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Wk 6, Case 3 - Review

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Patient History

53-year-old male with a history of tobacco use and recurrent chest pain. The graded exercise treadmill was equivocal, with limiting chest pain but no ischemic ECG changes. Request for CCTA for further risk stratification.

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: 200mg Lopressor, 800 mg nitroglycerin

Contrast: 85 mL Visipaque 320 injected at 6 mL/s.

QC (signal/noise): Good

Artifacts: None that are significant with stair-step artifacts.

Complications: None

Heart rate: 60 bpm sinus rhythm.

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 vessel that bifurcates to form a left anterior descending artery, and a left circumflex artery. There is a small amount of partially calcified plaque with spotty calcification with minimal (1-24%) stenosis in the proximal left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that supplies three diagonal vessels before wrapping the apex. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis in the mid-LAD and first diagonal branch. There is a short superficial myocardial bridge in the mid-LAD.

Left circumflex artery (LCX):

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

Right coronary artery (RCA):

The right coronary artery is a medium-caliber, dominant vessel arising from the right cusp, which gives rise to acute marginal branches before terminating as the posterior descending artery and right posterolateral artery. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis in the proximal RCA and mid-RCA.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is normal with no left atrial appendage filling defect. The left ventricular cavity size is within normal limits. There are no abnormal filling defects.

Myocardium: Normal thickness. No outpouching or masses.

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

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

Aorta: There is no aortic rupture, aneurysm, dissection, intramural hematoma.

There is a small amount of non-calcified plaque in the descending aorta.

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

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

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

2. Non-obstructive coronary artery disease with minimal (1-24%) stenosis of the proximal left main mid-LAD, proximal LCX, OM3, proximal RCA, and mid-RCA.

3. There is a short superficial myocardial bridge in the mid-LAD.

RECOMMENDATIONS:

CAD-RADS: 1 (Minimal non-obstructive CAD up to 24% stenosis). Consider non-atherosclerotic causes of chest pain, and consider aggressive preventive therapy and risk factor modification.

Plaque: P2 moderate amount of plaque.

Final diagnosis: I25.10 CAD, native

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 CT (SCCT Cat B1 Video Case)

Cardiac CT

Cardiac

Acquired/Developmental

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