An 80-year-old male presented with persistent right shoulder pain, achy in nature for the last couple of weeks. No significant improvement post local cortisone injection.
PMH: CAD s/p 4V CABG (grafts occluded except RCA graft). Coronary/graft angiogram in 5/2022 performed for similar symptoms showed RCA vein graft ostial 95% stenosis s/p PCI with resolution of his shoulder pain. Also, had balloon angioplasty only to proximal LAD in-stent restenosis as already has 2 stents at that location. He was doing well till 4-6 weeks ago when his right shoulder pain recurred. He also has CKD stage IV, PVD, carotid artery disease s/p intervention and ischemic CVA with no obvious residual weakness.
His initial EKG from 12/2022 and second EKG done this week. Also, limited echo images posted. His echo in 4/2022 showed LVEF 55% with no regional wall motion abnormality.
It is a bread and butter case. What is the echocardiogram findings?
-Did he have a LIMA graft? Was it patent?
-The most prominent, and pertinent, echcardiographic finding is the severe hypokinesis of the inferior wall. This finding with the clinical presentation and the inferior ischemic changes on the EKG raises suspicion of the possibility of issues with the SVG graft to RCA (? new lesion vs. in-stent restenosis of the ostial stent).
Also, there is a mobile mass seen in RA which is probably a Chiari network or other benign finding.
Next steps: Cath (if creatinine is permissible) and TEE if you need to further delineate the RA mass.
LIMA graft was known to be occluded.
I do agree with the suspicion of RCA graft issues.
The right atrium finding related to Chiari network.
The hypokinetic segments are basal inferoseptal/inferior/inferolateral and mid inferior/inferolateral segments.
@Mansour Khaddr Did you Cath him?