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Wk 4, Case 3 - Review

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Patient History
58-year-old male with a history of hypertension, mixed hyperlipidemia, and chest pain with exertion. 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 60-80%

Medications: 200 mg Lopressor, 800 mcg sublingual nitroglycerin

Contrast: 70 mL Visipaque 320 injected at 5 mL/sec.

QC (signal/noise): Fair

Artifacts: None

Complications: None

Heart rate: 51 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 vessel that transitions to a left anterior descending artery. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the 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 medium amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal LAD, and mild (25-49%) stenosis of the mid LAD. There is no plaque or stenosis in the diagonal branches and the distal LAD.

Left circumflex artery (LCX):

The circumflex is a medium caliber, non-dominant vessel with an anomalous origin that gives rise to one obtuse marginal branch before terminating within the AV groove. The vessel has a separate ostium in the right coronary cusp with a non-acute take-off angle (69°) and level above the aortic valve commissure as it follows a retro-aortic course. The proximal vessel has a normal diameter and no evidence of vessel narrowing or an intramural course. There is a medium amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal LCX, and OM.

Right coronary artery (RCA):

The right coronary artery is a medium 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 plaque with mild (25-49%) stenosis in the proximal RCA, minimal (1-24%) stenosis of the mid RCA, distal RCA and PLB.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is normal in size with no left atrial appendage filling defect. The 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.

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 partially calcified plaque in a multivessel distribution.
2. Non obstructive coronary artery disease with mild (25-49%) stenosis of the proximal RCA, and mid LAD, and minimal (1-24%) stenosis of the distal left main.
3. The circumflex has an anomalous coronary anatomy with no evidence of high-risk findings.

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

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