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Kumar R, Kumar J, O'Connor C, Ullah I, Tyrell B, Pearson I, Matiullah S, Bainey K. Coronary Artery Fistula: A Diagnostic Dilemma. Interv Cardiol 2023; 18:e25. [PMID: 38125927 PMCID: PMC10731518 DOI: 10.15420/icr.2022.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 06/01/2023] [Indexed: 12/23/2023] Open
Abstract
Coronary artery fistula (CAF), although one of the rare coronary anomalies, is becoming increasingly more detectable in the recent years due to advancements in cardiac diagnostic imaging. Its long-term prognostic implications and importance for the cardiovascular system remain a dilemma for cardiologists and patients. Based on a variety of haemodynamic symptoms and complications, cardiologists must be aware of the characteristics of CAF and the diagnostic importance of multi-slice CT in evaluation, pre-procedural management and follow-up. Both surgical and percutaneous options are available for symptomatic patients or those with complications, while management of asymptomatic CAF remains a viable alternative.
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Affiliation(s)
- Rajesh Kumar
- Department of Cardiology, St James’s HospitalDublin, Ireland
- Mazankowski Alberta Heart Institute, University of Alberta HospitalEdmonton, Canada
| | - Jathinder Kumar
- Department of Cardiology, St James’s HospitalDublin, Ireland
| | - Cormac O'Connor
- Department of Cardiology, St James’s HospitalDublin, Ireland
| | - Ihsan Ullah
- Department of Cardiology, St James’s HospitalDublin, Ireland
| | - Benjamin Tyrell
- Mazankowski Alberta Heart Institute, University of Alberta HospitalEdmonton, Canada
| | - Ian Pearson
- Department of Cardiology, St James’s HospitalDublin, Ireland
| | | | - Kevin Bainey
- Mazankowski Alberta Heart Institute, University of Alberta HospitalEdmonton, Canada
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Narh JT, Zahid E, Shivaraj K, Sahni S, Kariyanna PT, Khan A. Steal and strain: A case of coronary artery fistula presenting with coronary steal syndrome and underlying bronchiectasis. Respir Med Case Rep 2020; 31:101301. [PMID: 33318920 PMCID: PMC7724369 DOI: 10.1016/j.rmcr.2020.101301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/16/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Coronary artery fistula is a relatively rare disorder with an incidence rate of 0.05-0.9%, and the majority of fistulae are detected incidentally. Most coronary artery fistulae are congenital, and the acquired variant is very rare. Herein, we present a possible acquired coronary artery to pulmonary artery fistula, most likely secondary to bronchiectasis in the adjacent lung. We will analyze the hemodynamic significance of the fistula in this case and also seek to understand the outcomes of various treatment modalities. CASE PRESENTATION A 56-year-old male patient presented with hypoxemia secondary to acute pulmonary edema during a hypertensive emergency. He developed myocardial ischemia after treatment with diuretics and nitroglycerin, due to shunting of blood from the right coronary artery to the right lower lobe branch of the right pulmonary artery, via the fistula. This resulted in coronary steal syndrome. Coronary angiogram confirmed the fistula connecting the right coronary artery to the right lower lobe branch of the right pulmonary artery. An attempt at coil embolization was unsuccessful due to the inability to advance the microcatheter beyond the fistula. DISCUSSION The majority of coronary artery fistulae are asymptomatic as they are hemodynamically not significant and are incidentally detected by coronary angiography, CT angiogram, echocardiogram or multi-detector row computed tomography (MDCT) with 3D reconstruction. The development of congenital fistula can be explained by the Hackensellner involution-persistence hypothesis, but the anatomy in this case and the bronchiectasis in the part of the lung adjacent to the fistula makes an acquired cause very likely due to local inflammation and the age of patient at initial diagnosis. An initial diagnosis of bronchiectasis was made at age 51, which was 5 years prior to the detection of the coronary artery fistula in this patient. Symptoms have been described mostly in the elderly and include chest pain, dyspnea, fatigue, syncope, and palpitations. Such symptomatic fistula should be treated either by percutaneous transluminal embolization or surgical ligation. CONCLUSION This is a unique case of acquired coronary to pulmonary artery fistula in the setting of bronchiectasis in a patient in which PTE was attempted and failed. More research is required to understand the pathophysiology of acquired fistula. The decision regarding the method of closure should be individualized and decided on a case by case basis.
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Affiliation(s)
- Joshua Tetteh Narh
- Dept. of Internal Medicine, Brookdale Hospital Medical Center, Brooklyn, NY, USA
| | - Erum Zahid
- Dept. of Pulmonary and Critical Care Medicine, Brookdale Hospital Medical Center, Brooklyn, NY, USA
| | - Kiran Shivaraj
- Dept. of Internal Medicine, Brookdale Hospital Medical Center, Brooklyn, NY, USA
| | - Sonu Sahni
- Dept. of Internal Medicine, Brookdale Hospital Medical Center, Brooklyn, NY, USA
| | | | - Abdullah Khan
- Dept. of Cardiology, Brookdale Hospital Medical Center, Brooklyn, NY, USA
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Jain N, Achar S, Garg NK, Kumar S. Coronary-pulmonary fistula with common sac: An uncommon variant. Indian J Radiol Imaging 2018; 28:239-241. [PMID: 30050249 PMCID: PMC6038206 DOI: 10.4103/ijri.ijri_399_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
A 68-year-old male patient presented with chief complaints of chest pain and dyspnea on exertion. On physical examination, his pulse was regular at 82 bpm and blood pressure was 140/80 mmHg. Resting electrocardiography (ECG) was within normal limit and chest X-ray also did not reveal any significant abnormality. Routine blood investigations were unremarkable; transthoracic echocardiography also did not show any significant abnormality. Catheter coronary angiography revealed severe triple vessel disease and showed possibility of coronary artery fistula. Computed tomography (CT) coronary angiography showed three aberrant branches arising from right and left coronary arteries forming a sac which subsequently opened into the main pulmonary artery.
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Affiliation(s)
- Neeraj Jain
- Department of Radio Diagnosis, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Shashidhar Achar
- Department of Radio Diagnosis, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Naveen K Garg
- Department of Cardiology, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Sunil Kumar
- Department of Radio Diagnosis, SGPGIMS, Lucknow, Uttar Pradesh, India
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Yun G, Nam TH, Chun EJ. Coronary Artery Fistulas: Pathophysiology, Imaging Findings, and Management. Radiographics 2018; 38:688-703. [DOI: 10.1148/rg.2018170158] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Gabin Yun
- From the Department of Radiology, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do 436-707, Republic of Korea
| | - Tae Hyun Nam
- From the Department of Radiology, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do 436-707, Republic of Korea
| | - Eun Ju Chun
- From the Department of Radiology, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do 436-707, Republic of Korea
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Characteristics of Coronary Artery to Pulmonary Artery Fistula on Coronary Computed Tomography Angiography. J Comput Assist Tomogr 2017; 40:398-401. [PMID: 26854415 DOI: 10.1097/rct.0000000000000370] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the characteristics of coronary artery-to-pulmonary artery fistula (CPAF) found by coronary computed tomography (CT) angiography. METHODS Among 10,121 cases of coronary CT angiography performed for 7 years, we found 32 cases of CPAF. We retrospectively evaluated the demographics, clinical symptoms, and anatomical characteristics such as the origin, number of origins, course, opening site of the fistula, and the presence of aneurysmal changes (defined as dilatation 1.5 times the diameter of the origin). We also categorized the fistula openings according to size compared with that of the proximal left anterior descending coronary artery. RESULTS The patients were 14 men and 18 women with a mean (range) age of 56.5 (34-86) years. Nineteen patients had no related symptoms, and the other 13 patients had symptoms such as angina, chest discomfort, palpitations, or shoulder pain. Among these patients, 2 patients were diagnosed with coronary artery disease. The origins of CPAF were single (n = 15, 46.9%) or multiple (n = 17, 53.1%). The CPAFs arose most commonly from the conus branch of the right coronary artery (n = 20, 62.5%) and proximal left anterior descending (n = 17, 53.1%). All CPAFs coursed anteriorly to the main pulmonary artery and drained into the anterolateral aspect. Twenty-five patients (78.1%) exhibited aneurysmal changes. The openings were small in 13 (40.6%), medium in 13 (40.6%), and large in 6 (18.8%) patients. CONCLUSIONS More than half of patients with CPAF had no related symptoms. Coronary artery-to-pulmonary artery fistula may have a single origin or multiple origins. All of the CPAFs coursed anteriorly to the main pulmonary artery and drained into the anterolateral aspect; the CPAFs identified here frequently exhibited aneurysmal changes.
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Abstract
OBJECTIVE The purpose of this article is to describe the evaluation of congenital coronary artery fistulas (CAFs) with MDCT angiography with ECG gating (MDCTA), including the clinical manifestations, scanning techniques, differential diagnosis, and other imaging methods that may be used. CONCLUSION Congenital CAFs are rare coronary artery anomalies of termination. MDCTA is a first-line modality for pretreatment planning, and imaging findings should be recognized because CAFs may be detected incidentally.
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Challoumas D, Pericleous A, Dimitrakaki IA, Danelatos C, Dimitrakakis G. Coronary arteriovenous fistulae: a review. Int J Angiol 2014; 23:1-10. [PMID: 24940026 DOI: 10.1055/s-0033-1349162] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Coronary arteriovenous fistulae are a coronary anomaly, presenting in 0.002% of the general population. Their etiology can be congenital or acquired. We present a review of recent literature related to their epidemiology, etiology, pathophysiology, clinical presentation, diagnostic approach, and therapeutic management.
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Affiliation(s)
- Dimitris Challoumas
- School of Medicine, Cardiff University, Heath Park Campus, Cardiff, United Kingdom
| | - Agamemnon Pericleous
- School of Medicine, Cardiff University, Heath Park Campus, Cardiff, United Kingdom
| | | | | | - Georgios Dimitrakakis
- Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom
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Oyama-Manabe N, Sugaya T, Yamaguchi T, Terae S. Non-coronary cardiac findings and pitfalls in coronary computed tomography angiography. J Clin Imaging Sci 2011; 1:51. [PMID: 22184544 PMCID: PMC3237007 DOI: 10.4103/2156-7514.86666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 10/03/2011] [Indexed: 11/09/2022] Open
Abstract
Non-coronary incidental findings are not rare. Kirsch et al found 67% non-coronary abnormalities with coronary computed tomography angiography (CCTA). Radiologists are expected to identify the extracoronary, intra- and para-cardiac anatomical structures and distinguish them from pathologic processes in CCTA. We have reviewed 2000 CCTA studies done at our institution with 64-MDCT. This pictorial essay presents case studies of non-atherosclerotic cardiovascular findings to recognize cardiac anatomic structures and how to distinguish them from pathologic processes. Correct interpretation of benign, clinically insignificant findings is crucial to avoid unnecessary additional imaging tests.
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Affiliation(s)
- Noriko Oyama-Manabe
- Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, kita-ku, Sapporo, Japan
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Zhang P, Cai G, Chen J, Wang Y, Duan S. Echocardiography and 64-multislice computed tomography angiography in diagnosing coronary artery fistula. J Formos Med Assoc 2011; 109:907-12. [PMID: 21195889 DOI: 10.1016/s0929-6646(10)60138-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND/PURPOSES There are various types of coronary artery fistula (CAF) with complex shapes; therefore, it is important to obtain a correct diagnosis and to understand its relations to the adjacent structures before surgery. This study evaluated echocardiography and 64-multislice computed tomography (64-MSCT) angiography in diagnosing CAF. METHODS Sixteen patients with CAF, confirmed by surgical operation or digital subtraction angiography, were examined by echocardiography. Five of them were further examined by 64-MSCT angiography for detailed anatomical information before surgery. The imaging data for echocardiography and 64-MSCT angiography were analyzed retrospectively. RESULTS Among the 16 patients, 12 were correctly diagnosed by echocardiography, of whom five were confirmed by 64-MSCT angiography. Four cases missed diagnosis by echocardiography, and one of these was correctly diagnosed by 64-MSCT. Seventeen fistulae were found, of which, two appeared in one patient. Ten fistulae originated from the left coronary artery and seven from the right. The draining site was the right heart in eight, pulmonary artery in five, left heart in three and aorta in one. CONCLUSION Echocardiography can act as the routine examination of CAF, and 64-MSCT angiography can provide more detailed anatomical and pathological information for surgery than echocardiography.
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Affiliation(s)
- Ping Zhang
- Department of Radiology, Teaching Hospital, Fujian medical University, Xiamen, China
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Oto MA, Yorgun H, Aytemir K. Percutaneous approaches to closure of coronary artery fistulas. Interv Cardiol 2011. [DOI: 10.2217/ica.10.91] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Macduff R, Roditi GH. An S-shaped sinoatrial nodal artery coronary artery fistula demonstrated by multidetector CT. Br J Radiol 2011; 84:e88-90. [PMID: 21224306 DOI: 10.1259/bjr/17451817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
- R Macduff
- Department of Radiology, The Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF.
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Mavroudis C, Dodge-Khatami A, Stewart RD, Jacobs ML, Backer CL, Lorber RE. An overview of surgery options for congenital coronary artery anomalies. Future Cardiol 2010; 6:627-45. [DOI: 10.2217/fca.10.82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Congenital and acquired coronary artery anomalies are associated with significant morbidity and mortality and can be sudden in onset. The spectrum of congenital lesions include anomalous origin from the pulmonary artery, critical left main stenosis/atresia, coronary artery fistulas, anomalous aortic origin and intramyocardial courses. The spectrum of acquired lesions include Kawasaki disease, late postoperative obstructions in patients who had coronary artery surgical manipulations and iatrogenic injuries that can occur in the catheterization laboratory or the operating room. Surgical therapies for ischemic syndromes associated over the long term of these anomalies are presented herein.
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Affiliation(s)
| | - Ali Dodge-Khatami
- Department of Pediatric Cardiac Surgery, University Heart Center Hamburg-Eppendorf University of Hamburg-Eppendorf School of Medicine, Martinistrasse 52, 20246 Hamburg, Germany
| | - Robert D Stewart
- Center for Pediatric & Adult Congenital Heart Diseases, Cleveland Clinic Children’s Hospital, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Marshall L Jacobs
- Center for Pediatric & Adult Congenital Heart Diseases, Cleveland Clinic Children’s Hospital, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Carl L Backer
- Division of Pediatric Cardiovascular-Thoracic Surgery, Department of Surgery, Children’s Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard E Lorber
- Center for Pediatric & Adult Congenital Heart Diseases, Cleveland Clinic Children’s Hospital, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Huang HC, Liu CY, Lu TM, Hsu CP. Applying preoperative multidetector computed tomography to bilateral coronary artery fistulas. J Chin Med Assoc 2010; 73:431-4. [PMID: 20728855 DOI: 10.1016/s1726-4901(10)70092-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 06/17/2010] [Indexed: 12/30/2022] Open
Abstract
Coronary artery fistula arising from both the right coronary artery and the circumflex coronary artery is rare. A 28-year-old woman with non-insulin-dependent diabetes mellitus and end-stage renal disease who was on regular hemodialysis complained of recent progressive exertional dyspnea. Congestive heart failure was diagnosed during work-up for simultaneous kidney and pancreas transplantation. Bilateral coronary fistulas draining into the coronary sinus were found by coronary angiography and further characterized by multidetector computed tomography followed by 3D reconstruction preoperatively. The operation was performed smoothly without heart arrest.
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Affiliation(s)
- Hsiao-Ching Huang
- Division of Cardiovascular Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan, R.O.C
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Barone-Rochette G, Vanzetto G, Saunier C, Machecourt J. Combination of anatomic and perfusion imaging for decision making in a professional soccer player with giant coronary artery to left ventricle fistula. J Nucl Cardiol 2009; 16:640-3. [PMID: 19127396 DOI: 10.1007/s12350-008-9047-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Revised: 11/24/2008] [Accepted: 12/01/2008] [Indexed: 10/21/2022]
Affiliation(s)
- G Barone-Rochette
- Clinique de Cardiologie, CHU de Grenoble, BP 217, 38043, Grenoble Cedex 9, France.
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Doganay S, Bozkurt M, Kantarci M, Erkut B. Coronary artery-pulmonary vein fistula diagnosed by multidetector computed tomography. J Cardiovasc Med (Hagerstown) 2009; 10:428-30. [PMID: 19300278 DOI: 10.2459/jcm.0b013e328329ac14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Coronary artery fistulas are rare congenital or acquired coronary artery anomalies that can originate from any of the three major coronary arteries and drain in all the cardiac chambers and great vessels. Multidetector computed tomography has provided cross-sectional anatomy of the heart with excellent spatial and temporal resolution, which shows the anatomical and functional changes in cardiac disorders. Here, the first case of noniatrogenic coronary artery to pulmonary vein fistula depicted by multidetector computed tomography has been presented.
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Affiliation(s)
- Selim Doganay
- Department of Radiology, Develi Government Hospital, Kayseri, Turkey
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Abstract
Cardiac computed tomography (CT) has evolved into a valuable clinical tool for cardiac evaluation. Cardiac CT is increasingly used for imaging of the coronary arteries for the evaluation of (suspected) coronary artery disease, but many other cardiac structures may be the topic for CT investigation. This article reviews general indications for cardiac CT imaging. Common variants and pathologies of the cardiovascular system are illustrated by clinical examples.
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Chung JH, Gunn ML, Godwin JD, Takasugi J, Kanne JP. Congenital thoracic cardiovascular anomalies presenting in adulthood: A pictorial review. J Cardiovasc Comput Tomogr 2009; 3:S35-46. [DOI: 10.1016/j.jcct.2008.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Revised: 10/23/2008] [Accepted: 11/25/2008] [Indexed: 01/03/2023]
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