Coronary artery anomalies diagnosed by magnetic resonance angiography

Coronary artery anomalies are uncommon entities that may be associated with sudden death. Because of its 2-D projection imaging nature, conventional X-ray coronary angiography may not accurately delineate the origins and course of aberrant coronary arteries with respect to the great vessels. Non-invasive, cross-sectional imaging techniques such as coronary CT angiography and magnetic resonance angiography are increasingly used in clinical practice to diagnose coronary artery anomalies. Although this study reviews coronary artery anatomy and selected anomalies as seen with true fast imaging with steady-state precession magnetic resonance angiography, the information provided is equally applicable to electrocardiogram-gated coronary CT angiography.     

Evaluation with 64-slice CT of the prevalence of coronary artery variants and congenital anomalies: a retrospective study of 3,236 patients

Purpose

This study retrospectively evaluated the prevalence of anatomical coronary artery variants and congenital anomalies in 3,236 patients imaged with 64-slice computed tomography (CT).

Materials and methods

Over a period of 4 years, 3,236 patients underwent CT coronary angiography performed with the standard protocol. We assessed coronary artery dominance, presence of the intermediate branch, presence and number of diagonal and marginal branches and coronary anomalies subdivided into anomalies of origin and course, intrinsic anomalies and termination anomalies.

Results

Coronary dominance was right-sided in 88.1% of patients; the intermediate branch was present in 21.3%, the number of diagonal and marginal branches was one to two in >90%, and the number of coronary anomalies was 224 (89 of origin and course, 129 intrinsic anomalies and six termination anomalies).

Conclusions

Sixty-four-slice CT coronary angiography provides accurate three-dimensional evaluation of the coronary artery tree with correct visualisation of any coronary anomalies, a relatively common finding that had a prevalence of 5.7% in our study population.     

Anomalies of coronary artery origin: Evaluation on multidetector CT angiography

Anomalies of origin of coronary arteries are an uncommon occurrence and found in approximately 1–2% of the general population. While a large proportion of these anomalies are clinically silent, a few might be hemodynamically significant and may even result in sudden cardiac death. Comprehensive knowledge of the normal as well as variant anatomies of the coronary artery origin and familiarity with imaging appearances and clinical significance of these anomalies is imperative for precise diagnosis and subsequent planning of treatment, whenever required. Multidetector computed tomography angiography, on account of its non-invasiveness, faster scan times and multiplanar reconstruction capabilities, is increasingly being utilized for characterization of coronary artery origin anomalies and their three-dimensional spatial relations. It shows a superior rate of detection of these anomalies compared to conventional angiography, providing more accurate delineation of the ostium as well as course. With the advent of newer generation CT scanners and use of advanced dose reduction techniques, images can be obtained rapidly having excellent spatial resolution and with minimal radiation dose. In this review article, we present the multidetector CT angiography imaging findings of the spectrum of anomalous coronary artery origin, using a third-generation dual-source CT scanner.     

An anomalous origin of left coronary artery and sudden death in a soccer player: a case report

Coronary artery anomalies, after hypertrophic cardiomyopathy, are the second most common cause of exercise-related sudden cardiac deaths. These anomalies have been associated with myocardial ischaemia, arrhythmia and sudden death during exercise. Anomalous origin of the left coronary artery from the right sinus of Valsalva with anterior or posterior courses is not always thought to be a benign anomaly. A 22-year-old man died suddenly on a football field. At autopsy, there was an abnormal origin of the left coronary artery from the right sinus of Valsalva. The abnormal course of the artery between the aorta and pulmonary trunk had limited victim's functional capacity. The history, cause of death and patho-physiology are discussed, and some preventive strategies suggested.     

Detection of malignant right coronary artery anomaly by multi-slice CT coronary angiography

Coronary artery anomalies occur in 0.3-0.8% of the population and infer a high risk for sudden cardiac death in young adults. Diagnosis is usually established during coronary angiography, which is hampered by poor spatial visualization. Magnetic resonance imaging is an alternative, but it is not feasible in the presence of metal objects or claustrophobia. In this report, a 15-year-old boy experienced ventricular fibrillation and was successfully resuscitated. Cardiac catheterization was inconclusive, and pacemaker implantation prohibited the use of MR imaging. Multi-slice CT coronary angiography revealed a malignant anomalous right coronary artery.     

成人先天性冠状动脉畸形的分类及其发生率

目的 探讨成人冠状动脉(冠脉)造影人群先天性冠脉畸形(CCA)的类型及其发生率.方法 2000年10月～2006年10月共1 520例成人患者行冠脉造影检查,对检出有CCA患者的影像资料进行回顾性分析,并根据CCA解剖学特征进行分类.结果 1 520例成人患者共检出各类CCA 58例,发生率3.82%.冠脉起源和分布异常26例,发生率1.71%;其中前降支和回旋支分别开口于左冠窦14例,左主干或回旋支起源于右冠窦各1例,右冠脉分别起源于升主动脉4例、左冠窦3例和无冠窦1例,单支左冠脉2例.冠脉终止异常11例,均为冠脉瘘,发生率0.72%.冠脉结构异常21例,发生率1.38%,其中心肌桥18例,回旋支发育不良2例,窦房结动脉起源于左室后支1例.本组病例未发现有冠脉间异常交通者.结论 冠脉造影是诊断成人CCA的主要方法之一,按解剖学特征进行分类有助于阐明CCA类型及其发生率.     

Exercise-related sudden death due to an unusual coronary artery anomaly

Coronary artery anomalies are, after hypertrophic cardiomyopathy, the second most common cause of exercise-related sudden cardiac death in young American athletes. These anomalies have been associated with myocardial ischemia, arrhythmia, and sudden death during exercise. A 14-yr-old male with no previous abnormal medical history collapsed during soccer practice and was successfully resuscitated without defibrillation. An extensive cardiac workup did not reveal any abnormalities. Two weeks later, he experienced a cardiac arrest while running and could not be resuscitated. Autopsy demonstrated an acute angle take-off of the left main coronary artery and a transverse slit-like opening with a fibrous cushion, which created a kink near its origin. This case report illustrates the difficulty in diagnosing coronary artery anomalies in general, and acute angle take-off and ostial ridges in particular.     

Detection,visualization and evaluation of anomalous coronary anatomy on 16-slice multidetector-row CT

Early identification and evaluation of relatively frequent anomalous coronary anatomy is quite relevant because of the occurrence of sudden cardiac death or related symptoms of myocardial ischemia. Selective coronary angiography (CAG) is invasive, expensive and cannot always provide the required information adequately. Recently, non-invasive imaging techniques such as magnetic resonance imaging and multidetector-row computed tomography (MDCT) have been shown to provide a good anatomical view of the coronary artery tree. This study aims to demonstrate the value of 16-MDCT for evaluation of anomalous coronary anatomy. In 13 patients scanned using 16-MDCT, six different coronary anomalies were diagnosed [two absent left main, one single vessel left coronary artery (LCA), three LCA originating from the right (two with interarterial course), six right coronary artery originating from the left, one double left anterior descending (LAD)]. Mean diagnostic quality, recorded by two observers using a 5-point scale (1= non-diagnostic to 5= excellent diagnostic quality), resulted in a mean score of 3.73 (SD 1.19) without any non-diagnostic result. MDCT offers an accurate diagnostic modality to visualize the origin and course of anomalous coronary arteries by a three-dimensional display of anatomy. Shortcomings in CAG can be overcome by the use of contrast-enhanced MDCT.     

Coronary variants and anomalies: Methodology of visualisation with 64-slice CT and prevalence in 202 consecutive patients

PURPOSE: This paper aims to provide the tools for a complete anatomical evaluation of the coronary tree using 64-slice computed tomography (CT) and evaluate the prevalence of anatomical variants and anomalies in a population of 202 consecutive patients. MATERIALS AND METHODS: Two hundred and two patients with suspected coronary artery disease underwent 64-slice CT with a standard protocol. Two observers working in consensus evaluated and collected the data regarding anatomical variants and anomalies of the coronary vessels. RESULTS: In the 202 consecutive patients, the prevalence of anatomical variants was: left dominant circulation (7%), absent left main (5%), presence of intermediate branch (17%), aortic origin of conus branch (13%) and circumflex origin of sinus node branch (15%). Coronary anomalies (origin and course, intrinsic and termination) showed an overall prevalence of 25%. CONCLUSIONS: CT is the ideal method for the three-dimensional evaluation of the coronary tree. Anatomical variants and anomalies of the coronary arteries are quite common and should be known and recognised promptly by the operators.     

Coronary artery anomalies: Role of contrast enhanced MDCT coronary angiography

Objective

The purpose of this study is to evaluate the role of MDCT in the depiction of coronary artery anomalies.

Patients and methods

Sixteen patients were included in this study. Retrospectively gated coronary CT angiography was performed in 11 patients and prospectively gated CT coronary angiography was performed in 5 patients. Post-processing techniques as maximum-intensity projection, curved multiplanar reconstruction, and volume rendering were applied to assess the origin and course of the coronary vessels.

Results

Origin and course anomalies of the central coronary artery segments were seen in 11 patients (67%), anomalies of only coronary artery origin in 2 patients (13%), origin and course anomalies of the peripheral coronary segments in 2 patients (13%) and coronary arterio-venous fistula in one patient (7%). The origin and course anomalies of the central coronary artery segment were more common in the left coronary artery involving 8 patients (73%). Malignant inter-arterial course between aortic root and pulmonary artery or the right ventricle outflow tract was seen in 3 anomalous arteries.

Conclusion

MDCT coronary angiography can precisely depict the origin and course coronary artery anomalies and is recommended in young patients and before cardiac intervention or surgery to prevent possible complications.     

Congenital anomalies of coronary arteries: Diagnosis with 64 slice multidetector CT

Objective

Congenital coronary artery anomalies are generally incidental, uncommon and asymptomatic. Some can cause severe potentially life threatening symptoms. The common mode of studying the coronary arteries is Conventional Coronary Angiogram. ECG-gated-multidetector CT is a non invasive modality. The objective of our study was to identify rare congenital coronary artery anomalies and discuss their clinical significance.

Material and methods

A total number of 900 MDCT coronary angiograms were carried out at our institution between the period of April 2006 and October 2010. Patients with coronary artery anomaly constituted the subject of study.

Results

The incidence of anomalous anatomical origin and course of the coronary arteries in our study was 1.55%. Hemodynamical significance was seen in five patients. 3 cases of single coronary artery originating from right coronary sinus were seen. 1 case of anomalous left coronary artery arising from main pulmonary artery was seen. 4 cases of anomalous RCA arising from left aortic cusp, 6 cases of absent LMCA with separate origin of LAD and LCX were seen.

Conclusion

Multidetector row CT is a noninvasive modality in cardiac imaging. It provides superior resolution of coronary tree and its variant. No projectional vascular overlap is seen. Various postprocessing techniques outclass catheter angiography imaging. Definition of ostia and proximal course of the coronary arteries by Multidetector CT is better than catheter angiography.     

An S-shaped sinoatrial nodal artery coronary artery fistula demonstrated by multidetector CT

The presented case and discussion illustrate the use of CT coronary angiography to depict coronary artery fistulae. A 41-year-old man presented with an acute myocardial infarction. Invasive angiography revealed an incidental coronary artery fistula but was unable to depict its course. CT coronary angiography was undertaken to define the course and termination of the fistula. This confirmed a fistulous connection between the left circumflex artery and the superior vena cava that followed the typical course of an S-shaped sinoatrial nodal artery. Even in such an unusual anomaly this case highlights the ability of CT coronary angiography to accurately depict the coronary artery anatomy.     

Anomalous coronary arteries in adults: depiction at multi-detector row CT angiography

PURPOSE: To retrospectively determine the imaging features of anomalous coronary arteries depicted at multi-detector row computed tomographic (CT) angiography in 18 patients seen at four institutions. MATERIALS AND METHODS: Eighteen patients underwent imaging with a four- or 16-section multi-detector row CT unit by using retrospective electrocardiographic (ECG) gating after infusion of 120-150 mL of intravenous contrast material. Section thicknesses of 0.8-3.0 mm were achieved during breath holding, and images were reconstructed with a 50% overlap. Volumetric reconstructions were obtained for each patient. Each study was assessed retrospectively for the origin and course of the anomalous coronary artery by two thoracic radiologists; decisions were made in consensus. Institutional review board exemption and informed consent waiver was granted at each institution. The study was compliant with the Health Insurance Portability and Accountability Act. RESULTS: Seventeen patients were referred because of equivocal findings at cardiac catheterization or echocardiography; in one, the anomalous coronary artery was incidental. A total of 20 anomalous vessels were found. Twelve patients with 14 variant vessels had an anomalous origin of a left coronary artery (right cusp, 13; noncoronary cusp, one). In four patients, an anomalous right coronary artery originated from the left side; one patient had a single coronary artery arising from the right cusp. In one patient, a left coronary artery-to-vein fistula was observed. In 10 patients, the anomalous vessel passed between the aorta and the main pulmonary artery or right ventricular outflow track. In each case, the origin of the anomalous coronary artery and its course in relationship to the great vessels were unequivocally demonstrated. Volumetric images were useful for showing the three-dimensional orientation of the anomalous coronary artery with respect to the great vessels and cardiac chambers. CONCLUSION: Multi-detector row CT angiography provided accurate depiction of vessel origin and course in this review of 20 anomalous coronary arteries. The results of this study suggest that CT is a viable noninvasive modality for delineating coronary arterial anomalies, particularly if findings at coronary angiography are equivocal.     

冠状动脉解剖异常及临床意义(二)——冠状动脉走行、终止、结构异常及发育不良

原发性冠状动脉解剖异常较为少见,但有部分冠状动脉解剖异常所导致的后果较为严重,比如猝死、晕厥、其他先天性心脏病、心绞痛综合征等.由于无创检查手段的广泛应用,特别是多层螺旋CT的成功应用,冠状动脉异常的报道日益增多.本文就近年来关于冠状动脉数日及起源异常报道作简介,以便临床更加深入地认识本病及在临床工作中调整治疗方案.     

64排CTA对冠状动脉埋藏式走行的诊断价值

目的:探讨64排128层螺旋CT对先天性冠状动脉起源异常及埋藏式走行的诊断价值。方法:回顾性分析25例冠脉起源异常患者的64排128层CT冠脉血管成像及冠脉血管造影(CAG)资料。CT检查资料采用容积再现(VR)、曲面重组(MPR)及最大密度投影(MIP)等方法进行图像后处理,观察冠状动脉的起源及走行,并与CAG的结果进行对照。结果:MSCTA显示25例患者均为冠状动脉起源于相反主动脉窦开口,16例(16/25)为右冠状动脉起自左冠状窦,其中6例为右冠状动脉走行于主动脉与肺动脉-右室流出道之间,呈埋藏式走行;9例为左冠状动脉起源于右冠状窦,其中2例为左冠状动脉走行于主动脉与肺动脉-右室流出道之间,呈埋藏式走行。8例埋藏式走行的冠状动脉中7例冠脉与主动脉间夹角<45°,7例管腔狭窄>50%。25例患者中CAG仅正确诊断冠脉起源异常22例,漏诊2例、误诊1例,8例冠脉埋藏式走行均未能提示。结论:64排128层CTA对冠脉起源异常及冠脉埋藏式走行的诊断准确性高,优于冠状动脉造影检查。     

Coronary anomalies: Cardiac CT evaluation of the symptomatic adult athlete

Cardiac CT has become widely available as a diagnostic test. It is noninvasive, low risk (for contrast allergies), quick, and highly sensitive for identifying the coronary origins and course. Two coronary anomalies, the left main artery from the right sinus of Valsalva, and the right coronary artery originating from the left sinus, have been associated both with myocardial ischemia and sudden cardiac death when they course between the aorta and pulmonary arteries. These anomalies can go undetected into adulthood. The yield of noninvasive exercise testing is low. In the past, the ability to demonstrate these anomalies depended on a high index of suspicion and an aggressive invasive work-up with cardiac catheterization. Now cardiac CT can demonstrate these anomalies with ease and facilitate appropriate treatment.     

Coronary CT angiography in asymptomatic middle‐aged athletes with ST segment anomalies during maximal exercise test

The clinical significance of ST segment anomalies occurring during exercise test in asymptomatic subjects is still debated. We designed a cross‐sectional study to evaluate if the presence of these exercise test abnormalities were related with coronary CT angiography findings. Nine hundred forty athletes (range 30 to 60 years old), performed a maximal exercise test for sport eligibility. Forty‐six subjects (4.9%) showing ST abnormalities during exercise and/or the recovery phase were referred to a 64‐slice coronary computed tomography (CT) angiography. Among 44 subjects who underwent coronary CT angiography, 23 had an equivocal while 21 had a positive exercise test. Coronary CT angiography found, six and eight subjects with significant and not significant coronary artery disease, respectively. Further, seven patients demonstrated origin and course coronary anomalies. The positive predictive value for significant coronary artery disease of the exercise test was 13.6%. Our data suggest the referral to coronary CT angiography even of patients with equivocal repolarization anomalies during exercise and its recovery phase. Although the positive predictive value of a maximal exercise test in asymptomatic athletes appears lower than what observed in patients at high risk for coronary artery disease, about half of athletes with equivocal or positive exercise test demonstrated some coronary abnormalities.     

Coronary Artery Imaging in Children

Coronary artery problems in children usually have a significant impact on both short-term and long-term outcomes. Early and accurate diagnosis, therefore, is crucial but technically challenging due to the small size of the coronary artery, high heart rates, and limited cooperation of children. Coronary artery visibility on CT and MRI in children is considerably improved with recent technical advancements. Consequently, CT and MRI are increasingly used for evaluating various congenital and acquired coronary artery abnormalities in children, such as coronary artery anomalies, aberrant coronary artery anatomy specific to congenital heart disease, Kawasaki disease, Williams syndrome, and cardiac allograft vasculopathy.     

Visualization of anomalous coronary arteries on dual-source computed tomography

The purpose of this study is to assess the capability of dual-source computed tomography (DSCT) in evaluating coronary artery anomalies. Early detection and evaluation of coronary artery anomalies is essential because of their potential association with myocardial ischemia and sudden death. In 16 patients (12 men, mean age 50 ± 14 years), anomalous coronary arteries were detected on contrast-enhanced DSCT in a patient cohort of 230 individuals (incidence of 7%). Six different types of anomalies were diagnosed (three fistula, four anomalies of the circumflex artery, four anomalous right coronary arteries, three anomalies of the left coronary artery, one absent left main coronary artery, and one left coronary artery arising from the pulmonary trunk). Of the 16 patients, 10 also underwent conventional coronary angiography (CAG). Retrospective evaluation of the CAGs by an experienced interventional cardiologist resulted in a precise diagnosis in 50% of patients. With DSCT, sufficient image quality and exact visualization of the aberrant anatomy were achieved in all patients. Therefore, DSCT seems to be an accurate diagnostic tool for examining the precise origin, course, and shape of aberrant coronary arteries.     

MR imaging in the definition of coronary artery anomalies

Coronary angiography remains the standard imaging technique to study coronary artery anatomy. Coronary artery aneurysms and fistulas are often incompletely visualized with routine angiography. Magnetic resonance (MR) imaging of such coronary anomalies is presented. The MR images improve the preoperative assessment of patients with coronary artery aneurysms and fistulas.