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Wk 9, Case 4 - Review

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Report

Patient History

39-year-old male with a history of anomalous coronary artery involving the RCA s/p CABG due to chest pain with ischemia, presents for recurrence of chest pain. Request for CCTA to assess for arterial graft patency.

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: 90mL Visipaque 320 injected at 6 mL/sec.

QC (signal/noise): Good

Artifacts: None

Complications: None

Heart rate: 51 bpm.

Findings:
CORONARY ANGIOGRAPHY:

The left coronary arises from the left coronary cusp while the right coronary cusp arises at the sinotubular junction above the left coronary cusp. The coronary circulation is right dominant.

Left Main (LM):

The left main is a large caliber vessel that transitions into a left anterior descending artery. There is no evidence of plaque or stenosis in the left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that supplies three diagonal vessels before wrapping the apex. There is a small amount partially calcified plaque with minimal (1-24%) stenosis in the second diagonal branch. There is a superficial long myocardial bridge in the mid LAD.

Left circumflex artery (LCX):

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

Right coronary artery (RCA):

The right coronary artery is a medium caliber, dominant vessel that originates in the sinotubular junction above the left coronary cusp. The vessel has an acute take-off angle (37.3°) 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 intramural course and length of narrowing of 9.96 mm. The vessel gives rise to acute marginal branches before terminating as the posterior descending artery and the posterolateral branches. There is no plaque or stenosis in the RCA or its branches.

Grafts:

There is an atretic RIMA to PLB Graft.

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. There is a small patent foramen ovale.

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. There is a small amount of partially calcified plaque in the ascending aorta.

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 small amount of partially calcified plaque in a two-vessel distribution.

2. Anomalous right coronary artery with a separate ostium in the sinotubular junction above the left coronary cusp with high-risk features to include an acute take-off angle, an inter-arterial course with an intramural oval-like orifice (<50% stenosis) with length of narrowing ≥ 5mm. The RIMA to PLB graft is atretic.

3. Minimal (1-24%) stenosis of the D2, and 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

Coronary arteries

Congenital

Cardiac CT (SCCT Cat B1 Video Case)

Cardiac CT

Cardiac

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