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Wk 5, Case 3 - Review

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Patient History
58-year-old male with a history of shortness of breath with exertion. Patient underwent a resting regadenoson myocardial perfusion SPECT (Single Photon Emission Computed Tomography) test that revealed inconclusive findings of reversible ischemia on the basal to mid anterolateral segments vs possible wall attenuation artifact. Request for CCTA for further risk stratification.

Report
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: 100 mg Lopressor, 800 mcg sublingual nitroglycerin

Contrast: 125 mL Isovue 370 injected at 6mL/sec.

QC (signal/noise): Good

Artifacts: Cardiac motion artifact

Complications: None

Heart rate: 68 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 bifurcates to form a left anterior descending, and a left circumflex artery. There is a small amount of partially calcified plaque with positive remodeling and spotty calcification and minimal (1-24%) stenosis of the mid left main.

Left anterior descending artery (LAD):

The LAD is a medium caliber vessel that supplies a large first diagonal vessel and small second diagonal vessel before wrapping the apex. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal LAD. There is a small amount of non-calcified plaque with positive remodeling and mild (25-49%) stenosis in the mid LAD. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the first diagonal branch.

Left circumflex artery (LCX):

The circumflex is a large caliber, non-dominant vessel that gives rise to three obtuse marginal branches before terminating as a small vessel within the AV groove. There is a small amount of partially calcified plaque with moderate (50-69%) stenosis in the proximal LCX. The remainder of the vessel and its branches have no evidence of plaque or stenosis.

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 small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal and mid RCA. The remainder of the vessel and its branches have no evidence of plaque or stenosis.

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. The right ventricle is dilated.

Myocardium: Normal thickness. No outpouching or masses.

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

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

Aorta: There is no aortic rupture, aneurysm, dissection, intramural hematoma with a small amount of partially calcified plaque in the visualized thoracic aorta.

Pulmonary arteries: Dilated in size at the main pulmonary artery 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.

EXTRACARDIAC FINDINGS:

Mediastinum: unremarkable.

Lungs: The visualized lung, pleural and airways are unremarkable.

Upper Abdomen: Visualized structures are within normal limits.

Bones/Soft tissues: There are degenerative changes of the spine.

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

2. Obstructive coronary artery disease with a moderate (50-69%) stenosis of the proximal LCX. Mild (25-49%) stenosis of the mid LAD, and minimal stenosis of the left main, proximal LAD, first diagonal, proximal and mid RCA.

3. The right ventricle and pulmonary artery are dilated. Consider further evaluation with TTE to assess for pulmonary hypertension.

4. Unremarkable extracardiac findings.

RECOMMENDATIONS:

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

Plaque: P3- Severe 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

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