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RS Academy - ANGIOGRAPHIC VIEWS and Interpretation 4th July 2020 — Transcript

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0:17No
0:42how can you hear me
0:50listen okay yeah okay I I just need one
0:56more minute I just get my slides open up
0:59please wait
1:27a minute can you hear me hello yes sir
1:34yes sir just give me a couple of minutes
1:37I'm just getting my slides okay
1:57hello sir here that's sir what uh what
2:02happened sir
2:02yeah who is that sir but I feel ya
2:05Nikhil filming I was trying to call you
2:11sir no no I just two minutes late I'm
2:18just getting my slides they open OH
2:20[Applause]
2:55all right how many people are doing
2:58about 50 people okay good time to go
3:01start I'll just share my screen
3:05meanwhile you can identify a few people
3:08to answer to three people
3:10ah yes yes okay can you see my slide
3:23yes
3:31right so only going to answer questions
3:34today yes
3:37vanishing less earlier their sorrow
3:46Kapadia a visit card Carter a I'm not
4:00saying I'm not hearing any response from
4:02them they are there yes they are there
4:05in the meeting was him doctor was him
4:08you are there one or two sir okay so the
4:53today's talk is basically because I
4:57think one of you requested me to take a
5:01talk on surface markings of the cardiac
5:06chambers so that you are able to
5:08identify the angiograms because you
5:12people are used to coronary and you but
5:14you're not used to chamber angiogram and
5:16you do not know the radiological anatomy
5:19of the heart I have prepared this talk
5:22might take a little longer than unusual
5:25time are you you do you have any class
5:28after this no sir okay I will try to
5:37finish it by a pass three or so low okay
5:42if you remember right I told you that we
5:45will discuss one day the anatomy of the
5:48heart esteem in angiogram and how to
5:50identify it and there are some ways of
5:53learning it some of you who works I mean
5:55here with angiogram maybe the senior
5:57guys may be already familiar with what I
6:00am talking but a lot of you may not know
6:04what the views are how to identify
6:06chamber and moreover even the ones who
6:08know is always good to revise the
6:13angiographic and read because this one
6:15of the most crucial things in your
6:18cardiology practice whether you do echo
6:20cardiogram whether you do heart surgery
6:24whether you do diagnostic angiography of
6:27congenital heart disease or you do
6:29coronary angiography or you do coronary
6:31intervention or you are going to do
6:34Tavor and pulmonary valve and other
6:37implantation mitral valve repair the
6:39radiographic anatomy is the single most
6:43important thing so this is something
6:45which you must it must it must be burnt
6:48into your hard disk no like no we don't
6:52think twice before we say one plus one
6:55is equal to two we never think twice now
6:58you all it's it's ingrained in your
7:00brain two plus two is equal to four
7:02nobody thinks the answer we already know
7:05it answer that that is the way the
7:07radiographic anatomy should be in your
7:08mind okay that's the whole idea of just
7:11talk some of this is very basic some of
7:13this will be things which we haven't
7:16discussed before so the heart is a very
7:20complex structure as you know that and
7:23it's a very nicely neatly but very
7:25compactly packed inside the thorax so
7:28that's okay for its protection and for
7:29its efficient function but when we want
7:33to image it and identify chambers and
7:36different parts of the heart it makes
7:38our life very difficult
7:40you can see that it's not a simple
7:43geometrical structure it's it's neither
7:46square not a spherical nor oval it it
7:50doesn't have each other
7:51it has a whole shape it has a very
7:53complex contour
7:55it's lying in a very oblique position in
7:58the heart in the chest surrounded by
8:01many other structures and there were
8:03many structures attached through it
8:04entering it leaving it so each one of
8:07these is important for our cardiology
8:08diagnosis
8:09now the remember I told you that I use a
8:14hot model to understand the anatomy of
8:19the heart now this is a model they were
8:22talking about this is I don't know
8:24what's made up or some light material
8:26plastic or something it is a colored
8:30blue and right it's like it just about
8:33the size of my hand so that support the
8:35size of my adult adult my person's heart
8:38it's a normal expected size of a heart
8:41and they're different models you will
8:44have hard model you will have soft model
8:46you'll have intricate model some this is
8:50a very simple model where is exterior
8:52Anatomy this of a normal heart and you
8:55can actually take out the anterior wall
8:57away from the model and see the interior
9:00of the heart and as you can see the
9:03heart is a very very complex turkey
9:05doesn't although we draw diagrams like
9:07array on top of our we'd LA on top of l
9:10lv an array and L lay side by side it's
9:14not like that a very very complex
9:15Anatomy and that whole set of chambers
9:18are twisted around each other
9:20and this is an anterior wall where on
9:23the epicardium where's all the coronary
9:24arteries running so we will be using
9:26this model quite I use this model very
9:29very often to understand anatomy I use
9:31it now and then even now to when I
9:33report and I on you and I always have it
9:36on my table so that when I talk to a
9:39patient I can explain
9:40the anatomy to that patient sometimes
9:44when I have doubt about an angiogram I
9:45have to go back to the model I strongly
9:47recommend that you should you people
9:49should get my ideal thing would be to
9:51have a heart a human heart in your hand
9:53but that's not possible pathological
9:55specimens are much very very difficult
9:57to get and therefore this model is the
9:59next best okay all right Wow radiography
10:06started in simple no anteroposterior
10:08view
10:09and that's the typical I was talking
10:13about with the anterior wall put onto
10:15her and looks like it and if you look at
10:17the plain just takes a it's very easy to
10:18identify it's a plain just take away
10:20when you have all the bones visible and
10:22the clavicles with the will just find
10:24you way straight where you can say it's
10:26a frontal x-ray
10:27you also know what the post
10:29ontario-based come because the scapula
10:31is not so on that so you're seeing the
10:33entire set of two rib entire scent of a
10:36clavicle and therefore you know
10:37everything is symmetrically placed
10:40around the midline and therefore it must
10:42be a frontal x-ray that is enter
10:45posterior or post onto your view
10:46actually under you the heart inside the
10:50chest is sitting in this moral of this
10:52position and that just correspond to
10:54that so if you have an Anatomy the curl
10:57model in your hand you can identify what
10:59are the cardiac border the uppermost
11:01border is formed by the superior vena
11:03cava here the ascending I utter lies
11:07just inside the superior vena cavae
11:08normal heart and therefore it may not
11:10reach the cardiac bottom but when they
11:12are sending out a dilate it forms a
11:15convex border here again and below T is
11:18so pretty vena cava you have the right
11:20atrium right atrium goes all the way to
11:22the diaphragm it in fact you don't see
11:26the IVC at any part of that for that
11:28array goes all the way to the diaphragm
11:29that's about the left card right correct
11:32bottom when you come to the left cardiac
11:34border this one is actually in the supra
11:38just below the suppressed or not you
11:39don't it under the clavicle so you won't
11:42see it in the play I have performed it
11:43just like three so the first structure
11:45you see below the clavicle is Neotech
11:47method so you see that correspond to the
11:49shadow here and in fact I have described
11:52all this here also you can correlate the
11:55x-ray the model and the line diagram
11:58here are you able to see this figure
11:59than just below the iota you get the
12:08bump of the main pulmonary artery here
12:10the LP actually goes posteriorly arches
12:13backwards and watches down although I
12:16have shown it here you don't really see
12:17it in the model but going backwards and
12:19no problem and once the branch of going
12:21through the lung you don't really
12:23clearly
12:23see just below that you see a little bit
12:25of the Aliyah pending and that that's
12:28the elephant age here and then you see
12:30the elephant written now you can see
12:33that the right atrium for cardiac border
12:36here the left ventricle forms the border
12:38here and the right ventricle doesn't
12:40appear anywhere in the cardiac border it
12:43lies in the middle here it lies between
12:46the interventricular group that is the
12:49left anti defending artery here and the
12:52AV groove here that is the right
12:54coronary artery and the diaphragmatic
12:56border so that's what is shown here the
12:59right triQuint Achilles line doesn't
13:00form the Caribe therefore in a frontal
13:03x-ray you never talk of right
13:05ventricular enlargement okay never form
13:08the correct products and of course the
13:11the right ventricle leads to the
13:13pulmonary artery which is well shown
13:15here so now you can correlate a simple
13:17straight chest x-ray with the cardiac
13:20structure and you also know where the
13:22expected chambers are I showed you a
13:26pacing lee last time which was
13:28perforated if you remember correctly and
13:30the likud was almost still here
13:35remember that x-ray any of you yes yes
13:40yes so if you know that the normal right
13:44when tickle stops quite some distance
13:46from the left caudate border so if you
13:48have it just takes three today and it
13:50just excited tomorrow on the leaders
13:51migrated to the left caudate border you
13:54would know that it is in the left
13:55ventricle so it's got the importance of
13:57knowing this versus Anatomy and this is
13:59a simple straightforward frontal view
14:01but obviously with such a struck impress
14:05structure like now in the frontal view
14:08remember what you're seeing is actually
14:10only the right atrium and the right
14:11ventricle the entire left heart
14:14you left all this little a little bit of
14:16steam here but the entire left side of
14:18structure actually lying behind the
14:20right side Jimmy you're not seeing it
14:22now although we call it right atrium and
14:24left atrium the left atrium is actually
14:27behind the right atrium behind this here
14:29and the left ventricle is predominantly
14:31behind the right quantity and what
14:33you're seeing when you remove this wall
14:35is actually the ventricle
14:37you don't okay so if you remove this
14:40right when ticular wall you'll see the
14:41ventricular septum and then therefore
14:44that would have shown the next figure
14:45here for example in the frontal view you
14:48see this there's a book at I can picture
14:50therefore don't mind this layer labeling
14:53but you can see that the right ventricle
14:55actually superimposes the left ventricle
14:58completely and only a little bit of
15:01screen on the side therefore when you do
15:03an Army angiogram you see the right
15:05ventricle but you will still see a
15:07little bit of card excel at outside the
15:09border of the right context with
15:10elephant comes when the dye goes to the
15:14recirculation when the dye goes all the
15:16way from pulmonary artery pulmonary
15:17veins come back to LA and then it comes
15:19to LV you'll see the left ventricular
15:21filling at that time you will see this
15:23Tillet now you don't see the LV here
15:26because the LV is hidden behind the army
15:29and the contrast has to be through the
15:32pulmonary vein to the LV to be with the
15:33boot so in a frontal x-ray you see in
15:36this mu you should take a van RV what if
15:38you do not behind you and follow it
15:40through the leave of faith you will see
15:42the LV now do you understand how the
15:44anatomy of the heart is in when they are
15:46placed the anatomical position they are
15:49left to call left to right but they are
15:51actually more anterior and posterior
15:53right you have to say yes or no I won't
16:00know whether you're hearing or not okay
16:03now that's a very simple frontal view
16:06and remember in radiology we are seeing
16:12what is called a sectional anatomy no
16:14we're not seeing a three-dimensional
16:16anatomy is it an angiogram or in a
16:18coordinate ER in cine angiogram MRI we
16:23don't see a three-dimensional on it we
16:24only see a 2-dimensional so when you see
16:27two dimensional view of any structure
16:29you cannot to view it somebody sees this
16:32cell phone in this view you will say it
16:35looks like a pillar doesn't it if
16:40somebody sees it in this view he will
16:42say it looks like something flat
16:44instrument with some buttons so if you
16:48remember the story of four blind men
16:50who described an elephant no one brine
16:53one blind man cannot caught hold of the
16:55leg one blind man caught hold of the
16:57tail one blind man caught hold of the
16:58year and he h1 described the elephant
17:01according to his own description but the
17:03total description will come only when
17:05you get all these views together
17:07am I correct so throw the that the
17:12message is that radiological Anatomy
17:15always has to be sought in a minimum of
17:17two views preferably in as many views as
17:20possible to get the full picture
17:24otherwise you will get a very distorted
17:26you'll feel you'll think that the
17:28structure is a pole or you'll think that
17:31the flat structure but it's neither you
17:35have to get a three I meant it to be at
17:37least two orthogonal views orthogonal
17:39means to use at perpendicular teacher
17:41then or preferably as many views as
17:44possible okay so then people started
17:48taking lateral chest extremes
17:50what does the lateral is just if you see
17:52in since I've done that when you turn
17:54the heart in your hand into your lateral
17:56view look at it from the side the
17:58contours look quite different the heart
17:59has become much more rounded it's no
18:03longer oval it rounded the length it
18:07looks much shorter in length because the
18:09epics is coming towards you no it's
18:12coming towards you and it's sort of the
18:15front shook front of the heart looks
18:17somewhat flattened out in a chest x-ray
18:19how do you identify lateral very easy
18:21because the spine is at the back and the
18:24heart is cleared the spine the heart is
18:26entirely in front of the spine okay that
18:29you know that it's a lateral view and
18:32auntie really see the sternum and the
18:35sternum is well profile the final proof
18:40of being lateral you see that there are
18:42two sets of ribs so one is the right
18:44side ribs and the left-sided rim now
18:46both the ribs are perfectly overlapping
18:48each other so you see only one set of
18:50ribs so that is a lateral view if it
18:55were robably you will see if it were
18:58probably you will see some ribs in front
19:00of the spine and you will see some ribs
19:02behind us
19:03with an oblique view okay so that is how
19:08relaxed of you go you should keep the
19:09heart in your hand always when you
19:11interpret and and you gram so that
19:13you're very clear about the lie of the
19:15heart so but then AP and lateral is not
19:21enough for interpreting correct
19:24structure again it's such a complex
19:27structure to use probably or not enough
19:29and therefore you need oblique views so
19:33started taking oblique just take series
19:35so when you take an oblique just take
19:37say you can have a right anterior
19:40oblique or a left anterior oblique and
19:42that fundamental to your interpretation
19:43you must know how to identify a left
19:45anterior ee how to identify right and
19:49irritably know right anterior oblique is
19:52very easy
19:52the typical contour of the heart know
19:55the contour of the heart is that
19:56egg-shaped or ovoid shape is there in
19:59right hand aerobic it becomes
20:01exaggerated really forms very well right
20:05and the spine moves towards the left
20:08that is mean if you do right anterior
20:10oblique the spine moves towards the left
20:13of the heart the left means the
20:15operators left I'm talking or patients
20:17right okay I shouldn't confuse okay
20:20we'll talk about the patient's left and
20:21right now right so this is the patient's
20:24left and this is the patient right so
20:27when you do right anterior oblique the
20:31spine moves towards the right the heart
20:34mode
20:34towards the left now important to
20:38differentiate that it is not lateral
20:40when you do lat when you do a our
20:42overview what happens is the left-sided
20:45ribs are seen in front of the spine
20:48but the right-sided ribs are seen behind
20:51the spine right so this is not lateral
20:56you one set of ribs are seen here one
20:58set of ribs are seen here there as in a
21:00two lateral you should see only one set
21:02of ribs okay secondly the heart is
21:07moving to the left and the spine is
21:09towards the right therefore this must be
21:10right anterior oblique view in contrast
21:14when you go to the left anterior
21:17break view as you rotate the patient
21:19left-hand rubric you the spine moves
21:21towards the left of the heart and in now
21:24you see thee I'm sorry I made a mistake
21:29in our AVO view you see the right-sided
21:33ribs in front and the left sided ribs
21:35behind okay in a Labour view you see the
21:41left-sided rips behind and the
21:44right-sided ribs in front right so this
21:49in this view should be you've imprinted
21:52in your patient the ovoid shape the
21:55position of the spine and the set of two
21:58ribs if you see this shape and this
22:01shape corresponds so anterior and ra-vu
22:03look like similar to each other and this
22:06shape of the heart not a rounded shape
22:08with a with a with a shortened epoch
22:11correspond to the ALU of these two look
22:13more similar the lateral and nelio will
22:16look similar
22:16ra.one EAP will look similar now it's
22:20very easy to may not re ellipse which is
22:25posterior and which is anti changes to
22:27repeat itself
22:28yeah okay so so can you imagine the
22:32chest let's go back to this so when you
22:36rotate this page oh sorry one second see
22:40this patient now rotate that the right
22:43shoulder comes forward and the left
22:45shoulder goes backwards can you this
22:48frontal x-ray beam up here imagine the
22:51right shoulder comes forward and the
22:53left shoulder both backwards okay and
22:55you are looking from here then the right
23:00ribs are in front of the heart of front
23:03of the spine and the left ribs are
23:05behind the spine that is our view okay
23:14now imagine this you rotate this way
23:18they said that the left shoulder comes
23:20forward and right shoulder goes
23:23backwards okay
23:27and the left shoulder comes forward and
23:29right shoulder goes backward and you're
23:31looking from the side from here like
23:35this then the left ribs will be in front
23:39and the right-sided rift will be behind
23:43okay okay you don't write anything I
23:46ditched observe we have behind and back
23:48okay all those things you don't need to
23:50identify I'm only saying that they don't
23:52go overlap like this that's all you need
23:54to know yes
23:55okay use you make sure that they are not
23:58overlapping with each other and then
24:00look whether the heart is in front of
24:02the heart is to the right of the spine
24:04on left of the spine that's all you need
24:06to make hook and you have to look at the
24:08shape of the heart is it rounded or is
24:10it over these are three points okay so
24:17this is La Voz you and that's arrived of
24:20you now you can also have such markings
24:24in the LA overview on our overview but I
24:28will be using more of this Hill when I
24:30use the and the discussed angiogram but
24:33again you must know what is the surface
24:35anatomy when you do are above you the if
24:40you do a steep are you the heart has
24:43come clean of the spine it has left the
24:45spine and come clearly in front if you
24:48do a little shallow degree of REO and
24:50some of this heart will overlap just
24:52right so that is how you know authority
24:55shallow or a or steep horrible now
24:59because you don't have to die when
25:00you've shown an angular gram and docked
25:02in the examination or in practice you
25:05don't have to say with a twenty degrees
25:07are a or thirty degrees or 45 degrees
25:09are not not needed all you have to say
25:12mild ra-vu or steep ra-vu or lateral
25:16right now mild are you mean the corrects
25:20alert will overlap the spine steep re
25:24woman it will clear the spine lateral
25:27means these two ribs will be poor
25:30lapping with each other
25:33what
25:36yes yes yes now when you come to the
25:40cardiac Anatomy when you rotated a hot
25:43and ra-vu view the the right atrium
25:47still forms the reporter but now it is
25:50the posterior border no longer red
25:52borders no because the higher above you
25:54this becomes the posterior border right
25:57now because you have rotated the heart
25:59the SVC does not form the cardiac board
26:02or a game now the left atrium comes and
26:04forms the porch a correct border here
26:07left atrium and pulmonary means from the
26:09bottles of course you won't be able to
26:10see the pulmonary veins and often but
26:12you will see a vague shadow here around
26:15red shadow now what forms the anterior
26:17border and take a border formed by the
26:20right ventricle and going into the
26:22pulmonary artery iota is not seen inside
26:26the card excellent but they are chill be
26:28seen in there high up in the neck here
26:31so these line diagrams are something
26:34very very important you must always have
26:36it in your memory when you go to LM of
26:39you now why is it a level because the
26:41heart is somewhat rounded it is the apex
26:45is foreshortened the spine have gone to
26:49the left of the heart it has gone
26:51towards the left of the heart and it
26:53oblique because the two ribs are not
26:55overlapping each other now what is the
26:57posterior most structure here left
27:00ventricle it forms the hell you attic
27:03water and just above that form by the
27:05la-la doesn't is not seen in the frontal
27:08view but in a lev of your lateral view
27:10it will be seen forming the purported
27:12correct border whereas when you come to
27:14the front it will be the entire body is
27:16formed by the right ventricle and going
27:19up into the mulberry art anyway we'll be
27:21discussing this more when we discuss on
27:23yoga okay just remember these two
27:26figures it will come again and again
27:27when you discuss and your answer
27:30sorry know again I have to come it's a
27:35heart is a very complex structure if you
27:37are looking at the pulmonary artery
27:40starts here but then it goes obliquely
27:41then goes backward and then it goes
27:44downwards the right permit ago the arch
27:46forms a ash form the right side goes
27:48backward and to the left
27:50so it's all a very complex phase
27:51coronary artery if you see the left
27:53corner gotta start from the aorta
27:55come behind the boundary artery in the
27:57horizontal manner and then it obliquely
28:00and then it goes here and at the epoch
28:03it turns around and goes back books know
28:05they're a complex course record is shown
28:07here for example this is the left
28:09coronary artery no did you see the
28:10circumference how it come that first
28:12part is different from the second part
28:14and then the third part is different the
28:15last part is curves your own similarly
28:18RCA comes forward right AV groove makes
28:21you loop round a weak sulcus goes up
28:25from the loop and then go to such a
28:27complex structure you cannot see in one
28:29view or two views on or not even in AP
28:32later are available you probably need
28:35different angulations to see all parts
28:37of the heart and all parts of the
28:40coronary arteries and that's the
28:43importance of taking multiple
28:46angiographic views and angled use the
28:50view which shows the left main artery
28:53may not show the middle ad the view
28:56which shows middle ad may not show the
28:59distal led the view which shows proximal
29:02RC may not show the test LRC we need
29:06different views therefore you need more
29:10than one view multiple views and that's
29:12the why and when you open the heart for
29:16ventricular angiogram it becomes even
29:18more complicated look at the septum the
29:21septum is not normal even me law when
29:24you draw a diagram to explain to anybody
29:26we just draw our v lv and then we've all
29:28draw a straight line this is the septum
29:30but the actual septum is not a straight
29:32line it's a very very curved stroke it
29:35has curvature in two views if you
29:37remember the your echo in short axis it
29:40forms a curve like this it forms a curve
29:43then you do remember the curved septum
29:47in short axis view like this like this
29:50it forms ILS okay in addition there is
29:53another curve can you see this it comes
29:55up like this and it bends
29:58backward this is another curve
30:02so the septum is a very complex
30:05structure it it's curved in more than
30:08one plane in different places therefore
30:11again one view will not show the all
30:14parts of the septum similar in the RV
30:17also all parts may not be shown in one
30:19view whatever you show the right mental
30:21or the inflow may not show is the right
30:22went to color all flow very well this is
30:25right when tickle comes from behind
30:27comes forward and to the left and then
30:31it goes forward so clearly and then it
30:35arches backwards into the rb/o so such a
30:38complex root will not be shown in one
30:41view again left ventricle can you see
30:43the septum with curved if you take a
30:46horizontal section it is curved like
30:47this and if you take a longitudinal
30:50section it is curved like this so if you
30:54have a VSD in this location you will
30:58need a different projection to profile
31:00it then if you PSD is in this location
31:05okay so then we need multiple views and
31:11multiple views not only in AP lateral
31:14our AO and a level but you also need
31:18cranial cranial our Ukrainian leleo
31:22caudal a live-work-play plane coddle
31:25coddle our AO and multiple views so that
31:28you can see all parts of these curved
31:30structures that's the most important
31:32thing and that's why you need a catalyst
31:37the modern cath lab the three three
31:40major component to give you a diagnosis
31:43of course the machine is very important
31:47the subject you have to do as a
31:50procedure safely and get him out of
31:52phase and the third most important thing
31:56is you and the most important person who
32:00does the interpretation the first two
32:02factors will not give you the
32:04interpretation you have interpreted with
32:07the use of the this piece of equipment
32:12now the modern Catholic I think I'm
32:14you're all familiar quickly going
32:16through it we have an imagined things if
32:18I am here and sorry yeah so x-ray x-ray
32:22Souls here and an image intensifier here
32:25and the patient lies on the table and
32:28therefore this is the view for a
32:29posterior or a frontal view you turn it
32:32around and in modern machine you don't
32:34move the patient when we learnt
32:37cardiology the tube was fixed and the
32:40patient had to be rotated but now the
32:42machine throw treats so the this is the
32:46lateral projection I think this the most
32:48of you are familiar and I won't spend
32:49much time on it
32:50you can also do a live of you where the
32:54x-ray source enters from the left
32:57posterior aspect of the patient and
32:59image intensifier is in close proximity
33:02with the right anterior chest that's the
33:05left anterior oblique you can have
33:07different degrees of left I'm terribly
33:09as I said mild moderate and through
33:13lateral and you can add cranial tilt
33:18when the when the x-ray tube goes caudal
33:21and the imaging testifying goes cranial
33:23you get what you called a cranial tilt
33:26you can do cranial tilt with any degrees
33:28of obliquity that is you can do cradle
33:30tilton re or a level or in a plane a
33:33preview or could do the reverse and
33:35quartered now it's important to know how
33:39an angiogram looks in all these views
33:41because you never know in a given
33:43patient what view will profile a
33:45particular part of the coronary artery
33:47or a particular part of the heart so you
33:50have to know the cardiac anatomy in
33:56every single projection in space in 360
34:00degrees you if I afraid I can turn the
34:03heart in any direction in any way if I
34:05show you the heart you must be able to
34:07identify on I angiogram what chambers
34:10lie where and that is the purpose of my
34:13talk today again this is a
34:16representation of the arrow the patient
34:19is lying here with the head and towards
34:22me so the the
34:26it can rotate to the sorry head and
34:29rotate away from me
34:30so the the image anticipate going to the
34:34right of the patient gives you a rave of
34:37you frontal and if it goes to the left
34:39of the patient it'll be la Veuve you and
34:42extreme will give you lateral right now
34:48you could theoretically do more even
34:50more steep you but we don't require need
34:52to do that because if you understand
34:53these these are only a reverse of other
34:57views so we don't need to the give us
34:58custom s now this is another view of the
35:04patient to show you the cranial and
35:05caudal tilt I will explain to you why we
35:08do the cranial and colleges later but
35:10when you do a cranial tilt the the
35:14source of X I ignore towards the feet
35:16and the image intensifier moves toward
35:18the chin of the patient and encoded tilt
35:20it more the opposite way okay now before
35:26we go on to interpretation of angiogram
35:28please remember that the algebraic image
35:32is only a shadow and shadow depends on
35:38where the source of light is and what is
35:41its relationship to the object therefore
35:44the shy you know you've also seen when
35:45you're standing in the Sun when the
35:47light is on one side and depending on
35:51how close you are to the light your
35:53shadow can be very small it can be very
35:54long it can be oblique and it can be
35:58moderately low it can become very long
36:00depending on the angle of the light to
36:02these body similarly if a shadow in the
36:06Sun you have seen it's now when a pole
36:08and the shadow of the Sun changes
36:10according to the position of the Sun so
36:13the most conventional view is suppose
36:15you have a structure like this tube if
36:18you take a cross-section out of it this
36:20view is called a cross-section also
36:22called a n fast view so it'll look like
36:24a circle if you look at it from the side
36:28it will look like two parallel lines I
36:31mean you want in a sectional view you
36:34won't see the third dimension that I
36:36have drawn here to show you the tube but
36:38what you will see actually only two
36:39parallel lines
36:40when you see two views you put both
36:44together and know that it is a tube
36:47little otherwise if you see this alone
36:50you will think it is a circle if you see
36:53this alone you will think you would
36:55think it is a rectangle if you see more
36:59these together you know that it is the
37:01hollow tube am i clear yes yes now these
37:10two views are called orthogonal views
37:12this is cutting straight across and this
37:16is looking at it from the side there is
37:18a called orthogonal views but if I don't
37:20take trickly perpendicular I take at
37:24angles no like this then what will
37:28happen this will not be a circle anymore
37:30it will become an oblong it will become
37:36oval right now that oblong is important
37:41for echocardiographic image which I will
37:43talk to you in a separate lecture but
37:46remember that in x-ray as bian lie we go
37:49to go perpendicular views so that even
37:53in our interpretation is correct now
37:56this orthogonal views is also important
37:58for the reason suppose we have a Nazi
38:01Roma occupying the lumen like this in
38:04one view it will look like this that it
38:07is occupying a indentation like this
38:15here but in another view if you look at
38:17it from here you may think that the
38:20lumen is normal because the die is
38:21extending from wall to wall you get my
38:25point
38:25if you look from here you will see the
38:28indentation in the contrast like this
38:30because of the earth Roma here but you
38:33look from here the die is extending from
38:35wall to wall the black is a die okay
38:38from here to here so from looking from
38:41here now active will look normal but
38:43looking from here the artery will look
38:45like 60% indentation that is why you do
38:51multiple views in core idiotic can you
38:53see here
38:54which is very market in this view in
38:58another oblique view it's not so much so
39:03the same reason in two different view
39:06may may look different at my point
39:11remember this is how I remove this is
39:14our F of U and this is La Voz
39:16so the same reason in two views may look
39:19quite different in one view very tight
39:21in another view are not so tight so you
39:25need orthogonal views anything Singh now
39:29look when you do orthogonal views that's
39:35why you take multiple views and multiple
39:37thing and also since you take multiple
39:41views you may also know the codec
39:44Anatomy when you do in corner 90 for
39:47example here now I will go back to let
39:51me go to the heart again yeah see look
39:57at the left main coronary artery here if
40:00you do a straight away oh and you're
40:02here you are looking along the length of
40:07the left main coronary artery and the
40:08proximal led can you see that so the
40:12left main coronary artery and and the
40:14proximal led will be for shorten
40:17therefore you may not be able to see the
40:20details of the proximal led very much
40:23here the other hand if you do a left
40:26anterior oblique with cranial tilt you
40:30will enlarge and elongate the proximal
40:33part of the left hand to the cemetery
40:36yes okay so when you do that you get
40:43better views when you do when you do
40:44Craney view I didn't get it you said
40:51something okay so most so what profile
40:59what elongate the proximal part of the
41:01coronary artery will shorten the distal
41:03part of the coronary or teeth made do it
41:05differently therefore you have to do
41:07again
41:07other view for the little corner at Lee
41:09I keep repeating that again and again
41:11because that's the principle of
41:12angiography now whenever you do an
41:15angiogram you must know what the cardiac
41:17chambers are and I have borrowed some of
41:19these figures from a YouTube video I
41:22don't know maybe some operated have seen
41:24from cheese reaches Rossignol one dr.
41:27Rao has put up a YouTube video or and I
41:29borrowed some of these figure from that
41:31to know so so he's shown beautifully
41:35when you do a level cranial angiogram
41:38you must know where the left ventricle
41:39is you must know where the left atrium
41:41where must know where the right Kentucky
41:43list because then you can identify the
41:45branches much easier so they looked at a
41:49descending artery is in the
41:50interventricular group say anything to
41:52the left is left ventricle but anything
41:55to the left means only up to the
41:56circumflex artery anything above the
41:57circumflex artery is left atrium so it's
42:00beautifully marked here anything above
42:03the AV groove is a left atrium which is
42:05foreshortened here you don't see the
42:06full Lele you see the most of the LV
42:09here the septum is e end on so like the
42:12side of a cellphone you won't see the
42:14subcommittee except the profile all the
42:17branches here are on the surface of a LV
42:20and they are the diagonal branches or
42:23the om branches the branches on this
42:27side from the left coronary artery would
42:29be the acceptor the pride filter so that
42:35becomes simpler whenever you do a
42:37coronary and you know you must know
42:38where the cardiac chambers are now when
42:40I discuss with PG I find there when I
42:43are when I show those assigned you and
42:44they tell me whether they LA in this
42:46case I find many of them cannot identify
42:48where the LA's if I ask you where the
42:52pulmonary artery will lie in this view I
42:55doubt whether some of you couldn't tell
42:58me that so that you must know the
43:01character atomy even when you are doing
43:02a coronary and you okay the degree of La
43:06whoa you can judge by the degree of
43:10overlapping of the heart on the spine
43:13for example in front of you the heart
43:18overlap but it has got that
43:19characteristic ovoid shape the
43:21the frontal means as we go into la Veuve
43:23you the heart becomes oval in shape mild
43:27a level it overlaps 50% here and 50%
43:31here okay when you go to steep a level
43:37only a little bit is behind the spine
43:39only 1/3 is behind the spine
43:40most of the heart is in front of the
43:43spine and when you go to lateral the
43:45entire heart is in front of the spine
43:47now why am I telling you this because I
43:50already told you how to identify oblique
43:51views the chest x-ray isn't it
43:53why am I take you this because when you
43:57do an angiogram you tend to reduce the
44:00field of interest you don't get
44:04clavicles ribs everything in a non yoga
44:07you get a much more limited view when
44:09you do a angiogram because that improves
44:11the quality of thank you now look at
44:13this view do you see the clavicles do
44:17you see the two set of rims so how do
44:20you make out it the LA or are you you
44:23make out the LA or are you suppose you
44:25didn't have the car ready and you're
44:26here how do you make ghost one the heart
44:29is ovoid in shape to the time is always
44:33visible whatever be the degree of field
44:36cutting you do the spine will always be
44:39visible the spine is on going towards
44:42the left of the heart therefore this
44:46must be LA of you how much you live of
44:49you they very little of the heart is
44:52behind the spine very little of a heart
44:55and therefore this must be quite a steep
44:58a live of you so this is a steep a level
45:02view and why is it cranium because
45:04you're looking at it from above and the
45:07diaphragm machine
45:08now all those ribs and clavicle and
45:12everything are useful when you interpret
45:15an angiogram they are not visible so you
45:18must learn to identify are a bordello
45:20based on the shape of the heart on the
45:23position of the spine on the amount of
45:27heart behind the spine and whether
45:30diaphragm is visible or not the
45:33close to your identifying the projection
45:36that the foremost point in describing an
45:39angiogram you must know what is the view
45:43so you know familiar how to identify a
45:46level cranium in a limit in a limited
45:49field yes okay so this is the figure
45:57which tells you a P shallow and a move
46:00deeper level and lateral how much of the
46:03heart you know the same thing holds good
46:05for our above you when you go to our
46:07overview the AP when you turn into our
46:10sorry is this the AP view when it turned
46:12into our river view you'll get it a the
46:16typical cardiac egg contour but some of
46:19the heart will still be overlapping on
46:21the spine steep array of you will be
46:24very little will be overlapping and and
46:26lateral array of you or right lateral
46:29the heart will be clear of the spine
46:31the second principle on the array will
46:33be also okay alright one doubt sir sure
46:41is that about the diagonals are what you
46:44told like cranial and caudal reading yes
46:49when you look from above you normally
46:52you're looking like this at a horizontal
46:55plane okay you don't see the diaphragm
46:57but you don't see much of the diagram
46:58but when you look from cranial from here
47:01like this a heart and back from an
47:03overlap so if you see a lot of diaphragm
47:08on the heart you mean you know it is a
47:10cranial end you can you see the
47:11diaphragm is almost half of the heart
47:14yeah yes sir yes
47:16therefore it is cranial angulation dream
47:21now are a ovo to identify re-review look
47:25I told you know this is the typical the
47:28egg-like contour of the heart the spine
47:31is here the spine are gone to the right
47:33of the heart therefore it won't be an RF
47:35of you but it is still overlapping the
47:38spine therefore it must not be a lateral
47:41view so this must be a somewhere shallow
47:45shallow or
47:46you can you see results on our overview
47:49overlapping the spine if it was steep
47:52our review the heart would come and
47:54overlap very little on the spine or it
47:57would clear the spine like this these
48:00are two examples of array of abuse I'm
48:03sorry maybe this is AP and desirable
48:05this is AP this sorry
48:06oh no no wait sorry this is our evo
48:13straight which is ra-vu cranial I live
48:17it because can you see can you see the
48:19diaphragm is thin yes yes yes sorry yes
48:27sir yeah so this area both straight and
48:29our Ukrainian now is this also you must
48:32be able to identify the chamber where is
48:36ALV here look for their lady anything on
48:39the left side of LV leds lv shown in
48:43yellow here anything on the right side
48:47of LED is RV but only up to the AV group
48:50what is it what is lying a Navy crew
48:56hello
48:58they're complex yeah so now you know
49:04where we will be you know where the RVs
49:06and now you know behind the circumflex
49:09is LA shown here okay right where will
49:19they be no tell me
49:29come on we'll be behind behind behind
49:33womb they had what I know you can't
49:38point out in this NGO but you can tell
49:39me no describe it nicely behind are we
49:45in this figure
49:46tell me Baba how do I know behind behind
49:48I see la there come on guys I have been
49:58talking for 45 minutes I thought you
50:01understood because we'll be running on
50:08that side so we won't be able to see in
50:10this on fastview
50:15not exactly see the RA will be lying
50:19probably in front of LA here it'll be
50:23just you cannot mark are a no because it
50:25will be lying on this here exactly they
50:29you will see the atrial septum n face
50:32you will see the atrial septum also
50:35called as the frontal view of the it'll
50:38septum or the on face view of mental
50:40septum yeah the RA and la will be lying
50:44one behind the other
50:46so if I have to draw array I will draw
50:48it exactly on top of la are you
50:52following or not Esther yeah yeah don't
50:57don't say behind anybody worthy this is
51:00the AV group so the RA has to be here
51:02the only thing I cannot draw it
51:04separately it will I to overlap the RA
51:06la sorry ra and la will be overlapping
51:09here ra will be in front la will be
51:11behind yes
51:18am i clear yes okay when you do when you
51:24do a cranial tilt you see more of
51:27diaphragm you see a game between the
51:30circumflex you know is a correct when
51:32you do a cranial till the circumflex
51:34goes up and the LED comes down you're
51:37familiar with all these views I are you
51:39know the public better than me but
51:42now the LV light between the circumflex
51:45and the LED here here and RA RB lies
51:50here but the problem is now the ena has
51:53shifted because the cranial tilt ela is
51:55no long you don't see the AV groove here
51:57anymore where the AV guru mo the AV
52:01groove is here because of the cranial
52:05tilt yes therefore anything anything
52:13above the AV groove will be L a very
52:15little of the LA will be seen here yes
52:22yes sir yes now this is something
52:26difficult to understand unless you have
52:29a model think about it in without
52:32cranial till you see our ll all side by
52:35side but manual cranial tit suddenly the
52:37create a circumflex and le disappears
52:39from sight and the heart is actually
52:43foreshortened you don't see the
52:45egg-shaped appearance anymore okay you
52:50are all familiar with this view and it
52:52what is it this is one of the most
53:02important view for bifurcation ll see a
53:05bifurcation okay but that's not what I
53:07am teaching you now what I'm teaching
53:09you whether the cardig chambers here the
53:12caudate chambers a lady is here
53:15therefore on the left side is left
53:18ventricle this is the circumflex
53:21therefore between the l lv circumflex
53:25and then comes what is this L a so this
53:29is a very unusual position you pose
53:30remember in a caudal view the L a Goes
53:33Down and between the LV and RV is the
53:38left anti descending artery so it is all
53:43very confusing unless you have a clear
53:45mental image when you do cranial tilt it
53:48looks like this when you do caudal till
53:51L V goes on top la comes at the bottom
53:55you do cranial tilt Elvie come down and
53:58ela goes on top okay are you able to
54:02relate to this figure yes okay any
54:09branch going in this direction what will
54:11be those branches from here going this
54:14way what will it be
54:16I'm showing you from the right is going
54:20like this
54:20what are those branches very good om
54:26branches if suppose some branches are
54:28going like this what will they be left
54:34entrance circumference yes it will
54:36branches very good suppose some branches
54:39are coming from like this what are they
54:47will you see the septal in this view
54:51well you may see a few septal but it but
54:54it but really speaking you won't see the
54:55septum here
54:56so this some foreshortened sepals will
54:58be seen so that's the important now if
55:00you see a little branch coming like they
55:02shouldn't take it for a diagonal or some
55:04other crime sometimes you do get
55:07fistulas you do get unusual but just
55:10filling from the coronary and you so you
55:12must know exactly in all view where will
55:15be is where the LA is okay what we use
55:19this very very sharp in these things
55:37nice nice view for profiling the middle
55:39lady also shows all the scepters
55:41beautifully that sir comes like this out
55:44of you behind okay so here the LV is all
55:49disappeared why it has disappeared
55:50because all you're seeing is a septum
55:53this is the on first view of the septum
55:55if you take out the LV are be wall you
55:59will see the on first view of the septum
56:00so what is overlying this part what is
56:02overlaying on top of this is the re
56:08to see only a little bit of LV in the
56:10day above portion so any branch going in
56:13this direction is diagonal any branch
56:15coming down perpendicularly is the
56:18chapter right
56:21what is this view for sorry what is this
56:27language yeah
56:30that's all agreed I tell I don't know
56:34where the cranial tilt has been given
56:36but a little bit of diaphragm that may
56:38be because the table is a little higher
56:40of position and I don't think it's
56:42cranial so in lateral you see the LED
56:46forms anterior most border and what is
56:50in front of the LED is a small bit of RV
56:53now one of the Radiological signs of RV
56:56enlargement is increase in the
56:58retrosternal space you must have read
56:59normally retro song space is limited if
57:02the space is the increase the RV it's
57:05supposed to be one sign of RV
57:06enlargement so this is the retrosternal
57:08space here so the most of the view in
57:12this you will see the LV and the
57:15circumflex is here and la seen a little
57:18bit above there so these figures are
57:22very useful to know the lie of the
57:25hearts okay right coronary artery
57:26equally complicated is it the beginning
57:29part comes it from the high order comes
57:32forward and then it goes down and right
57:35would make and your turns around the AV
57:38groove goes all the way to the crux then
57:41turns around and guards up to the apex
57:43they came forward and leftward so it's a
57:45very complex course you do many views
57:47and I've shown only one view here yes
57:50come on what views this one guys quick
57:57yo cranial elbow Lake English steeper
58:02level milder level you never told now
58:04I've been talking so long and you still
58:06you're not using my terms I want you to
58:08use fine is fine you see my insane heart
58:14is still overlapping this fine yes
58:17deeper level but it because most of the
58:19heart is most of the heart is in front
58:22and even the left coast collateral
58:25branches in front of this and ever it
58:27might be a very steep a level but it's
58:28still overlapping the heart and it's
58:30fine
58:30therefore it is not to lateral steep a
58:34level I am cranial cranial diaphragm is
58:39seen okay so now can you identify the
58:42chambers this is what is called the four
58:45chamber view isn't it
58:46when you do a echocardiogram to show
58:48this you you shall call it a four
58:49chamber view though you can see all four
58:51chambers this is the post a descending
58:53artery therefore the poce
58:55intraventricular group so it separates
58:57RV from lv are we LV above the AV grew
59:02is the atrium this is the re and la boat
59:06together
59:06there is no landmark to identify la and
59:09Ra there's nothing to identify this but
59:11anything above the a we grew with atrium
59:14right ventricle that's wonderful
59:17yes is that clear yes yes yes this is
59:24the acute marginal branch forming that t
59:27aquatic border and our overview
59:28I'm sorry la wood now these figures you
59:34have to memorize not memorize understand
59:37sorry okay this is the simplest way of
59:40when you do a are a row of the right
59:42coronary and you there left heart
59:45chambers are all hidden behind the array
59:47and la la lies behind the array here and
59:49he'll be lies behind the RV here
59:52therefore RA and RB are separated by the
59:55AV groove so you know where the RA ends
59:58and where the RV begins so any branch
1:00:00going on this side is they ought to be
1:00:05branch any branch going on this side is
1:00:07the
1:00:15branch ok so now we come to me with
1:00:19ventricular the ng Graham what views
1:00:21this angiogram REO cranial
1:00:30oh my god when the AP lateral is left
1:00:37can then caudal is left are Ukrainians
1:00:40steep a little cradle is wrong because
1:00:48the heart has still a typical egg-shaped
1:00:53cafeteria the heart the spine have gone
1:00:56to the right of the spine right of the
1:00:58heart therefore it is typically a ra-vu
1:01:02view well if steep Aria or mild ra-vu it
1:01:05is steep REO because the relation of the
1:01:07heart is overlapping on the spine if it
1:01:10was mild are you half of the heart would
1:01:12be overlapping on the spine if it's a
1:01:14total lateral the the heart would be
1:01:16clear of the spine so this is the are
1:01:20you now I don't think there's any
1:01:21cranial I think just because they have
1:01:23included more of vertical you know and
1:01:25vertical extend you're seeing the
1:01:27diaphragm because when you do a true
1:01:30cranial view the heart has to overlap
1:01:32the diaphragm okay you don't use the
1:01:36heart overlapping the background don't
1:01:42call it training you have to be careful
1:01:45now just because diaphragm is seen don't
1:01:46jump to conclusion it is cranial you
1:01:49have to you have to see whether the
1:01:51heart is overlapping the back from one
1:01:53or did somebody who opened the field
1:01:55from head to foot from here to here you
1:01:58will see the diaphragm unilaterally say
1:01:59you'll even see the pelvic bones if you
1:02:01open enough that doesn't make it cranial
1:02:05the harder to overlap the Typhon this is
1:02:08not cranial this is the simple trick
1:02:10ra-vu view done most commonly for lv
1:02:14assessment mr assessment and all that
1:02:17right and other and it is steep ra-vu
1:02:21view no tip means more than 40
1:02:25degrees that's typically 50 55 60 65 70
1:02:28doesn't matter okay and what have you
1:02:31anatomical trigger corresponding to that
1:02:34yes this one now sorry one moment oh
1:02:41just a minute I lost the image okay can
1:02:46you see me make no oh yes yeah see this
1:02:54this is just a diagram to explain design
1:02:57you although I've shown only the LV
1:02:58ideas though pacified you must know
1:03:00where the RV is lying it are we flying
1:03:02from on top of it like this like this so
1:03:07the septum is on fast its facing you
1:03:11that is why this view is not a good view
1:03:13to comment upon 4 vs T because the BAC
1:03:17is present it will be coming towards you
1:03:19how can you comment on a VSD which is
1:03:20coming towards you because the VSD jet
1:03:23will be hidden in the LV or pacified
1:03:25mass therefore this is not a good view
1:03:27for commenting upon vsts angiography is
1:03:31best for whatever is profiled sideways
1:03:34now for example this view is best for
1:03:36commenting upon the LV shape for the LV
1:03:39contractility for Mitel well for my
1:03:41children education into la for LA size
1:03:44for LV outflow for ascending aorta those
1:03:48are the structures which are best seen
1:03:50in this view but it's not a good view
1:03:52for seeing the arch because here it is
1:03:54not profiled it's not opened out yet
1:03:57so here the RV is not opened out your
1:04:00septum is not profiled therefore you
1:04:01should not talk about vsts in this view
1:04:03just to explain look this outlook
1:04:07although you are seeing the LV or
1:04:09pacified the the red color the RV blue
1:04:12color is actually sitting on top of it
1:04:14like this can you imagine that yes yes
1:04:22now you see now another important point
1:04:25which I will refer to again later on in
1:04:28my slide now you see there is a coronary
1:04:30artery coming from here I am going
1:04:33towards the left okay I want you to tell
1:04:36me whether this corner RT is in front of
1:04:38the polymer
1:04:38you're behind the poverty behind the
1:04:48column okay behind the pulmonary so why
1:04:51do you say that because I all-stars
1:04:53posterior and partly actress wait wait
1:04:58he's gonna not that's not enough no I it
1:05:00can come from iota and then go
1:05:02anteriorly it can come from my Orton
1:05:04then go anteriorly like this okay just
1:05:07remember this will come back to the
1:05:08trigger little later okay now these are
1:05:12what we use this their to your shown
1:05:19here here to can describe this both the
1:05:24views you describe this first and this
1:05:25first at the second come on this is a
1:05:28mysterious picture there's a movie in
1:05:34Leo plane so sorry sorry okay you're
1:05:39describing the first one the first one a
1:05:46second one yeah one person please say
1:05:54you when you talk together it I can't
1:05:56hear it yeah this is the first one can
1:06:01somebody tell me what muses
1:06:11so really a p a p a previous clean la
1:06:20abuser
1:06:21okay very good that is that that's not
1:06:25entirely correct but it is it is good
1:06:28okay yes so some guy from and yeah can
1:06:32you think art if no longer yet shape
1:06:35it's more oval and shape okay
1:06:40then you must also remember where is the
1:06:44spine the spine is here and you can see
1:06:47the arterial catheter coming from here
1:06:49therefore this is posterior yes so more
1:06:54than 50% of the heart is overlapping the
1:06:57spine so what we use that shallow
1:07:01Allu okay now half the heart is
1:07:06overlapping the diaphragm and therefore
1:07:11if what the reigning sign somewhat
1:07:15famous penalty this is also a level
1:07:17cranial fill of side this is a lower
1:07:21cranial tale but this is slightly
1:07:24different what weight is different this
1:07:29is all this is even less la oh can you
1:07:32see the electron trickles entirely
1:07:34behind the spine here half of the LVS in
1:07:38front of the spine half is behind here
1:07:40the LV is entirely behind the spine so
1:07:42this is their shallower level this is
1:07:45more deeper level but the difference
1:07:48between this and this is this ventricle
1:07:53is still avoid whereas this ventricle is
1:07:56elongated why did we do this elongation
1:07:59because we want to separate out the
1:08:02basal portion of the ventricular septum
1:08:04from the mid portion from the apical
1:08:06portion because we have a VSD here and
1:08:09here and here we want to separate talk
1:08:11do you want elongate the sacrum
1:08:12therefore you are given more cranial
1:08:15tilt and therefore when you give more
1:08:17cranial till the left ventricle becomes
1:08:20even more elongated can you see how
1:08:22elongated it
1:08:23comes so Phenix this is an example of a
1:08:29shallow sorry moderate a level mild
1:08:34rainy languishing this is an example of
1:08:37shallow a level with very steep cranial
1:08:39angulation why do you give steeper in
1:08:43relation then you enlarge and elongate
1:08:45the septum then you can separate the
1:08:47basal VSD from bit muscular bsd from
1:08:50epical via stage you can separate it too
1:08:53so we have two or three VSD you will be
1:08:55able to see three distinct gets but if
1:08:58you if you have three jets in this view
1:08:59one or two of them may overlap each
1:09:01other okay also the iota goes
1:09:07horizontally like this can you see this
1:09:09going going like this
1:09:12so the ll we all throw is foreshortened
1:09:15when you look from the left side it is
1:09:18shortened so if you give cranial tilt
1:09:21you can make it longer and so you have
1:09:22get a better view of the LV outflow
1:09:24tract therefore you give more cranial
1:09:29till if you want to elongate the
1:09:31ventricle and elongate the septum you
1:09:34also get better views of the left hand
1:09:36ticular outflow tract but when you give
1:09:41too much of cranial ill what happened
1:09:44the arch and all will get distorted so
1:09:47what is good for ventricle may not be
1:09:48good for arch we must remember that okay
1:09:52so you must plan you around you how many
1:09:55number of engines you can do and how to
1:09:57do it are you following what I'm saying
1:10:01yes right now let's come to the right
1:10:08particular range you now when you do a
1:10:10right particular angel what views this
1:10:11common practice for you you must what we
1:10:17used that
1:10:23people guessing because both the ribs
1:10:28are symmetrical there but people the the
1:10:31- what is called predict use of the
1:10:34vertebrae are exactly symmetrical and
1:10:36their spine doesn't appear rotated so it
1:10:39is a straight ap view so when you do an
1:10:41RBI and you an AP view the tricuspid
1:10:44valve lies on the left border of the
1:10:45spine as shown here this is a
1:10:48corresponding that diagram to explain
1:10:50the time you then are we in flow forms
1:10:53and apex here outside that is the LV
1:10:56which you won't see and then it leads
1:10:58into the or protract okay now this is
1:11:02what the model looks like ra la and it
1:11:07looks like okay now what is what is the
1:11:11problem in this view the problem in this
1:11:14view is although the RV and tricuspid
1:11:15valve as well shown this portion is
1:11:18foreshortened can you see it -
1:11:20overlapping here the RV is still here
1:11:22this this is the RV and the army outflow
1:11:26is overlapping here it is overlapping
1:11:28here can you make out yes well why is it
1:11:34overlapping because from here to here it
1:11:36is horizontal it is lying horizontally
1:11:40like this when it is horizontal in
1:11:44frontal view to overlap am i right yes
1:11:51okay so if you want to see RV or flown
1:11:54pulmonary valve well what you should you
1:11:56do I told you know anything in doubt do
1:12:054000 you can do cranium or you can do
1:12:09lateral okay one of the P the cranium or
1:12:15lateral so just what we have done here
1:12:19see we have done Latin why it is lateral
1:12:21why it is Latin can you explain why this
1:12:23lateral to me are with anterior
1:12:35you see that the spine
1:12:37is clear of the heart there's no overlap
1:12:41between heart and this time the sternum
1:12:43also the the to no man the sternum has
1:12:46two sets of borders the right border in
1:12:49the left border when you're an oblique
1:12:51they often separate out and you can see
1:12:53multiple borders here it is perfect and
1:12:55you can see you see only one set of ribs
1:12:57there is a perfect lateral and
1:13:00diminished retrosternal space indicating
1:13:03some right ventricular enlargement so
1:13:06when you do an IV angiogram you see the
1:13:07typical right when ticular triangular
1:13:09shape and Trebek relation now that's it
1:13:12that's the model to explain to you where
1:13:15the RV but once you do that you see the
1:13:17RV or flow angle it posteriorly like
1:13:20this and let's see what it shows up for
1:13:24in this view it's not triangulated by
1:13:27norm and in technology and all it angle
1:13:30it push it just particularly it's not
1:13:31going Antonello anyway so if it's
1:13:36angulation the cranial tilt or a lateral
1:13:38view will show that like okay now in
1:13:43this view you must know tell me where is
1:13:46the RA here can you tell me where that
1:13:49where is re here
1:13:55just in front of the third and one
1:14:00person please one person What did he say
1:14:05Marisa I'm lying here I want to know
1:14:07where the position of RA is sir in
1:14:11between the spine and are we very good
1:14:14because the catheter have gone from IVC
1:14:16to RA the sport this is re here on this
1:14:19pine and between the RV and spine and
1:14:22have gone through the tricuspid valve
1:14:23into RV and that is the tricuspid where
1:14:27okay by the way what catheter is that I
1:14:33but much more one connects Burman sir
1:14:37balloon is distal - sorry that
1:14:40incomplete you get only Cuauhtemoc what
1:14:49catheter is that / - design many
1:14:55catheter repeat a Behrman catheter you
1:14:56get only quarter mark reverse Burman
1:15:00catheters sorry you lose that loo you
1:15:03know that also
1:15:19okay here the balloon is at the tip
1:15:22holes are proximal to the Burma
1:15:24what do you fill the balloon with a
1:15:27vendor XA u you use carbon dioxide in
1:15:31your hospital then why do you say okay
1:15:36okay like not available is ya ideal it
1:15:41happened outside but if not available
1:15:44more stuff was new the air what is the
1:15:47disadvantage of air policy okay
1:15:56one day I'm going to ask you air
1:15:58embolism in the heart so suddenly I will
1:16:01ask you one day so you and you will tell
1:16:03me the clinical features and treatment
1:16:04and all I am NOT discussing it today but
1:16:07I've given you a warning but I will ask
1:16:09you okay now do you remember I asked you
1:16:15the lie of the coronary artery later but
1:16:17this is a very important ok can you
1:16:20describe these two NGOs for me
1:16:34yes the first one is the AP sir Lane AP
1:16:40sir you give me your asking sir yeah
1:16:43everything you know when I show an
1:16:46anchor I want you I want description of
1:16:49the NGO and one diagnosis is everything
1:16:52so the first one is the plane AP user
1:16:55you can see and with Otto Graham sir
1:16:59so the way to say it is I Otto Graham
1:17:02done in such and such of you don't say
1:17:04pain APU it's an eye on its top
1:17:08let's talk like a report now I have to
1:17:11ground down in such and such a view in
1:17:15the second one Otto Graham done in the
1:17:17lateral okay both of them are wrong them
1:17:22so nobody else can try hey come on this
1:17:28is the egg-shaped heart the apex is cut
1:17:31off your a harsh overlapping The Onion's
1:17:35typical ra-vu view and this is the
1:17:37typical a liver your heart keep a leave
1:17:39of your heart is overlapping the spine
1:17:41the spine is on the left side of the
1:17:42heart
1:17:43so this is our EV of uses a leave of you
1:17:46IATA Graham it's actually by plane of
1:17:48the same angiogram okay now what does it
1:17:50show
1:17:51it shows anomalous oh come on up
1:17:57triangle Graham anomalous coronary okay
1:18:05I know I'm talking about let's talk of
1:18:07coronary right I've shown you this
1:18:08angiogram already arrived this guy's
1:18:10right over the apparent subclavian
1:18:11artery everything I will discuss all the
1:18:13day I what is the coronary described the
1:18:16coronary for me okay and coming right
1:18:25coronary artery is coming from the guys
1:18:28come on you're sleeping yes I showed you
1:18:30the only one you have these little yes a
1:18:33single I think you guys are sleeping
1:18:38either today or you're sleeping last
1:18:40week okay so the right continuity
1:18:44arising from left coronary artery and
1:18:46coming into the right a we grew now what
1:18:49I am interested is whether this is
1:18:51coming in front of the PA or is coming
1:18:54behind the P that is what I am
1:18:57interested in you got to use here can
1:19:00you tell me
1:19:21see I'll tell you why that is why I have
1:19:26behind yes tell me what is that behind
1:19:29pulmonary artery's oh no you're wrong
1:19:33P the left corner artery comes from the
1:19:36left signer goes behind the pulmonary
1:19:38artery and emerges on the left side so
1:19:41it comes behind like that here there it
1:19:43gives off the RCA and the RCA is making
1:19:47it the convex loop upwards like this and
1:19:51coming to the right side
1:19:52yeah like this is coming now can you see
1:19:58the corresponding specimen here it's
1:20:00coming from the left and coronary artery
1:20:04like that if it was coming from the left
1:20:08corner ot behind the RB out flow it will
1:20:11have to be concave like this like this
1:20:16because this is the concave structure
1:20:18here and this is a convex picture here
1:20:22can you make Kirk similarly in olivo
1:20:25lateral or a lobe of your toe can you
1:20:27see the RCA is making a big convex loop
1:20:31on front now in this view where is the
1:20:34pulmonary artery the permeability is
1:20:36lying in this convex like this here you
1:20:38must that's the importance of knowing in
1:20:40the cardiac Anatomy so can you see this
1:20:42the polarity is flying here like this so
1:20:45you're not seeing the pulmonary artery
1:20:46here but you're actually lying here like
1:20:48this like this so now I know this artery
1:20:56is going like just to the right here we
1:21:00go it's coming from the iota and then
1:21:05it's going like this to the in front of
1:21:08the power like that for muttering you
1:21:11understand if it was going behind it
1:21:15would form a a concave loop but because
1:21:19if Parvati is lying like a circle here
1:21:22like this for batteries here it is in
1:21:27front you will see it like if it is
1:21:28behind you will see it like this
1:21:32I think I had a hangar in frontier
1:21:37laughs III I do you remember that
1:21:39anomalous LCA is that was going behind
1:21:42the RV o t know that I knew I must see
1:21:48if I have I can show it to you later
1:21:50anyway so can you see this this is in
1:21:54front and this is if it was behind it
1:21:57would go like this
1:21:58so you it's you have to imagine that the
1:22:01palmera t is lying in this concavity
1:22:03here and that is the specimen here this
1:22:08this sort of angiogram is much easier to
1:22:11interpret if you have this pesum on in
1:22:13your hand so the left cornea T emerges
1:22:16from the iota here see look it comes out
1:22:19here and then it arches like this on top
1:22:22of the formula or tree and go to the
1:22:24right AV guru patrols going behind it
1:22:28would form a concave loop like this I'll
1:22:32go back to the NGO I showed you right at
1:22:34the beginning remember I showed old you
1:22:36one annual comeback is gone
1:22:46wait
1:22:53yes no not fun I don't know where that
1:23:06is
1:23:06nothing of any weight yeah we'll we'll
1:23:09do it some other time so you are you
1:23:13going on that if you understand or not
1:23:19yes please you have to identify where
1:23:25the polymer artery and see whether it is
1:23:26in front or behind so it can go in front
1:23:29of the pulmonary artery it can go behind
1:23:31the pulmonary artery it can go even
1:23:32behind the aorta there are four three or
1:23:36four different courses for anomalous
1:23:37coronary artery please read up
1:23:39everything about it okay know if it is
1:23:42in front of the pulmonary artery it's
1:23:43important for patients with tetralogy of
1:23:45salò
1:23:46so example this patient as a writer I ot
1:23:48cards and all that therefore must be at
1:23:49all your fellow it's very important it
1:23:51crossing in front if it leave behind
1:23:54upon the real tree and it is in between
1:23:56the formula attain IO draw it can cause
1:23:58compression if it is behind the eye or
1:24:01top like to say nothing can compress it
1:24:04there because behind the outer is only
1:24:06la la Canne compress it okay
1:24:09this now this and you also I showed you
1:24:13some time back can you tell me what view
1:24:15is that laid back laid back view what is
1:24:21what is laid back you explain to me
1:24:28explain to me PA :
1:24:33this is not PA coddle coddle is right pa
1:24:37is not correct
1:24:41the ribs are all bleak not a liver heart
1:24:46is the it's a shallow illu okay anyway
1:24:50now can you this is the N fast way you
1:24:52can see one Karnataka this sign of one
1:24:54crunch over this again faster you see
1:24:56the three sinuses and cut beautifully
1:24:59and the corresponding you can he sees a
1:25:01caudal view here shown here a leave of
1:25:03you coddle I have turned their heart so
1:25:06that it reflects
1:25:07I've removed the anterior wall I've
1:25:09turned my model into la Veuve you and
1:25:12I'm looking at it from the apex this is
1:25:14the epic I am standing at the APEC and
1:25:16looking up at the IOT graph so the
1:25:18septum is foreshortened LV is
1:25:20foreshorten but I am able to see the
1:25:22three sinuses and three curves
1:25:24beautifully separately I can identify
1:25:27which karati is coming from which - just
1:25:30like one is coming from here when it
1:25:31comes from here in oak oratory coming
1:25:33from this sinus yeah no but this is okay
1:25:39this coral view and order though that
1:25:42laid-back view is okay for doing the
1:25:44sinus origin of coronary artery but then
1:25:47it doesn't serve much purpose for
1:25:49telling me the distal coronary arteries
1:25:50branches and only it also doesn't help
1:25:52me in the arch so I don't see the
1:25:55article why did I don't see the arch
1:25:59because in teep caudal view the arc is
1:26:02completely hidden
1:26:04it is foreshortened do you see the arch
1:26:08here it goes like this and then comes
1:26:15like this so you don't see the argue
1:26:17doesn't profile at all so this view is
1:26:20only for knowing the finest origin of
1:26:22the coronary arteries and this is the
1:26:24corresponding anatomical view again and
1:26:27emphasizing how to ID how to understand
1:26:30this anatomy and make a diagnosis this
1:26:32is the n fast view okay is that clear
1:26:38yes sir yes sir okay already 3:30 so I
1:26:47think I should stop now right so what I
1:26:51have done today is to show you the
1:26:53surface markings of the cadet chambers
1:26:56how to identify oblique views differ a
1:27:03PP you
1:27:03lateral view different degrees of
1:27:05oblique view different degrees of
1:27:06cranial and caudal till how the higher
1:27:09corrects alert changes in different
1:27:11shape how the coronary arteries change
1:27:14in different views and how to select
1:27:17views according to the structure that
1:27:19you want to see
1:27:21now you cannot understand and digest all
1:27:24of it in one session I can understand
1:27:28that you have to first thing is I think
1:27:31you have to get a model I would suggest
1:27:34strongly get a model available online
1:27:36it's available in anatomy and book shops
1:27:38everywhere so you can get immortal or
1:27:42even this medical companies some of them
1:27:44give it so try to make use of that
1:27:47whenever you describe an eye on Joe
1:27:49Graham so that you understand that some
1:27:51models are very good but some models are
1:27:52not very good could we find a good model
1:27:55which are really representative of the
1:27:57normal anatomy of course you cannot have
1:28:01models of abnormal Anatomy because they
1:28:03don't make it but model of normal heart
1:28:05if you have in your hand that is good
1:28:06enough so that you can identify
1:28:07structure but please try to interpret
1:28:12every angiogram in the light of and
1:28:14write in each one you must be able to
1:28:16identify where each chamber is each
1:28:18structure is suddenly one day somebody
1:28:19asked you where is the right coronary
1:28:20artery in this you must be able to
1:28:21pinpoint you shouldn't have the thing if
1:28:24a suddenly ask you where will be the
1:28:25left apex of the ill be in this
1:28:27angiogram you have 2.0 it's very
1:28:29important for your inter mental
1:28:30procedures to know where exactly east
1:28:33pot in the heart is without any landmark
1:28:37but most of the time when you do
1:28:38intervention you don't have a landmark
1:28:41okay I think I'll stop here you yeah
1:28:47any least for sure for shallow and steep
1:28:50any particular cutoff is there sir
1:28:52see if you mort angiogram nowadays give
1:28:57the printout you know most modern system
1:28:59when you do around you automatically it
1:29:01prints out on the top la authority a
1:29:04cranial 30 and all it prints it out so
1:29:08actually nowadays you describe it at 30
1:29:10degree there live over 60 degrees a
1:29:12level and so on but in an examination
1:29:17you don't really have to bother about
1:29:19that and and these values are not fixed
1:29:22in 1% 30 degrees are able to do your
1:29:25best image in another patient the 30
1:29:28degrees may not give you a best image 40
1:29:29degrees may give you a best image so
1:29:32somewhere between 20 to
1:29:34thirty degrees is considered shallow
1:29:37somewhere between thirty to sixty
1:29:39seventy considered moderate sixty
1:29:43seventy eighty s hundred steep and
1:29:45ninety considered laugh lateral
1:29:48similarly nao twenty to forty shallow
1:29:52forty to sixty seventy deep seventy to
1:29:57ninety bit is deep or lateral no Kisa
1:30:00okay any other question and I can't hear
1:30:12you sorry say that again normal heart
1:30:34always overlaps and shallow always
1:30:37overlap moderate always overlaps it is a
1:30:40steep and lateral we don't go overlap
1:30:44keep steep overlap very little and
1:30:47lateral doesn't overlap so the shallow
1:30:49one and ap always overlap so if you are
1:30:54considering by overlap you must say say
1:30:57half of the heart is overlapping it is
1:30:59shallow only one-third of the heart is
1:31:02overlapping deep no overlapping that'll
1:31:07okay
1:31:12search for chamber view is it shallow
1:31:14levels deep below sir she shallow she
1:31:17typically where 38 30 degrees 11 30 2530
1:31:21degrees
1:31:22cranial shallowly craniums serial also
1:31:33call it hepatic lobule of you 20 to 20
1:31:35to 25 degrees air level and 3035 degrees
1:31:38cranial pathological of you
1:31:40nowadays to describe it as
1:31:43hepatic clavicular for chamber and on
1:31:44the they actually describe what degrees
1:31:48they did so like you you described water
1:31:50you you d 20 degrees cranial with 30
1:31:52degrees a level that is the 44 di i
1:32:00think the jelly minor variations here
1:32:02the particular color all those thing
1:32:03minor book yes
1:32:10any other question it was the one i
1:32:26showed you the place to that anything
1:32:37crossing the are biota front or behind
1:32:39it remains the same and in fact i don't
1:32:41have the kind you i will show it you
1:32:43next time I hate is on my phone I would
1:32:45show it to you next it applies to that
1:32:49also anything crossing RV booty we have
1:32:52to check with it's concave or convex
1:32:54convex upward or concave downwards a
1:32:58convex downwards downwards so put up
1:33:03character we same as a apical for
1:33:05chamber view which is elevation apical
1:33:09for chamber is used in echo not using
1:33:11and you yeah respond to that corresponds
1:33:16to ESPN steering correct shallow level
1:33:19cranium
1:33:24so one more thing started like
1:33:27indications of views in a sdev SDPD and
1:33:31all those can we have certainly
1:33:33indication like what like for mr the
1:33:38good view like used for server is a REO
1:33:41user
1:33:42where gayness is their mark where you
1:33:44can see the LA and we out and so so like
1:33:48that different views were all very we
1:33:51are using sir that can we have such a
1:33:53short sure we can but I mean I thought
1:34:00the congenital fellows will be more
1:34:01interested in that I don't mind doing
1:34:03that but there must be other periodic
1:34:06shows also in your go yes yeah so then I
1:34:13can do the angiographic views for
1:34:16congenital heart disease you're talking
1:34:18now that's what you want yes yes I'm
1:34:21Geographic view for congenital heart
1:34:22disease at least I know at another's
1:34:23only the common one Cattrall V V SBA is
1:34:26the correct sector yeah we can do that
1:34:30we can do it one day but they can either
1:34:31to prepare it I don't have it often yes
1:34:43I yes I can but I need slides I don't
1:34:48have it ready now I've got some other
1:34:50time I'll load it down and some other
1:34:52time I will short out your question I
1:34:54know dot and I is I'm a also useful in
1:34:57there now and I'm just coronary artery
1:35:00yes I will explain to some other time
1:35:07when way because I need slides and they
1:35:10take a long time for me to find those
1:35:12flights and put it here so one if dot
1:35:15and I and one is an Geographic views for
1:35:17congenital heart disease anything else
1:35:21so we'll the coronary lay very with that
1:35:25sidedness
1:35:26on and you know it doesn't it won't vary
1:35:30without sidedness notes but it will vary
1:35:32if it is normal lie of the ventricle or
1:35:35in
1:35:35Pentacles like in a sea TGA the coronary
1:35:39arteries will be inverted great article
1:35:43inversion also in CTP doesn't depend on
1:35:46the great art it depend more on the
1:35:48ventricle the LV on the left side so
1:35:50left coronary will go on the left side
1:35:51sorry on the right side L will go on the
1:35:55right side so the morphological left
1:35:58corner he will go on the right slit but
1:36:01the IOT arch itself it doesn't change
1:36:21like I showed you that car that laid
1:36:23back and you're sure you know that's
1:36:25like a CPG actually I'll show you one
1:36:27second let me get it back can you see
1:36:38the end you know yes sir
1:36:41yes okay now normally the coronary
1:36:44arteries come from the which sinuses I
1:36:47explained to you this dislike occurred
1:36:49when I talked last week I thought it
1:36:51explained all this to you okay so that
1:36:59shows the current is normally the IATA
1:37:02lies behind the PA isn't it
1:37:04so which are the coronary which are the
1:37:07sinuses will give the coronary arteries
1:37:10left and right
1:37:12I noticed left and right what is the
1:37:14position left anterior and right
1:37:18anterior okay what life posteriorly is
1:37:21what the non Cornish - agree yes it is
1:37:28yes now in in CT j what is the position
1:37:32of the aorta it is anterior iota comes
1:37:39anterior and the per military goes
1:37:42posterior now except anatomical
1:37:46principle that coronary arteries we know
1:37:49we come from the facing sinuses that
1:37:52means the two sinuses adjacent to the
1:37:54pulmonary arteries will give off the
1:37:56coronary arteries the crimen we can away
1:37:58from the pulmonary artery normally will
1:38:00not give any coronary artery okay is
1:38:06that clear yes yes so in a CT da now we
1:38:13have three sinuses one two and three
1:38:17this is their what sinus is this and
1:38:25lyricists and TD at non coordinate final
1:38:28nonce I see no non non facing non
1:38:31coordinate final that means in a normal
1:38:36in a normal eye otic urge the non
1:38:40coronary sinus is posterior in a
1:38:43anteriorly place the outer then on
1:38:45coronary sinus is anterior that is the
1:38:48first and foremost thing so both the
1:38:50coronary arteries come from thee the
1:38:52true posterior so now there are two
1:38:53posterior sinuses okay one is the left
1:38:57and one is the right now coat the
1:39:00ventricles are inverted LV is lying here
1:39:03and the RV is lying on the left side
1:39:05they will be morphologically inverted
1:39:07that means the right morphological
1:39:11coronary artery will come from the left
1:39:14posterior sinus and supply the
1:39:17morphological RV am I making sense or is
1:39:21it confusing the left posterior signers
1:39:26will give the right morphological artery
1:39:31and it will supply the morphological
1:39:34systemic right ventricle I am going very
1:39:40slowly to make you understand
1:39:42the left coronary artery will come from
1:39:45the right posterior sinus it will be
1:39:50most logically left coronary arteries
1:39:52will be a circumflex and there will be
1:39:54work effect and a lady and it will
1:39:58supply the morphological LV
1:40:03did I make sense yes so if he doesn't
1:40:11erase the exposition it doesn't arise
1:40:14from the left sinus and go like that it
1:40:16doesn't it it arises from the
1:40:18corresponding sinus the left the right
1:40:21post your sinus now axes are left left
1:40:23sinus actually it plays on the right
1:40:26side which gives out an opera logical LC
1:40:32and you know it's the left coronary
1:40:35artery because the weight divided now it
1:40:36bifurcates into circumflex and a lady
1:40:39where this doesn't bifurcate in fact if
1:40:47you carefully see you can see can
1:40:50running in the AV grew here you've got
1:40:58it how now you understood what is a CPG
1:41:00a corner a lie pattern so when you want
1:41:06to do a coronary and you in CTG a
1:41:08patient it's better to take a multi
1:41:14catheter a multi-purpose catheter so
1:41:16good know whether it's the left sign is
1:41:19the right sinus or anterior Steiner a
1:41:21multi catheter would be much more easier
1:41:23they preform jetking may sometimes give
1:41:26you difficulty because it may not be the
1:41:28ideal one for entering a posterior sinus
1:41:30artery but sometimes even the jet can
1:41:33just it's simple and yet not a problems
1:41:38go to hunt for the posterior sinus if
1:41:41you if you can't hook it to easily sit
1:41:44sit right we'll hook the left and left
1:41:47we'll hook there it is it so yes now
1:41:51this is only for a straightforward CT
1:41:53gabr dextrocardia and all that and it
1:41:55becomes more complicated I'm not talking
1:41:56about the straightforward CT j if you
1:42:00hook it like a left you probably will
1:42:02get the morphological RC and if you hook
1:42:06it like the left or right you may get
1:42:10LCA
1:42:11but you may have to hunt for it because
1:42:13I asked rc8 not coming from thee not
1:42:16coming from 90 assign a normal RC come
1:42:18from anti sinus now it's coming from the
1:42:20postage sinus so you sometimes anomalous
1:42:22arts here you have to hunt for it not a
1:42:24little bit with a little bit of change
1:42:25of catheters maybe take big catheter or
1:42:28maybe with the ampler catheter or even
1:42:31say a multi focus catheter your hunt for
1:42:33it a little bit not difficulties is easy
1:42:45yes sir okay any other question
1:42:55now we're done okay yeah yes sir okay
1:43:02next time we're going to I want to
1:43:05discuss something about the angiography
1:43:08more a little more about angiography
1:43:09maybe how to do an angio of contra to in
1:43:15diction and all those things so so we'll
1:43:20discuss probably on Tuesday I am the
1:43:23little motorboat angiogram and your
1:43:26graphic contrast and other things then
1:43:28how much inject what what not and all
1:43:30those things hmm right so no more
1:43:33questions
1:43:34yeah what is the attendance today so I
1:43:38think around us eighty people join okay
1:43:41right okay
1:43:48right thank you thank you thank you
1:43:50thank you thank you sir thank you thank
1:43:53you so much okay thank you sir thank you
1:44:05sir

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