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Wk 5, Case 5 - Review

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Patient History
55-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: mis-alignment artifact

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 trifurcates into a left anterior descending, ramus intermedius, and left circumflex arteries. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that supplies one diagonal vessels before wrapping the apex. There is a small amount of partially calcified plaque with mild (25-49%) stenosis of the proximal LAD. There is a small amount of partially calcified plaque with positive remodeling and spotty calcification with moderate (50-69%) stenosis of the mid LAD. The distal LAD is not evaluable due to motion and misalignment artifact. There is no plaque or stenosis in the first diagonal branch.

Ramus Intermedius (RI):

The RI is a large caliber vessel that courses along the lateral wall. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the RI.

Left circumflex artery (LCX):

The circumflex is a medium caliber, non-dominant vessel that gives rise to one obtuse marginal branch. There is no plaque or stenosis in the proximal LCX. The OM and distal LCX are not evaluable due to motion or misalignment artifact.

Right coronary artery (RCA):

The right coronary artery is a medium caliber, dominant vessel. The vessel has a separate ostium in the sinotubular junction above the left coronary cusp. The vessel has an acute take-off angle (29°) 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 9.6 mm.

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: 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 two-vessel distribution.

2 The right coronary artery has an anomalous coronary origin with high-risk features to include an acute take-off angle, an inter-arterial course, a slit-like orifice (≥50% narrowing) with an intramural course and length of narrowing > 5mm.

3. Moderate (50-69%) stenosis of the mid LAD.

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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