Giovanni Lorenz Cardiac Radiology
@Giovanni_Lorenz
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Cardiac & Thoracic Radiologist throughout the US. Preventive Imaging enthusiast. Texas based Venture. Air Force veteran. Farming & sunshine y’all. USA
San Antonio, TX
Joined December 2013
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Good time as any:
I’m Giovanni, a Cardiothoracic Radiologist. I’m a physician.
I image the anatomy of the heart, lungs and vascular system to determine disease.
More importantly I give insight to help you make decisions about your health.
I focus on preventive strategies.
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66yom immunocompetent with CT Chest exams stable to 2015. Thoughts?? 🧵
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BREAKING NEWS 💡
Radiologist will win major awards and save lives if they identify coronary calcium on CT Chest exams and…
Put that finding in the impression.
90% will identify coronary calcium BUT only 2% will put that finding in the impression (in this cohort).
Add a
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What is a CT Calcium Score?
🫀This is a non contrasted gated CT Chest exam for risk prediction
🫀If you have chest pain, the 1A recommendation is a CT Angiogram of the coronary arteries (see my last post on how to knock out 30 in an afternoon).
🫀Acquired in late diastole
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I’d like to re-introduce the “pill” that has a lung cancer cure rate of 80%.
It’s called the Low Dose CT Chest.
Takes 30s. Less radiation than a mammogram. And is available everywhere.
…And less than 5% of eligible patients take advantage. Ask your doctor to see if you’re
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Power in silence. Power in your voice.
When we as Radiologist don’t yell from the top of our lungs and pedestal of knowledge/foresight we lose opportunities to change someone’s life.
This is a CT abdomen/pelvis from 2016. No mention in the impression of the severe coronary
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Value. Is it in the eye of the beholder or who holds the needle?
I did this one…and nobody thought about paying me more for my skill set.
That space is 0mm. It doesn’t exist unless you hydrostatically create a lane for your “must have biopsy” needle.
Sticking a needle for a biopsy through lung tissue - right next to a pulsatile major artery- getting paid $155.00. Plumber gets more. Yeah this is inane. Meanwhile UAW looking for a 40 percent pay raise….
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Highly academic nerdy and rare (thanks
@docpanel
). Pulmonary Hyalinising Granuloma is a multifocal, bilateral smoothly marginated distribution of centrally calcified nodules.
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Great case example of cardiac imaging at its best. Chest pain? Yes. Coronary disease? No. Vasculitis results in long segment thickening of the aorta and involvement of the Ostia of the Left Main…resulting in high grade narrowing of the coronary artery. Oof. Glad we did a CCTA.
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Yes it’s only the 1st week of Chest rotation…but here we go!
40yom with lung transplant evaluation. (Test alert): lung window means we’re looking for airways or lung finding.
#radres
#radtwitter
#chestrad
@TLHM_MD
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@NeriOxman
Sounds like defamation. There’s no intent here for newsworthy journalism. The real intent is clear. Be strong Neri and Bill.
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29yom with dx Covid this week. CTPA for PE rule out. What’s cool here is that the iodine map (derived from a dual energy subtraction) confirms no anatomic filling defect (precapillary), no anatomic alveolar disease (capillary)…but..
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We are now requiring coronary calcium identification in the impression on all CT Chest.
Coronary disease is the
#1
killer of humans on this planet.
#seeitsayitgetthescan
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If you zoom in you can see a lamellar appearance which histopathologically correlates on bx. Often seen following or during an autoimmune flare. This is now considered part of the IGG4 family by some authors. Fun fun!
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The call to action is for every Radiologist who reads the Chest, to see it, say it and put the finding in the impression. 👇🏼
Most of the time they contain calcification, which is one image marker for ASCVD (other being noncalcified plaque).
Radiologist can turn this entire
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@10kStonesPoet
I know this is tweet-bait…but yeah. Marriage is the best. I’m more fulfilled and happy with a partner and kids and small group of friends. It’s the same simple old truths.
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Pulmonary cryptococcus in a 42yo immunocompetent female in southern CA. Usually clustered nodular or mass like with “wet” ARDS if antigen response is high. Look for organizing changes in subsequent exams.
#radtwitter
#chestimaging
#cryptococcus
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Flesichner society really did a great job outlining these terms but a terrible job marketing it to everyone outside of cardiothoracic Rads.
Thanks Tan. And here is a link to the society Glossary of Terms if needed 👇🏼
Helpful infographic on lung conditions 🫁 Cr.
@DocScribbles
#medtwitter
@Sthanu5
@IhabFathiSulima
@AvrahamCooperMD
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Although the structures haven’t changed-there is an updated nomenclature for this space as defined by ITMIG.
#radtwitter
#chestrad
#rad
Dr. Constantine Raptis shares his approach to anterior mediastinal masses. [1/4]
Condensed by
@MaximilianoKlug
from
@igolfandreadcxr
´s great talk during
#STR2021
.
#MedTwitter
#MedEd
#radres
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40yom screening physical. Diagnosis?
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See anything?
Interesting thought after my resident missed this.
He said he didn’t see it. I saw it. So it didn’t exist from one perspective but existed from another.
I’m learning (in my last few months of training future Radiologist) that visualizing (eyeballs) and seeing
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Pulmonary hypertension has many biomarkers-including size greater than 29mm. But you have to be on the look for it and then design a mgt (echo or
#whycmri
) that can characterize among the typical types.
It’s out there. Go get it!
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Lot of discussion of AI in lung nodule detection.
Some of us have been tracking since 2017.
It’s 2024 and this is what I’m dealing with.
This isn’t an incentive or regulation issue…it’s a “your crap doesn’t work” issue.
@radiology_rsna
@rad
@Radiology_AI
#lungrad
There are over 200 Artificial Intelligence (AI) software for radiology currently available in the European Union alone.
How does the performance of these products compare?
A
#RadInTraining
Tweetorial of a study just published in
@radiology_rsna
👇
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Most Radiologist will run into this structure; it’s called the heart.
And one common finding is post infarct remodeling with subendocardial fibrofatty curvilinear hypoattenuation (as detailed in 2009 by Ahn et al
@AJR_Radiology
:192) OR it could be interventricular fat.
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Going into the weekend and looking for inspiration. Who’s got the W this week?
I’ll go first: finished up Trauma call in San Antonio and one of the last cases was an 18yom shot point blank. This is a kill shot.
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@RatickM
@DougDrachmanMD
@NilayPatelMD
@DrDarshanDoshi
@MGHHeartHealth
@MGHCVFellows
Ultimate trifecta: salmon + steamed broccoli + kale…heated. 🔥
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70 coronary calcium exams in 2hrs.
Not even breaking a sweat. LFG
Radiologist are preventive health physicians.
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Even 34 year olds have coronary disease. Partial calcified plaque in the ostial LAD.
Protect your coronary arteries.
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California Radiologist:
Public health alert sent out recently on the increase in coccidiomycosis infection aka “Valley Fever”
Couple reminds when looking at CT Chest exams for “community acquired pneumonia”, “SOB”
🫁fungal infection where the lung is primary site
🫁aerosolized
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Give me less than 30min and I can diagnose cardiac amyloidosis for your patients in any outpatient center.
No radiation, no labs…just high tech analysis and efficient workflows.
#whycmri
#radtwitter
#radres
#cardiacradiology
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So what do you think we got???
-thymoma
-terrible lymphoma
-teratoma/seminoma
-thyroid
#chest
#radres
#cardiothoracic
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Supporting a good friend and cardiac imager
@KateHanneman
and her talk. 🙌🏼 should be good!
#radtwitter
@themrionline
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Lots of potential causes for unilateral vocal cord paralysis…but consider
#cardiovocal
syndrome
#ortners
syndrome. 70yom with left paralysis. Enlarged thoracic Ao and left atrium likely compressing recurrent laryngeal.
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The only one I trust to teach the world about the cardiovascular benefits of CT Photon counting -follow
@FCademartiri
#cardiovascularimaging
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@DrSpooky_ER
It's 2024...why do television/streaming shows still blast commercials at insane volume compared to the show?
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@Dallas_Holladay
Honestly; bring a gift to the tribe wait for approval from Chief and wear markings of new tribe. It’s that simple. And candy.
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Cardiothoracic Radiologist here…not surprised. We’ve got a ways to go.
But will make big gains I’m sure.
#radtwitter
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Radiologist! What is this??
Dx: septal variant hypertrophic cardiomyopathy and associated Systolic Anterior Motion (SAM) with narrowing of LVOT and reduced blood flow.
This can lead to death and is considered part of the anatomic ddx of Sudden Cardiac Death (SCD).
Reminder
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CADRADS 4a-70-99%
What was the problem here? Why didn’t the CAC score (1st image) from 11/23/2020 say anything?
🫀one of the failures of the arbitrary system of calcification is the density is set to 130 hounsefield units (at a specific energy 140KV).
🫀Different energy,
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“We can split the report…that’s what we’ve always done.” The value of a Cardiothoracic Radiologist reading your
#yescct
. (These were my first 5 cases of the evening…
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Dramatic case of right pneumothorax, pnemuomediastinum and pneumoperitineum (localized to lesser gastric space/winslow) likely from perf proximal stomach wall lining. Endo pending this morning to confirm.
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In a few months I’ll be a veteran…thank you to all who put on the uniform in defense of our nation. 💥
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35yom for cough. CT Chest. What do you think? Arrows?
So this is a congenital cardiac bronchus which describes the embrylogical remnant of an airway directed medially to the cardiac structures, off the bronchus intermedius.
Look for stranding and airway wall thickening as
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#yescct
for chest pain. Coronary aneurysm fascinates-up to 5% of CCTA cases, although considered rare.
Remember the >1.5x normal caliber rule to differentiate from ectasia.
Excellent mgt write up in
@JACCJournals
here
#cardiacimaging
@TLHM_MD
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Can you name each sequence from (radiology) right to left???
#whycmri
🫀
#radtwitter
Techsareamazing
#RadTechWeek
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42yo with cough, chest pain. Cxr: anything?
Here’s the report: left lower lobe pneumonia.
CT chest done 30min later (ED doc not convinced). 2 coronal images in lung window shows the anterior and then posterior left lung. Just as reported left lower lobe pneumonia.
So
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Happy Saturday~
Daily reminder that population screening recommendations don't always apply to your own risk...
Right chest pain...mass picked up on the chest radiograph.
CT Chest 2wks later picked up the pulmonary metastatic lesion that corresponded to radiograph...and the
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History is everything but there are tools to sniff out the right dx. Let’s play.
53yom with hx prolonged exposure to marble dust…chest pain.
-start with a MIP. I know it’s crazy but you want to define apical to basal gradient. ✅
-flip to a bone window in the MIP or go to
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Yes sir! The strongest fastest and highest resolution
#whycmri
dedicated to
#cardiacimaging
in the
#dod
…and they’re trusting me with it. 😬
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Really awesome to see so many starting their
#radiologist
career today!
Congrats to all of you. Just a tiny plug for cardiac and thoracic fellowship.
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You’ve heard of colonic diverticula…but have you seen ilieal/small bowel diverticula?
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*Engagement bait for cardiac imaging*
😮
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Air in the brachiocephalic vein. Is this a problem? Mention in the findings?
#radtwitter
#radres
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Is all lymphoma just lymph node eval??
No.
Good example of known lymphoproliferative metastatic disease to the lungs.
In this example, known hx of chronic lymphocytic leukemia B cell, with surveillance exam.
🫁 metastatic disease can include cell lines involve solid organs
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You can diagnose iron deposition noninvasive (ie no needles) with a 5min cardiac mri scan.
Uses: pre or post blood transfusion; iron overload disease, metabolic disease.
Needle-less stress evaluation using BOLD style (fMRI) evaluation of oxy: deoxy hemoglobin quantification
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87yof for chest pain. CAC=0. CADRADS 0. So what’s the problem? FOV. In a coned down FOV (26cm) this is supposed to provide a coronary friendly interpretation…but it’s really designed to remove Extracardiac structures.
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This is a pericardial cyst.
It is a common finding that requires no advanced imaging. How do you write it off on a single exam??? 👇🏼
🫀Location. These are always adherent or near the pericardium and pericardial recess locations (other cystic lesions of the mediastinum can be a
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Do everything you can to protect your coronary arteries. You have agency!
Initial evaluation for chest pain with occlusive p,mLAD disease on CCTA in a 50yom stated healthy male.
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Merry Christmas 🎄🎁
Did you give the gift of screening? Or did you get grinched??
59yom with intermediate risk. I dunked the guidelines as I could tell this was going to end up bad for my patient.
🫀follow up exam to a post I did on the “when you see this why aren’t you
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Why mess around? Just look at your coronaries.
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80yom with dyspnea. PFT with 85% predicted DLCO. What do you think?
#chestimaging
#ild
#pulmtwitter
#radtwitter
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Free hits of CCTA protocol for low dose and high efficiency exam (if you need to read fast for RVU and accuracy). Total dose 372mGycm
🫀imaging center should be sure all patients have an approved (preauth) CCTA order, and medication prior to arrival
🫀lots of different
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I think there are more benefits in using a structured report than costs. I utilize the
@RadiologyACR
ILD Rads and have found it to be a wonderful way to create an institution registry and
#QCT
opportunity. Our
#pulmonologist
have been on board.
New article
@DiagnIntervRad
-Structured report helps radiology residents to detect fibrosis findings, and aids radiology residents not to overlook alternative diagnoses.
Radiology residents’ reporting time is shorter when the report is structured.
#ILD
#CT
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I go below the diaphragm for big…otherwise it doesn’t exist.
#cardiothoracic
sub-diaphragm travel.
#radtwitter
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Amplatzer closure device for Atrial Septal defect repair. 👏
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Photon counting CT will change preventive imaging.
SOA PCCT - 4DVR Coronary Artery
What is the standard of care for cardiac/coronary imaging?
This time just a nice movie to look at. 4DVR of an LAD running beyond the apex of the Left Ventricle.
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Fitting to be newly approved as faculty within the Dept of Radiology, Fienberg School of Medicine at
@NorthwesternMed
during
#rsna23
!
@docpanel
@NURadiology
Thank you to all!
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From an imaging standpoint we differentiate plaque by its density:
Plaque in the coronary arteries is early and noncalcified (low density)
OR
Chronic and calcified (high density).
Early noncalcified coronary evaluation is best done with a CT coronary angiogram.
Late and
Don’t be fooled.
Your cholesterol matters.
Your CAC matters too but your cholesterol definitely matters.
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How can you tell this is sarcoidosis ILD? Look for upper lobe perilymphatic nodules, fissure involvement and architectural distortion.
#radtwitter
#chesttwitter
🫁
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That’s a wrap
#RSNA23
I am so thankful for all the friends, meetups and vibes at
#rsna23
. So much fun. How about we do this again next year? Eh?
@qure_ai
@HeartFlow
@docpanel
@TeraRecon
@themrionline
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A reminder that most CAC exams are done in an imaging center run by Radiologist.
Great job! Your words are improving awareness and health in cardiovascular, coronary risk with a CAC exam. 💥
See it say it get the scan.
Use this little pick list template we created. 👇🏼
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Did we (and NICE) get it right??? Appears so. Excellent work
@JWeirMcCall
@SCMRorg
@Heart_SCCT
@JACCJournals
#SCMR23
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Choose the right image biomarker!
If you choose coronary calcium evaluation (CAC)…then the technique will find just calcium.
If you choose a CCTA (contrast exam, with IV placed), then you can see earlier and sometimes more dangerous plaque.
Here is a 57yom with abnormal US
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35yom with dyspnea and Covid history.
Big conclusion to draw is that qualitative assessment is hard and takes many cases, yrs (or both) to be able to see what others miss (arrows).
But if you have automated quantification based pixel analysis…well it just pops right out!
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Views views views views.Quadricuspid aortic valve.
Who wore it better US or MRI?? 🤔
Truth is that each modality offers insights that can help determine clinical relevance.
#cardiacimaging
#radtwitter
#radres
@TLHM_MD
@PraveenRangana9
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New bilateral chest wall masses?
#elastofibromadorsi
is a benign soft tissue tumor related to recurrent friction of the scapula and chest wall. Can def cause pain.
#radtwitter
#cardiothoracic
stable across 5yrs.
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CAC score v CCTA. Might’ve missed that huge low dense plaque in the proximal LAD with that noncontrast exam. 71yom no symptoms.
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@BillAckman
@Harvard
Our institutions WERE pillars of light. Hopefully we can get back to that space. Great job
@BillAckman
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Miraculously the bullet stopped 18mm from his heart. IDK the remainder of the circumstances, but I hope that this human can do good, find joy and live a long life given this 2nd chance. 🙏
#radiology
#inspirational
#tgifriday
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