Anomalous origin of coronary arteries in adults

In lack of structural congenital heart disease, anomalous origin of a coronary artery is rare with an angiographic prevalence of approximately 1%. The prognosis depending on anatomical features, initial course of coronary ectopic vessel is important to be considered. Although some anomalies are associated with sudden death, the majority are simply incidental anatomic findings. In patients with high-risk coronary anomalies, the treatment is not clearly codified. Large-scale prospective multicenter studies are needed to define recommendations in the future.     

Non-invasive coronary angiography by multidetector spiral computed tomography and magnetic resonance imaging

Coronary angiography is the reference standard to confirm the presence and severity of coronary stenoses. Given the invasiveness of this procedure, a noninvasive mean allowing to visualize coronary anatomy would be of obvious clinical interest. Multidetector spiral computed tomography and magnetic resonance imaging are new and promising techniques for noninvasive detection of significant coronary stenoses. The purpose of this article is to review the present knowledge on these noninvasive techniques.     

A unique case of anomalous coronary origin detected by 64-row multislice computed tomography coronary angiography

The anomalous origin of the left coronary artery from the right sinus of valsalva is an anatomical abnormality that is usually associated with myocardial ischaemia and sudden death. We report on a case in which three different diagnostic techniques were used to find the cause of the ischaemic symptoms in a patient whose left coronary artery originated anomalously in the right sinus of valsalva and followed a course between the aorta and the pulmonary trunk. The techniques were treadmill exercise test for ischaemia, conventional angiography, which was used for the initial diagnosis, and 64-row multislice computerised tomography, used to determine the anomalous course of the artery.     

Visualization of coronary artery anomalies and their anatomic course by contrast-enhanced electron beam tomography and three-dimensional reconstruction

Anomalous coronary arteries are rare conditions. However, they may cause myocardial ischemia and sudden death and their reliable identification is crucial for any imaging method that attempts coronary artery visualization. We studied the ability of contrast-enhanced electron beam tomography (EBT) to identify anomalous coronary arteries and their course. Thirty patients with previously identified coronary anomalies and 30 subjects with normal coronary anatomy were studied. By EBT, 40 to 50 axial images of the heart (3-mm slice thickness, 1 mm overlap, electrocardiographic trigger) were acquired in a single breathhold during continuous injection of contrast agent (160 ml, 4 ml/s). Based on the original images and 3-dimensional reconstructions, the EBT data were analyzed by 2 blinded observers as to the presence of coronary anomalies and their course. Results were compared with invasive angiography. EBT correctly identified all normal controls and all patients with coronary anomalies. The anatomic course of the coronary anomalies was correctly classified in 29 of 30 patients (97%), including right-sided origin of the left main coronary artery (n = 4) or of the left circumflex coronary artery (n = 15), left-sided origin of the right coronary artery (n = 9), and 1 coronary fistula from the left circumflex coronary artery to the right atrium. Only the distal anastomosis of a second fistula from the left circumflex coronary artery to a bronchial artery was not correctly identified. This study demonstrates that contrast-enhanced EBT is a reliable noninvasive technique to identify anomalous coronary arteries and their course.     

Anomalous coronary arteries in adults detected by multislice computed tomography: presentation of cases from multicenter registry and review of the literature

Anomalous coronary arteries are a rare condition, but they may cause myocardial ischemia, heart failure, and sudden death. We evaluated the prevalence and multislice computed tomographic (MSCT) findings of anomalous coronary arteries in a large number of patients from the multicenter registry. At four institutes, 29 (0.74%) out of 3910 patients were found to have anomalous coronary arteries by MSCT. They consisted of 15 patients with anomalous origins of the right coronary artery, 1 with right-sided origin of the left circumflex artery, 1 with right-sided origin of the left main coronary artery, 2 with double right coronary arteries, 2 with the absence of the left circumflex artery, 1 with absence of the right coronary artery, 6 with coronary artery fistulas, and 1 with Bland-White-Garland syndrome. Multislice computed tomography findings were consistent with those obtained by conventional coronary angiography in all 14 patients undergoing both diagnostic procedures. Multislice computed tomography permits three-dimensional comprehension of coronary arteries, which is suitable for the diagnosis of anomalous coronary arteries.     

Evaluation of coronary atheroma by 64-slice multidetector computed tomography: Comparison with intravascular ultrasound and angiography

BACKGROUND:

Recent improvements in multidetector computed tomography (MDCT) with 64-slice scanners have allowed acquisition of a coronary study in 5 s to 6 s, with good temporal and spatial resolution. Previous studies have reported an underestimation of plaque burden by MDCT. Whether shorter scan times can allow correct assessment of plaque volume requires comparison with intravascular ultrasound (IVUS).

METHODS:

Patients (n=30) scheduled for coronary angiography also underwent MDCT and IVUS examinations within 96 h. MDCT examination was performed with a 64-slice scanner. Nitroglycerin was administered before all imaging procedures. MDCT, quantitative coronary angiography (QCA) and IVUS analyses were performed by observers blinded to other results. Plaque volumes were determined by MDCT and IVUS in one vessel, and maximum percentage diameter stenosis was identified in each coronary segment by MDCT and QCA.

RESULTS:

The mean (± SD) plaque volume was determined to be 179.1±78.9 mm³ by MDCT and 176.1±87.9 mm³ by IVUS. There was a strong positive correlation for plaque volume between MDCT and IVUS (r=0.84, P<0.0001). Percentage diameter stenosis assessed by MDCT and QCA also correlated well (r=0.88 per patient and r=0.87 per vessel, P<0.0001 for both). The maximum percentage diameter stenosis per vessel was 38.1±30.2% with MDCT and 34.1±27.6% with QCA. The sensitivity and specificity of MDCT in detecting stenoses above 50% per vessel were 100% and 91.0%, respectively.

CONCLUSIONS:

Plaque volumes measured by 64-slice MDCT and IVUS correlate well, without systematic underestimation. The sensitivity and specificity of MDCT to detect stenoses greater than 50% by QCA are excellent with the administration of nitroglycerin before imaging.     

The prevalence and anatomical patterns of intramuscular coronary arteries: a coronary computed tomography angiographic study.

OBJECTIVES: This study sought to report prevalence and radiologic patterns of intramuscular coronary arteries (myocardial bridging) on coronary computed tomographic angiography (CCTA). BACKGROUND: Reported prevalence of intramuscular coronary arteries varies between 5% and 86% in autopsy and 0.8% and 4.9% in coronary angiography. Intramuscular coronary arteries can cause technical problems during coronary bypass surgery, including inadvertent perforation of the right ventricle. METHODS: One hundred and eighteen consecutive patients were studied with CCTA using Brilliance 40/64 multidetector computed tomography (Philips Medical Systems, Cleveland, Ohio). Parameters evaluated were number, length, and depth of intramuscular coronary segments; diameter and evidence of atherosclerosis in the involved artery proximal and within the intramuscular segment; and its course in relation to the interventricular septum and right ventricular wall. RESULTS: Forty-seven intramuscular segments were identified in 36 of 118 (30.5%) patients. Most were located in mid left anterior descending coronary artery (LAD), 27 of 47 (57%), and distal LAD, 7 of 47 (15%). The CCTA features in the LAD showed 3 patterns: superficial septal, 10 of 34 (29.4%); deep septal, 14 of 34 (41.1%); and right ventricular type, 10 of 34 (29.4%). Intramuscular segment length ranged from 13 to 40 mm. Coronary diameter proximal and within the affected segment was 2.2 +/- 0.5 mm versus 1.6 +/- 0.6 mm for the LAD, and 1.9 +/- 0.3 mm versus 1.5 +/- 0.6 mm for the remaining arteries, respectively. Depth ranged from 0.1 to 5.6 mm. CONCLUSIONS: Prevalence of intramuscular coronary arteries on CCTA is in concordance with most pathological reports and higher than in angiographic series. The CCTA clearly showed presence, course, and anatomical features of intramuscular coronary arteries. Coronary computed tomographic angiography may provide potentially useful information in the preoperative evaluation of candidates for coronary bypass surgery.     

Congenital mitral insufficiency caused by anomalous mitral arcade in an elderly patient: use of echocardiography and multidetector computed tomography for diagnosis.

Anomalous mitral arcade is a rare congenital malformation and few survive to adulthood. A 65-year-old man presented with mild dyspnea and cardiac murmur. Transthoracic and transesophageal echocardiography showed an arc-like configuration of the papillary muscles, constrained by an interconnecting fibrous band in direct continuity with the anterior mitral leaflet, and mitral insufficiency caused by the restricted mobility of the mitral valve. Multidetector computed tomography confirmed these findings.     

Evaluation of coronary calcium score by multidetector computed tomography in relation to endothelial function and inflammatory markers in asymptomatic individuals.

BACKGROUND: Coronary calcification has been correlated with the presence and extent of coronary artery disease (CAD), so in the present study the associations between coronary artery calcification score (CACS) and endothelial dysfunction, as well as the important inflammatory markers C-reactive protein (CRP), interleukin (IL)-6, and oxidized low-density lipoprotein (OxLDL), were studied in asymptomatic individuals at intermediate risk for CAD. METHODS AND RESULTS: The study group comprised 177 subjects (103 males) aged 50.6+/-5.9 years. CACS was measured by multidetector computed tomography using the Agatston method. Endothelium-dependent flow-mediated dilatation (FMD) and endothelium-independent nitroglycerin-mediated dilatation (NMD) were measured by high-resolution external brachial ultrasound. Coronary artery calcification (CAC) was detected in 82 subjects (52 males), and the median CACS was 143 [31-311.25] units. After adjusting for gender and body mass index, log (CACS +1) correlated positively with age (r=0.401, p<0.001) and IL-6 levels (r=0.442, p<0.001), and negatively with FMD (r=-0.511, p<0.001). The correlations of log (CACS +1) with CRP and OxLDL levels, and with NMD, were non-significant. In a multivariate-adjusted logistic regression model, age (odds ratio (OR) =1.083 [1.014-1.156]), serum IL-6 level (OR=3.837 [2.166-6.798]) and FMD (OR=0.851 [0.793-0.913]) were significantly and independently associated with CAC. CONCLUSIONS: Peripheral endothelial function inversely correlated with CACS, whereas IL-6 level was associated with CACS. Testing for endothelial function and IL-6 level may improve cardiovascular risk assessment and help target the therapeutic strategies in asymptomatic patients at intermediate CAD risk.     

Effect of age and plaque morphology on diagnostic accuracy of dual source multidetector computed tomography coronary angiography

Background Multidetector computed tomography （MDCT） coronary angiography represents one of the most exciting technological revolutions in cardiac imaging and it has been increasingly used in the diagnosis of coronary artery disease. The purpose of this study is to investigate the effect of age and coronary plaque calcification on diagnostic accuracy of MDCT. Methods The patients were examined by using dual-source MDCT and conventional coronary angiography. MDCT results were analyzed with regard to the severity （＆gt;50%stenosis） and morphology （non-calcified, mixed, or calcified） of coronary atherosclerotic plaques evaluated in a 16-segment model. Results In total, 181 patients （94 men and 87 women） with 2,687 coronary artery segments were examined with MDCT. Ninety three patients were older than 65 years of age （group A, 42 men） and 88 were younger （group B, 52 men）. Two-hundred nine coronary artery segments （7.2%） were ex-cluded because of small distal coronary vessel segments and/or motion artifacts. The overall number of segments with non-diagnostic image quality was similar in both groups of patients. Of the 2,687 evaluated segments, 157 （5.8%） were significantly diseased, and 144 of them were correctly detected by MDCT. Diagnostic evaluation showed that the sensitivity, positive predictive value, specificity, and negative pre-dictive value were 89.5%, 62.5%, 96.0%, and 99.2%, respectively in group A, and 95.2%, 64.8%, 97.5%, and 99.8%in group B, respectively. In addition, detailed segment-based analyses in coronary segments with non-calcified, mixed and calcified plaques in both groups were simi-lar diagnostic accuracy. Conclusions Very high diagnostic accuracy observed in this study suggests that MDCT coronary angiography could be a suitable diagnostic tool for not only younger patients but also for older patients.     

Radiation dose and diagnostic accuracy of multidetector computed tomography for the detection of significant coronary artery stenoses: A meta-analysis

We conducted a meta-analysis evaluating the critical ratio between effective radiation dose (ED), feasibility (Fe) and diagnostic accuracy (Ac) of multidetector computed tomography (MDCT) for the detection of significant coronary artery disease. By using our predetermined criteria, we selected human studies published in English in which the ED and raw data of Ac vs. invasive coronary angiography in a segment based model were specified. Data from 31 studies including 3661 patients (mean age 61.9±4.5years, heart rate 62.5±6.7bpm) and 50,236 coronary artery segments were analysed and are reported. Overall, Fe, sensitivity, specificity, negative predictive value, positive predictive value, Ac and ED were 95%, 90%, 96%, 99%, 69%, 95% and 10.4±5.4mSv, respectively. Multivariate analysis showed that prospective ECG-gating (-8.8mSv CI95% -13.4 to -4.3mSv, p=0.001), dual-source (-3.7mSv CI95% -7.9 to 0mSv, p=0.05) and BMI-adapted scanning protocols (-4.5mSv CI95% -8.7 to -2.7mSv, p=0.03) were independent predictors of ED reduction. In patients with low heart rate, the best compromise between ED, Fe and Ac (2.5mSv, 97% and 98%, respectively) was obtained combining prospective ECG-gating and BMI-adapted scanning protocols, while in patients with high heart rate the strategy associated with the best results (10mSv, 98% and 97%, respectively) was the use of dual-source MDCT with retrospective ECG gating and modulation dose. In conclusion, careful selection of CT scanning protocols according to the patient's characteristics is critical for keeping the radiation exposure "as low as reasonably achievable" (ALARA) without impairing Fe and Ac.     

Identifying the course of an anomalous left coronary artery using contrast-enhanced electron beam tomography and three-dimensional reconstruction.

Coronary anomalies are a rare but recognized cause of myocardial ischemia and sudden death. Until recently, invasive coronary arteriography was the diagnostic method of choice. However, contrast-enhanced electron beam tomography has the advantage of three-dimensional visualization of anomalous coronary arteries. We describe a case of anomalous origin of the left coronary artery.     

Acquired anomalies of the coronary arteries after arterial switch operation. Usefulness of coronary computed tomography angiography and impact on follow-up

IntroductionMortality and morbidity in patients with transposition of the great arteries after an arterial switch operation depends mainly on the status of coronary perfusion. Coronary computed tomography angiography (CCTA) provides accurate information on coronary morphology, however its use in these patients is not yet routine procedure.ObjectiveWe sought to assess its accuracy to identify acquired coronary anomalies in this population, compared to conventional angiography in a subset of patients, and assess its impact on postoperative management.MethodsRetrospective analysis of clinical data on transposition of the great arteries in patients who underwent CCTA between January 2013 and September 2017.ResultsBetween January 2013 and September 2017, 18 patients underwent CCTA. Seven patients (39%) disclosed iatrogenic coronary lesions (stenosis 1; kinking 2, occlusion 1; filiform coronary 3). The exam was performed in 78% of patients due to suggestion of myocardial ischemia (symptoms or altered exams). Only 16% needed to undergo additional exams, and in four patients the CCTA result modified therapeutic management.Conventional coronary angiography was also performed in 10 patients (55%), and in three cases, the results were discordant with underestimation or non-identification of coronary lesions on conventional angiography.The medium radiation dose used was 2.4 mSv and no complications after CT were reported.ConclusionCCTA accurately identified iatrogenic postoperative coronary lesions and it has proven to be superior to conventional angiography in this population. It should be performed routinely in this group of patients, even in the absence of symptoms.     

Visualization of coronary arteries and coronary stents by low dose 320-slice multi-detector computed tomography in a patient with atrial fibrillation

Cardiac multi-detector computed tomography (MDCT) is widely used in the diagnosis of coronary disease. However, the predictive value of this technique is limited in the presence of atrial fibrillation and coronary stents. Here we present a case showing the ability of the new 320-slice MDCT to assess coronary anatomy in a patient with atrial fibrillation and coronary stents.     

Cardiac arrest in a soccer player: a unique case of anomalous coronary origin detected by 16-row multislice computed tomography coronary angiography

Anomalous origin of the coronary arteries may be present in otherwise normal subjects without clinical significance, but can also be the cause of myocardial ischemia and sudden death in both adults and teenagers. In particular, the origin of the left main coronary artery or left anterior descending artery from the right sinus of Valsalva or right coronary artery may result in compression of the vessel during or immediately after exercise. We present a unique case of coronary anomaly with four separate coronary ostia originating from the right coronary sinus in a soccer player with sudden cardiac arrest. Multislice contrast-enhanced computed tomography has emerged as a valid noninvasive method for the diagnosis of coronary artery anomaly.     

Noninvasive assessment of plaque morphology and composition in culprit and stable lesions in acute coronary syndrome and stable lesions in stable angina by multidetector computed tomography.

OBJECTIVES: The purpose of this study was to assess morphology and composition of culprit and stable coronary lesions by multidetector computed tomography (MDCT). BACKGROUND: Noninvasive identification of culprit lesions has the potential to improve noninvasive risk stratification in patients with acute chest pain. METHODS: Thirty-seven patients with acute coronary syndrome (ACS) or stable angina underwent coronary 16-slice MDCT and invasive selective angiography. In all significant coronary lesions two observers measured the degree of stenosis, plaque area at stenosis, and remodeling index and assessed plaque composition. Differences between culprit lesions in patients with ACS and stable lesions in patients with ACS or stable angina were determined. RESULTS: We analyzed 40 lesions with excellent image quality in 14 patients with ACS and 9 patients with stable angina. Culprit lesions in patients with ACS (n = 14) had significantly greater plaque area and a higher remodeling index than both stable lesions in patients with ACS (n = 13) and in patients with stable angina (n = 13) (17.5 +/- 5.9 mm2 vs. 9.1 +/- 4.8 mm2 vs. 13.5 +/- 10.7 mm2, p = 0.02; and 1.4 +/- 0.3 vs. 1.0 +/- 0.4 vs. 1.2 +/- 0.3, p = 0.04, respectively). The prevalence of non-calcified plaque was 100%, 62%, and 77%, respectively, and the prevalence of calcified plaque was 71%, 92%, and 85%, respectively, in culprit lesions in patients with ACS and in stable lesions in patients with ACS or stable angina. CONCLUSIONS: We introduce the concept of noninvasive detection and characterization of coronary atherosclerotic lesions in patients with ACS by MDCT. We identified differences in lesion morphology and plaque composition between culprit lesions in ACS and stable lesions in ACS or stable angina, consistent with previous intravascular ultrasound studies.     

核素心肌灌注显像与电子束CT诊断冠心病的对比研究

目的 :比较核素心肌灌注显像 (SPECT)与电子束 CT(EBCT)冠状动脉钙化定量积分对冠心病 (CHD)的诊断价值。方法 :44例住院患者同时进行冠状动脉造影 (CAG)、SPECT和EBCT检查。以 CAG为金标准 ,比较 SPECT与 EBCT诊断 CHD的各项诊断指标 ,并评价平行试验和系列试验的诊断指标。结果 :SPECT诊断 CHD的敏感性为 88.9% ,特异性为 69.2 % ,准确性为 77.3% ;EBCT以钙化积分≥ 1 0分为阳性标准 ,敏感性、特异性、准确性分别为 77.8%、80 .8%及 79.5%。这两种方法对检测 CHD的价值相似 (P >0 .0 5)。 SPECT与 EBCT联合平行试验的准确性为 72 .7% ;系列试验的准确性为 86.4%。结论 :SPECT与 EBCT诊断 CHD的效率相近 ;SPECT显像和 EBCT冠状动脉钙化定量积分法均为非创伤性检查法 ,对 CHD的诊断各有优势 ,宜结合使用