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Wk 8, Case 1 - Review

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Patient History
49-year-old male with a history of hypertension, mixed hyperlipidemia, and coronary artery disease with 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 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 right coronary cusp.

The coronary circulation is right dominant.

Left Main (LM):

The left main is a large caliber vessel that bifurcates into a left anterior descending, and left circumflex arteries. The vessel has a separate ostium in the right coronary cusp. The vessel has an acute take-off angle (43.2°) and take off level above the aortic valve commissure as it follows an inter-arterial course. The proximal vessel has a oval like orifice (<50% narrowing) with an extramural course and length of narrowing of 13.7 mm.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that supplies two diagonal vessels before wrapping the apex. There is a small amount of non-calcified plaque with positive remodeling with mild (25-49%) stenosis of the proximal LAD. There is no plaque or stenosis in the mid to distal LAD and diagonal branches.

Left circumflex artery (LCX):

The circumflex is a medium caliber, non-dominant vessel that gives rise to two obtuse marginal branches. There is a small amount of non-calcified plaque with positive remodeling with mild (25-49%) stenosis n the proximal LCX and OM2.

Right coronary artery (RCA):

The right coronary artery is a medium caliber, dominant vessel that gives rise to acute marginal branches before terminating as the posterior descending artery and the posterolateral branches. There is a small amount of non-calcified plaque with minimal (1-24%) stenosis of the proximal RCA, mild (25-49%) stenosis in the PDA. The stent in the mid RCA is patent.

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 multi-vessel distribution.
2. Anomalous left main with a separate ostium in the right coronary cusp with high-risk features to include an acute take-off angle, an inter-arterial course with a length of narrowing ≥ 5mm.
3. Mild (25-49%) stenosis of the proximal LAD, proximal LCX, OM2, and PDA. Patent mid RCA stent.

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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