coronary artery spasm invest ultrasound can also be helpful. In this situation you have to be careful about as strong injections or making too many inter corner injections because you can extend the dissection I prefer to do scan patients from the federal artery because you have better backup, you're more coaxial to the artery unless slightly to call supply section of left main compared with radial artery approach. If you're thinking of. Than I would recommend you get a CD Angiogram I because it's safer. Actually is better at making the diagnosis because you can see the the false limited and the lumine better than with a direct coronary angiogram in terms of treatment has been mentioned in the podcast. Conservative treatment is preferable. The patient is stable especially since the risk of standing the false luminous high as happened. In this case, the true boom intends to collapse because it is composed of both intimate and the media in the muscular component of the media contracts when it separated from the tissue. The contrast passes predominantly in the false lumine so you can be fooled by the angiogram. The surgery is similarly, very difficult, and it is unlikely for the surgeon to find the true Lohman for the insertion of graft and doesn't ensured that there will be complete. Antiquated retrograde flow. My experience when we've had cases that we discussed with the surgeons been very reluctant to take these patients to surgery and ask us to perform a corner angioplasty instead, which is an indication whenever surgeon tells the cardiologists to do the case. The tells you that there are very reluctant in that that don't get good results with this I perform I only if the patient is unstable or has a large fart and. After, make the diagnosis and get a wire down the artery or sound. That's the best way of determining if you're on the true. Or False Lamon. Way You're doing pc I have to very careful because balloon tation can extend the dissection from pressing the blood in the false loom in. So we don't predate it's not necessary. These are very approachable of arteries. It's not like a sclerotic calcified arteries and you don't want to extend the blood moon false loom in extend the dissection I usually stand of both proximal disciplines first, and then the sections in between to prevent that extension of dissection, you have to be cautious when you're sending the proximal de. Proxima circumflex that it doesn't extend the dissection retrograde into the other vessel in the left main has happened in this case. When the case is finished, I perform bodies CT looking for fiber or muscular displeasure as they described in the podcast. These are challenging patients in the Cath Lab as well as just management as demonstrated in this very difficult case. But if you are able to get to the patient quickly and opened up the artery, you can reestablish blood flow and very success slow results which very rewarding with Cordera angioplasty. Thank you. And now I'd like to introduce an F. CPR segment by Dr Carol Watson who is in of our women's health cardiologists, and also our beloved program director who has our back and teaches us so much in support everything do what a great case that was. Thank you so much, Jay. Hillary, you know ten years ago. We almost never heard of SCAT, but it's probably much more common than we ever recognize. We now know it's seen in as many as thirty four percent of women under the fifty women just like this patient. What we know is that Scott is the majority of pregnancy associated myocardial infarctions as well. So the more you look for the more you see it something we always have to have a high index of suspicion for in the right patient population. Just as you guys mentioned, we really want to treat Gad medically, there's so many risk in intervening. Just as you said, it's real easy to wire the false woman just like Truman in again propagating the dissection is what we absolutely don't WanNa do. But of course, as you say, there are instances where you have to. Can you guys think of a worse location? To have had them where this poor patient had her scat, the goodness is you know there are so many advanced therapeutics that we have available to us in cardiology that eventually I mean if you have absolutely have to, we can go to transplant and that's where this case in virtually ended up. But on the other hand, it's actually quite fortunate that this was available to this patient. There's a lot of things that we also have to think about we're just learning about the pathophysiology of scattered were learning about the overall vascular apathy that this represents it's not just an isolated dissection in one part of the. Tree where there's an abnormal vessel one place there's probably a number of admirable segments as well. So we know that Scott is associated with Piper muscular displeasure throughout the body we've a lot of scattered patients at UCLA and we routinely pan-scanned all of them and you would be shocked at how many vascular abnormalities I find. There's a lot of FM FMD, not just in the renal arteries in the carotid arteries in other vulnerable arteries there are aneurysms there are other what look like healed I, sections that we see. So I think it's important to have a High end except suspicion for a lot of vascular abnormalities when you see a patient with scab now that brings me to the patient population and the things we see at Ucla we're very fortunate to be a catchment hospital for so many outlying areas. We see all of the interesting cases we see first presentations of many cases. We see many esoteric cases we see the KARTINYERI tertiary care patients. So we're very lucky in our cardiology fellowship really is focused and designed on training the future leaders in cardiology, we want to train leaders in the basic practice of. Cardiology leaders in research but basic and clinical research. We want to train leaders in health policy and standards that govern our field of cardiology. So that's what we set out to do with our cardiology fellowship program all our fellows exposed to research all of them and they did great work. We had thirty seven peer reviewed publications from our fellows last year, and those who really want to make research the primary component of their career at the star. Fellowship available to them. Stars Fellowship is a unique program where we combine advanced training in research leading to A. PhD With Clinical. Training in cardiology it's one of the only programs like this. In the country it's not just an Md. Ph D. type of program is a program that we fully support you in developing your own research career. We support you with funding fully throughout there's no need to get your own grants but many of our fellas do again, the goal of this fellowship is to train the leaders in cardiology we have two different tracks. We are clinical track that's the three year program we accept about seven or eight dollars in that track per year. then. The Star Trek that just mentioned we accept two to three calls per year in that forum. But all of these programs will all TRAE GIO to be excellent clinical cardiologists with background in research some people. To, focus research some choose to focus on Quality Clinical Care Sarah that whatever your choices we plan to make you the best you can be. Now, just to let you know we practice what we preach. Our recent graduates have become real leaders in the field at really young ages. In the last two years, we have received graduate who is a leader in the ACC sports in exercise cardiology section one who's a leader in the ACC women cardiology section. One of our recent graduates currently sits on the ACC AJ Data Standards Committee. So again, we have practice what we preach. Exactly. What we help to see is exactly what our fellows do. We have a very strong peer mentoring program at Ucla called the House of cards. This is a program where every single fellow is assigned to a house. When they started them, every house includes the faculty mentor at Third Year a second year efforts you fill. So from day one, you have a built in support system. There's never someone who can't find someone who they can contact about anything whether it be a critical patients, the CEO or the best childcare they can find or just CNN where you can get the. Best Pizza. The thing that we're really really proud of is what our fellows do in terms of teaching our fellows truly are a heart and soul of our division. Each of the last three years our fellows have swept the fella teaching wards. They're just so good at it because they love it and that's one thing that we cultivate and our fellowship. We're very proud of our fell in their accomplishments are fellows Wendy, California ACC, Jeopardy Championship in twenty, nineteen, twenty twenty, and we're currently the second-place winners of the National Jeopardy Championship Twenty Nineteen, unfortunately, the twenty twenty competition was cancelled, but we really do have a great fellowship. It's the heart and soul of our division. There's a very close alliance between fellows and faculty and staff and everyone. So we sure hope you'll consider our fellowship. We'd love to meet adventure the next generation of cardiology leaders. Thank you. Wow plus an amazing case a huge thanks to the fellows and faculty for enriching us with yet another terrific discussion and incredible addition to the cardinals case report series. Be sure to check out the show notes for all the case media available for key take home and discussion points and links to the program. If you'd like the Educational Takeaways and graphics delivered directly to your email signed up for the heartbeat of the Cardio nurse newsletter, you can join the email is using a link in the episode description as well as from our website www dot cardinal dot com. We thank the ACC fit section chaired by Dr No. She reasons for their support and collaboration and a very special thanks to our incredible production for elevating our platform call him Blumenthal Tommy Dogs Unit. Student. Rick for Abilene songs and. All internal medicine residents at the Johns, Hopkins Hospital, as well as the Phenomenal Med mentor and University of Maryland Cardiology fellow site. If you love the show as much as we do be sure to spread the word rate and review us your favorite podcast platform and consider becoming a patriots a show on. Patriot right. 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