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Wk 7, Case 2 - Review

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Patient History
42-year-old male with a history of recent myocardial infarction with invasive coronary angiogram suggestive of possible spontaneous coronary artery dissection vs vasospasm vs acute plaque rupture of a diagonal branch. Request for CCTA for further evaluation of etiology myocardial infarction to assess for evidence of coronary atherosclerosis vs coronary dissection.

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: 70 mL Visipaque 320 injected at 6mL/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 bifurcates to form a left anterior descending artery, and a left circumflex artery. There is no plaque or stenosis within the vessel.

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 eccentric tubular fibrofatty positive remodeling (HU -75 to 90) along the proximal segment of the second diagonal branch with mild (25-49%) stenosis with findings suggestive of a perivascular epicardial fat stranding. There is a short superficial myocardial bridge within the distal LAD.

Left circumflex artery (LCX):

The circumflex is a medium caliber, non-dominant vessel that gives rise to two obtuse marginal branches before terminating within the AV groove. There is no plaque or stenosis within the vessel. There is long superficial myocardial bridge in the proximal LCX.

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 no plaque or stenosis within the vessel.

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. There is a medium amount of eccentric tubular fibrofatty positive remodeling (HU -75 to 90) along the proximal segment of the second diagonal branch with mild (25-49%) stenosis with findings suggestive of a perivascular epicardial fat stranding from healed spontaneous coronary artery dissection.

2. No evidence of atherosclerotic plaque or stenosis in the coronary arteries.

3. There is a short superficial myocardial bridge within the distal LAD. There is long superficial myocardial bridge in the proximal LCX.

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

Non-infectious Inflammatory

Coronary arteries

Cardiac CT (SCCT Cat B1 Video Case)

Cardiac CT

Cardiac

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