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Wk 5, Case 4 - Review

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Patient History
64-year-old female with a history of aortic valve regurgitation and aortic root aneurysm s/p composite aortic root replacement and prior coronary artery anastomosis stenosis of the left main s/p PCI is now experiencing symptoms of chest pain and shortness of breath with activity. Request for CCTA for further evaluation of chest pain.

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: 200 mg Lopressor, 800 mcg sublingual nitroglycerin

Contrast: 85 mL Isovue 370 injected at 7mL/sec.

QC (signal/noise): Good

Artifacts: None

Complications: None

Heart rate: 55 bpm.

Findings:
CORONARY ANGIOGRAPHY:

The left and right coronaries arise from the aortic tube graft at their respective expected normal anatomic ostia. The coronary circulation is right dominant.

Left Main (LM):

The left main is a large caliber short vessel that bifurcates to form a left anterior descending and a left circumflex artery. There is a stent in the left main that is patent with mild (25-49%) stenosis of the ostial left-main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that gives rise to three small diagonal branches before it terminates as a diminutive vessel near the apex. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal LAD, and mid LAD. There is no plaque or stenosis in the distal LAD. The diagonal branches are patent.

Left circumflex artery (LCX):

The circumflex is a small caliber, non-dominant vessel that gives rise to two obtuse marginal branches before terminating as a diminutive vessel within the AV groove. There is small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal LCX. There is no plaque or stenosis in the OM branches.

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 medium amount of partially- calcified plaque with a severe (70-99%) stenosis of the proximal RCA at the anastomosis of the reimplanted RCA and minimal (1-24%) stenosis of the mid-RCA. There is no plaque or stenosis in the distal RCA, PDA, and PLB.

NON-CORONARY CARDIAC FINDINGS:

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

Myocardium: Normal wall thickness. No outpouching or masses.

Valves: Well-seated mechanical valve (21 mm SJM). Normal mitral valve leaflet thickness.

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

Aorta: Well-seated aortic root graft. Medium amount of partially calcified plaque in the visualized portions of the descending aorta. No aortic rupture, aneurysm, dissection, or intramural hematoma.

Pulmonary arteries: Normal in size 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.

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

2. Obstructive coronary artery disease with a 70-99% stenosis of the proximal RCA at the anastomosis of the re-implanted RCA. Mild (25-49%) stenosis of the ostial left-main.

3. Patent left main stent.

RECOMMENDATIONS:

CAD-RADS 4A (Severe stenosis 70-99%). Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy is recommended. Consider ICA and revascularization.

Modifier: Stent

Plaque: P1- Mild 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

Iatrogenic

Coronary arteries

Cardiac CT (SCCT Cat B1 Video Case)

Cardiac CT

Cardiac

Acquired/Developmental

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