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Wk 5, Case 2 - Review

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Patient History

52-year-old male with a history of hypertension, aortic valve stenosis hyperlipidemia undergoing perioperative evaluation for aortic valve surgery. Request for CCTA for further risk stratification and evaluation of coronary anatomy as invasive coronary angiogram revealed anomalous coronary anatomy.

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 6 mL/sec.

QC (signal/noise): Good

Artifacts: None

Complications: None

Heart rate: 51 bpm.

Findings:
CORONARY ANGIOGRAPHY:

The left and right coronaries arise from the left coronary cusp.

The coronary circulation is right dominant.

Left Main (LM):

The left main is a large caliber vessel that transitions into a left anterior descending artery. There is no evidence of plaque or stenosis in 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 small amount of partially calcified plaque with minimal (1-24%) stenosis in the proximal LAD, and mild (25-49%) stenosis in the second diagonal branch. There is no plaque or stenosis in the mid to distal LAD.

Left circumflex artery (LCX):

The circumflex is a medium caliber, non-dominant vessel that originates as a branch of the RCA and follows a retro aortic course and gives rise to two obtuse marginal branches before terminating as a diminutive vessel in the AV groove. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis in the proximal LCX and OM2.

Right coronary artery (RCA):

The right coronary artery is a medium caliber, dominant vessel that originates in the left coronary cusp. The vessel has an acute take-off angle (32.8°) and take off level above the aortic valve commissure as it follows an inter-arterial course. The proximal vessel has a slit like orifice (≥50% narrowing) with an intramural course and length of narrowing of 6.31 mm. The vessel gives rise to acute marginal branches before terminating as the posterior descending artery and the posterolateral branches. There is no plaque or stenosis in the RCA or its branches.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is normal in size. The left ventricular cavity size is within normal limits and the right ventricle size appears dilated.

Myocardium: Normal thickness. No outpouching or masses.

Valves: likely bicuspid aortic valve with moderately thickened, calcified leaflets. Normal mitral valve leaflet thickening.

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

Aorta: The ascending aorta is dilated measuring 4.0 x 3.9 cm. 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 small amount of partially calcified plaque in a two-vessel distribution.

2. Anomalous right coronary artery with a separate ostium in the left coronary cusp with high-risk features to include an acute take-off angle, an inter-arterial course with an intramural slit like orifice (≥50% stenosis) with length of narrowing ≥ 5mm. The LCX originates as a branch of the RCA and follows a retro aortic course.

3. Mild (25-49%) stenosis of the D2, and minimal (1-24%) stenosis of the proximal LAD, proximal LCX, and OM2.

4. Dilated ascending aorta, recommend serial monitoring.

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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