Stephen Clemons, MD gives an enlightening presentation on Myxoma and utilizing tools to help identify origins of tumors as well as the collaborative teamwork between cardiologists and surgeons at the first inaugural Heart & Vascular Symposium hosted by Georgia Heart Institute at Chateau Elan Resort & Winery in Braselton, Georgia.
We'll have time for questions after the uh after the next talk, which is uh gonna be given by steve Clements from uh Emory University on. I wish that I had known this a long time ago. Thank you very much. Have no disclosures and thanks for the invitation. The baby's not here. So, uh so take a look at these images and this is about Mick soma. So when you have a mix oma like stan and I have had in the past, you have to, first of all get all excited. And second of all, you have to look at it carefully. So when you look at it, you want to make sure that you try to identify the origin of the tumor and the origin almost always is on the inferior limb bas of the face of Alice. And that's what bob guiding told me. So if you leave those two images there, you can see that comes from the septum kind of lower down in the septum and you notice it's pulling on the inter atrial septum, same for the one on the right Uh side in the lower left image, the three D. And one thing you always have to do is to make sure there's nothing in the vena cava and nothing nothing in the pulmonary veins. So it's once you've established that then, uh you've made the diagnosis of Mick selma now this happens and you run across this in the cath lab every now and then I've I've shown this many many times and every time I show it as a matter of fact, we published it Every time I show it, it's uh, it's always, it opens the eyes of fellows that image on the left. You see the kind of venus stasis in that tumor uh image on the right, another one not quite so prominent. And uh if you happen to be passing a catheter up the inferior vena cava and you hit something as you enter the right atrium and you say, what is that? So when that happens in the cath lab, you should take a little contrast and go squirt. And when you do that and you see something like that middle image, then you know, something's wrong. And that image is that way because of that tumor just above it. There was a large maximum filling the entire right atrium. As a matter of fact, I went and grabbed the sent a gram of this patient. Somehow. You had a mug, a scan out of the trash can. If you look at the right upper images, you can see that filling defect in the in the right atrium from that mix Soma. So you know how to do this now. And you say, well I know how to diagnose make summer. So here we go. Right here. So we see these images. We get all excited and we uh start calling the surgeon and the surgeon comes said, okay, we've got, we've got to take that out. And then we say, wait just a minute here. We've got to follow our principles of looking at patients who have right actual masses? We've got to do the things that we just talked about. We've got to make sure that the Vienna cave is okay. We gotta make sure the pulmonary veins okay? And as we do that, our sin agua furs know to look down at the vena cava. And as you look at the Vienna cave in that right upper image you can see is totally loaded with something. And the reason that is, is illustrated in the left lower image via cable is full of something coming up from the left kidney. And that middle image is what that was. Uh it was a hyper to froma clear cell carcinoma of those tumors. Like to get into a cave and grew up to the heart under the microscope. You see the clear cells there on the right and instead of needing a thoracotomy, you need an abdominal incision and need the surgeon there to help you pull that out of the right atrium and hope that it pulls out. So. And then uh you say, well, I I've got this down and I know what to do in the situation of mix oma. And we see this when we get all excited. And uh we know that these things symbolized as kind of a surgical emergency. So we call the surgeon and the surgeon says, I'm calling the operating room and we're setting this patient up right now and we're going to the operating room now. Did we check the vena cava. Did we check the pulmonary veins? Well we've got to get this job done. So to surgery, we go and then you get the call and the call says from the surgeon said this was not a maxima did not originate from the interracial septum. The inferior limb, bits of the face of Alice came from a pulmonary vein. We took it out as much as we could but we obviously didn't get all of it out. And we did a ct and the ct showed that it came from the write up of pulmonary veins. And um the microscopic was on the right and it was a very aggressive sarcoma. Uh this is actually a recurrence and uh poses great difficulty for this young person. So check the pulmonary veins, Check the inferior vena cava and make sure you got all that checked off before you start sending the patient to surgery. So let's change channels a moment. So suppose that you're an interventional cardiologist and you get a call from the er and they fire this to you on your cell phone and say this patient is having chest pain and you see this and you say, well this is a stem e we're going to the Cath lab, you call the Cath lab in and up to the Cath lab. You go and you say, well I'm an expert electric cardiogram fee, I know everything about EKGs and this is an included so and so and I'm going to take out my captors and tell them to get out the right catheter first to shoot the culprit vessel. So so take out a left guider. So you get there. They got everything ready. You step up, take out the left guider and you have to remember that you don't know everything about EKGs, We're all still learning about them. And so you got the calf lab ready. You know the Cath lab with the left guide and shoot the left corner audit. There's nothing there. So what is going on here? So the L. A. D. Looks good. I was predicting that the lady was included. So we're obviously not gonna intervene there. So let's shoot the right and we shoot the right and the rights included. So what does that? E. K. G. Represent? So that represents the syndrome of right ventricular infarction which you know about in the coronary care unit. You couple that with approximate inclusion of a large right coronary artery and get an acute marginal. And you've got shocked that you've got to deal with. So you've learned your lesson. So then another day of patients in the G. I. Lab having a G. I. Procedure because he had G. I bleeding and he has a code. He goes into attack fibrillating, you have to shock him, resuscitate him. Then go to the Cath lab. So here we are going to the Cath lab after we get this E. K. G. So we have the E. K. G. And you say I know all about EKGs, I want to shoot the left system first. So I know which is a corporate vessel, it's led. So we shoot the left system and we see that L. A. D. In the left panel there. And uh we said you know that lesion must be it notice that that lesion doesn't have any trailing from bus. There's no fuzziness about it. So but let's but I'm thinking that's a corporate lesion. So let's wire it up and treat it. So we wire it up and uh put a stent in there. He said, well we gotta finish the case so we need to shoot the right corner. How do we shoot the right corner out in groups? As a total right coronary artery. We opened that episode. Non dominant, right. You don't have to worry about those non dominant rights. They don't hurt you, surgeons won't ever bypass them unless you beg them to. So uh here we go again. Uh he had issues with Plavix because he had gi bleeding. He had gotten some at the other hospital. I happened to make rounds that morning, Saw him and look good, walked out the door and the nurses started yelling. So something is wrong. This man is crying with pain. We just did a 12 lead. E. K. G. And he has S. T segment elevation is entire Precor really notice that those S. T. Segments have kind of concave down shape to them. This looks a little different from the other EKGs. Okay here we are on saturday morning. Let's go back to the Cath lab. So I missed the last one. So I'm gonna shoot this one and here we go. And L. A. D. Is occluded at the stent. And as it turned out, the stent was not fully applied to the walls of the vessel. There was no post hypnotic facilitation. So we started all over with that and uh and we treated that anterior infarction. Now, here we go. So on the top E. K. G. You can see what it looks like to have a right ventricular infarction involving your non dominant right coronary artery that caused you to have a cardiac arrest. Leave those concave upward sc segments and just the right prick ordeal leads. I don't that V. One V. Two V. Three, I don't have right prick ordeal leads. And if you're a right prick audio lead guy, you might do that. But you gotta think to do it and look at the bottom tracing kind of concave upward. That's the L. A. D. Occlusion. So in this one patient we've seen evidence of inclusion of a non dominant right coronary artery and then a few days later occlusion of the led rescued from both. So remember right ventricular infarction. Remember the E. K. G. And right ventricular infarction and remember the non dominant right coronary audience because they can hurt you. Usually the vector if you're a vector guy is a little bit rightward in that right ventricular infarction versus that S. T. Segment, elevation. Left ventricular infarction. That vector is a little bit to the left. So uh let's talk about another patient who comes to the emergency room with chest discomfort. He has that E. K. G. With T. Wave changes. We know what this is. So we go to the cath lab, we shoot that and we say there it is up there there's the lesion in the L. A. D. And it's enticing and I can fix that. So let's wire it up. So we wired up and we stand it and we shoot some more pictures. And we shot another picture and we said oh something is wrong here. We see another vessel company. And slowly within the margin of the heart from the R. E. O. Position. So what have we done? So we've opened a diagonal and we jailed the L. A. D. So where is the diagonal? If you teach people how to do our fellows how to do coronary arteriogram usually say let's start from 30 degrees R. E. O. Because the diagonal is out on the margin of the heart and the lady goes within the margin just like you saw in that and if you'll keep that in mind you won't make this mistake. So remember that the acute marginal can cause trouble. It can be a non dominant vessel. It can be part of the right. It causes S. C. Segment changes in a regular E. K. G. V. One V. Two V. Three. The vector of that maybe a little bit more to the right. Usually there's no alterations of initial anterior forces. So remember the diagonals on the margin of the heart. And when you look at it from the R. E. O. Position the lady goes within the margin of the heart. And uh if you if you'll remember all that particularly diagnosing right ventricle infarction when you're making rounds you win a prize. So this is actually a friend of mine who had this echo uh late one friday chemotherapy was anticipated. One of my colleagues read this E. K. G. Not stam left uh And said there's a mass behind the left atrium or behind the heart. And this patient has ovarian cancer. So it must be metastatic cancer. So I knew this person and she called me up and I said well you know I'm sorry to hear that I will check into the situation. So uh I go look at her M. R. I. And the M. R. I. Shows that her entire stomach was behind her heart. And that is not was not a mass from metastatic cancer. That was a large hydro hernia. Now had we just looked at the X ray ahead of time. We could have seen there's an air fluid level in her stomach there which is up in her chest. So we had another patient that came in for a dsc product, a liver transplant. So we got this baseline and I'm sitting in the control in the in the reading room and the nurses come in and said this patient has a big mass lymph node cancer. We've got to cancel the test and go send him back to the room. They she was almost off the bed when I came in. So I looked at the semi and I said wait just a minute here let's think a minute. So after we did that I said there's something that we need to do now right now. And I'm asking you that question, what would you do? So we thought that through. And I said go get some blank. So they went and got some blank and we let this patient take a sip of blank and watch that mass. You see it filling in. That's a bubble study from bubbles that were swallowed. So that's a Heidel hernia not metastatic cancer. And then one day in the Cath lab, the fellow and I had finished this procedure and we looked at the ap view and said what is that over at the right heart border said, well we know what occurs at the right heart border uh you know pericardial cyst like to get there. So I said now what what should we do? Said uh send her for a ct scan maybe. Ok call ct we'll send her for a ct scan. So I said wait just a minute here now let's let's think a minute and let's do something else. So go get me a blank. So go get me something that has bubbles in it and let her take a sip of it. Well she grabbed and took a sip of it before I could step on floor. Oh but notice that it's almost like uh seeing an upper G. I. Series there. So there it is. You can see the peristalsis going through the duodenum there. So she took a sip of soft drink. So we talked about some lessons learned from maximus, the E. K. G. The cath lab and tumors. And looking for the vina cave. And look at the pulmonary veins. One more mimic. This is one of my favorites here. So when you see this kind of U. K. G. I will tell you that sometimes these patients get sent to the Cath lab if they come to the emergency room and have done something that's um Cause chest pain for one reason or the other. And look at those S. T. Segments out louder. Look at that voltage, see that S. T. Segment elevation. That kind of biphasic T. Wave. That's dramatic. And when you see that and you're reading EKGs you should say left ventricular hypertrophy. But you should say one more thing. So there's nothing wrong with saying what the diagnosis is. But I've never seen anybody do it never. So what the next thing you should write is that this patient might have hypertrophic cardiomyopathy, the atypical variant. And this is what I'm talking about in the middle frame. You can see what it looks like in the Cath lab, a pickle hypertrophy and in the lower right when this is what you see what you saw a while ago on the cath. You see systolic compression of the septal perforation. Thank goodness that blood flow through coronaries goes in diastolic. So you see the systolic compression of the coronary. That's diagnostic when you shoot that you can tell what your target vessel is. If you're gonna do alcohol septal ablation. So what happens to these people? We've got to find them earlier. So this is one of my pet patients. So I dug all this up. She's been coming to my office about 20 years. You might imagine That that tracing on the bottom is like end stage disease. So if you how did it get there? Has it been that way all of her life or what? So if you look back at the tracing in 1982 there's something going on there. And can you think of any drug that we might give that patient that might have prevented this kind of end stage disease. She had although she has an I. C. D. And she plays golf a couple of times a week. Now she's had she's been shocked a few times from atrial fibrillation. She's got the appropriate amount of scar in her left ventricle. So there's a natural history on the E. K. G. Of Yamaguchi syndrome. Now I've shown this at conferences before and one time I showed it I got this low down at the bottom. It says uh talked about the E. K. G. And says I wonder if this patient of mine who has the same thing has that diagnosis. I believe it is. Thanks for the tip. So uh I hope some of you take that tip today. Thank you so much.
