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Wk 1, Case 4 - Review

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Patient History
47 years old male with a history of prior tobacco use, with new onset of intermittent substernal chest pain with increased physical exertion. A coronary CT angiogram was ordered for further risk stratification.
Findings
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: Coronary CT Angiography
Prospective ECG gating Cardiac; data acquisition between 65-80% of the R-R interval Cardiac CT: dual-source CT scanner with a 0.25 s rotation time
IVCM: 90 mL Administered at 6 mL/s
Medication: Sublingual nitroglycerin 0.8 mg, 200mg oral metoprolol
Heart rate: 56 bpm
Rhythm: sinus rhythm
Artifacts: slab artifact
The technical quality of the scan: Good.
CORONARY FINDINGS:
The left and right coronary ostia are in a normal anatomic position.
The coronary anatomy is right dominant.
LEFT MAIN:
The left main coronary artery is a short, large caliber vessel that trifurcates into the LAD, RI, and LCX. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal left-main.
LEFT ANTERIOR DESCENDING (LAD):
The LAD is a large vessel that wraps around the apex and gives rise to one small caliber diagonal branch. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the mid-LAD. There is no plaque or stenosis in the remainder of the LAD or its branches. There is a short superficial myocardial bridge in the mid-LAD.
RAMUS INTERMEDIAUS (RI):
The RI is a small vessel that courses along the lateral wall of the left ventricle. The vessel is patent.
LEFT CIRCUMFLEX (LCX):
The left circumflex is a medium-sized vessel that gives rise to one branching first obtuse marginal branch before terminating as a diminutive vessel in the AV groove. There is no plaque or stenosis in the LCX or the OM1 branch.
RIGHT CORONARY ARTERY (RCA):
The RCA is a dominant vessel and gives rise to a PDA and the PLB branches. There is no plaque or stenosis in the RCA or its branches.
NON-CORONARY CARDIAC FINDINGS:
Chambers: Normal left ventricular cavity size. Normal left atrial size. Normal right ventricular cavity size with normal right atrial size.
Myocardium: Normal wall thickness. Small myocardial crypt involving the basal inferior wall.
Valves: Trileaflet aortic valve with normal leaflet thickness. Normal mitral valve structure and mild leaflet thickening.
Pericardium: No pericardial effusion, calcification, or thickening.
Aorta: No aortic rupture, aneurysm, dissection, or intramural hematoma.
Pulmonary arteries: No enlargement. No central pulmonary embolism.
Pulmonary veins: There is a normal pulmonary venous return to the left atrium.
Impressions
1. Overall, there is a small amount of partially calcified plaque involving the left main and mid LAD.
2. Non-obstructive coronary artery disease with minimal (1-24%) stenosis of the proximal left main and mid LAD.
3. Short superficial myocardial bridge in the mid-LAD. Small myocardial crypt involving the basal inferior wall.
CAD-RADS 1 - Minimal non-obstructive CAD; Consider non-atherosclerotic causes of chest pain. Consider preventive therapy and risk factor modification, particularly for patients with a non-obstructive plaque in multiple segments.
P1- Mild 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

Cardiac CT (SCCT Cat B1 Video Case)

Cardiac CT

Cardiac

Acquired/Developmental

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