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Wk 6, Case 2 - Review

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Patient History
58 -year-old female with a history of diabetes mellitus type 2, mixed hyperlipidemia and family history of early coronary artery disease experiencing increased shortness of breath and intermittent chest pain with exertion. Request for CCTA for further evaluation.

Report
PROCEDURE:

1. Cardiac CT Angiography (Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed).) (CPT code: 75574)

TECHNIQUE:

Gating: Prospective; data acquisition between 70-75%

Medications: 200 mg Lopressor, 800 mcg sublingual nitroglycerin

Contrast: 85 mL Isovue 370 injected at 7mL/sec.

QC (signal/noise): Good

Artifacts: None

Complications: None

Heart rate: 55 bpm.

Findings:
CORONARY ANGIOGRAPHY:

The left and right coronaries arise from their respective normal anatomic ostia. The coronary circulation is right dominant.

Left Main (LM):

The left main is a large caliber short vessel that bifurcates to form a left anterior descending, and a left circumflex artery. There is no plaque or stenosis in the left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that gives rise to two diagonal branches before it wraps the apex. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal LAD, and mid LAD. There is no plaque or stenosis in the distal LAD. The diagonal branches are patent.

Left circumflex artery (LCX):

The circumflex is a large caliber, non-dominant vessel that gives rise to two obtuse marginal branches before terminating as a diminutive vessel within the AV groove. There is small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal LCX and OM branches.

Right coronary artery (RCA):

The right coronary artery is a large caliber, dominant vessel, arising from the right cusp, that gives rise to acute marginal branches before terminating as the posterior descending artery and postero-lateral branches. There is a medium amount of partially- calcified and non-calcified plaque with positive remodeling plaque with minimal (1-24%) stenosis of the proximal RCA, and moderate (50-69%) stenosis of the mid RCA and minimal (1-24%) stenosis of the distal RCA. There is no plaque or stenosis in the PDA and PLB.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is dilated with no left atrial appendage filling defect. The left and right ventricular cavity size are within normal limits. There are no abnormal filling defects. There is an unroofed coronary sinus with focal absence of the roof of the coronary sinus. The defect measures 1.9 x 1.9 x 1.6 cm. The coronary sinus empties via a small vein into the right atrium appendage.

Myocardium: Normal wall thickness. No outpouching or masses.

Valves: Trileaflet aortic valve with normal leaflet thickness. Normal mitral valve leaflet thickness.

Pericardium: Normal thickness with no significant effusion or calcium present.

Aorta: Small amount of partially calcified plaque in the visualized portions of the aortic arch. No aortic rupture, aneurysm, dissection, or intramural hematoma.

Pulmonary arteries: Normal in size without proximal filling defect. Not fully opacified.

Pulmonary veins: Normal pulmonary venous drainage. There are four pulmonary veins, two on the right and two on the left.

Impressions
1. Overall, there is a medium amount of partially calcified plaque in a multivessel distribution.

2. Obstructive coronary artery disease with a moderate (50-69%) stenosis of the mid RCA.

3. There is an unroofed coronary sinus with focal absence of the roof of the coronary sinus into an aneurysm of the left atrial wall. The coronary sinus also connects via a small vein into the right atrium.

RECOMMENDATIONS:

CAD-RADS 3 (Moderate stenosis 50-69%). Aggressive risk factor modification and preventive medical therapy. Consider anti-anginal therapy. Consider functional assessment. or consider ICA if frequent symptoms persist despite medical therapy.

Modifier: None

Plaque: P2- Moderate amount of plaque

Case Discussion

Faculty

Giovanni E. Lorenz, DO

Cardiothoracic Radiologist

San Antonio Military Health System (SAMHS)

Emilio Fentanes, MD

Director of Cardiac Imaging, Department of Cardiology

Brooke Army Medical Center

Tags

Vascular

Coronary arteries

Congenital

Cardiac Chambers

Cardiac CT (SCCT Cat B1 Video Case)

Cardiac CT

Cardiac

Acquired/Developmental

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