Anomalous Coronary Arteries That Need Intervention: Review of Pre- and Postoperative Imaging Appearances

Anomalous origin of the circumflex artery from the right pulmonary artery

Anomalous origin of the circumflex artery from the pulmonary artery (ACxAPA) is a rare but clinically significant condition in which the circumflex artery arises from either the main pulmonary artery or one of its main branches. Untreated patients with ACxAPA may develop severe heart failure or sudden cardiac death. Diagnosis is established with either catheter or CT angiography. We present a case of an adult male with no prior known cardiac history who was found to have ACxAPA after presenting to our institution in acute decompensated heart failure.

Prenatal Diagnosis of Crossed Pulmonary Arteries with a Postnatal Diagnosis of CHARGE Syndrome

Introduction: Crossed pulmonary arteries (CPA) is an abnormality in which the ostium of the left pulmonary artery is located rightward and the ostium of the right pulmonary artery is leftward. Case report: We diagnosed a fetus with CPA prenatally. In fetal echocardiography, left pulmonary artery was seen to pass beneath the ductus and directing toward the left side and pulmonary artery bifurcation could not be demonstrated at the same plane. Postnatal echocardiography reconfirmed the presence of CPA. Bilateral choanal atresia, genital hypoplasia, hearing loss with facial and external ear asymmetry and psychomotor delay of the newborn led to clinical diagnosis of CHARGE syndrome and was confirmed by gene analysis. Discussion/Conclusion: CPA may be one of the cardiac anomalies in CHARGE syndrome.

Image and Clinical Characteristics of the Right Coronary Artery Originating From the Left Coronary Sinus: A Database Review

This article systematically explores the imaging and clinical characteristics of a relatively rare cardiac anomaly: the right coronary artery originating from the left coronary sinus. Through a comprehensive analysis of existing literature, this study aims to provide a comprehensive understanding of the prevalence, diagnostic methods, and potential clinical implications of this anatomical variation. Anatomical classification is introduced, along with clinical imaging diagnostic methods, including coronary angiography, computed tomography, and magnetic resonance imaging. Additionally, the review delves into the clinical significance of this anomaly, including its potential associations with myocardial ischemia, arrhythmias, and acute cardiac events, outlining clinical approaches to diagnosing myocardial ischemia. The study results consolidate current knowledge about this cardiac variation, emphasizing the importance of recognizing and appropriately managing it in clinical practice.

Case Report: Multimodality evaluation and clinical management of a single coronary artery

A 14-year-old male with no significant medical history presented with intermittent palpitations for 2-3 months that occurred at rest and were associated with light-headedness. Electrocardiogram in clinic showed sinus arrhythmia with early repolarization and no ischemic changes. The echocardiogram showed normal cardiac structure and function, however, there was a concern for possible anomalous origin of the left coronary artery. Contrast-enhanced CT coronary artery angiogram confirmed a single coronary origin from the right coronary sinus. The single main coronary artery gave rise to the right coronary artery (RCA) and the left coronary artery (LCA). The LCA demonstrated a trans-septal course before it gave rise to the left anterior descending and left circumflex artery. There were intraarterial and intramural portions of the LCA, and the sinoatrial node artery arose from the LCA. The RCA demonstrated a normal course to the right atrioventricular groove, and the posterior descending artery arose from the RCA. Treadmill exercise stress test showed excellent functional capacity without exercise-induced chest pain or ischemic ECG changes. Invasive coronary angiography ruled out luminal narrowing or dynamic compression. Given the absence of physiologic or anatomic evidence of coronary flow restriction, no intervention was pursued and the palpitations were deemed to be likely unrelated to the coronary anomaly and eventually subsided spontaneously on 6 month follow-up.

Coronary Artery Fistula: A Diagnostic Dilemma

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.

Coronary Artery Anomalies: A Short Case Series and Current Review

Coronary artery anomalies (CAAs) are rare congenital cardiovascular defects that can present in various ways depending on the origin, course, and termination of the abnormal coronary artery fistula. It is sometimes detected incidentally during procedures such as coronary angiography or autopsies. While adults with this condition are often asymptomatic, some may experience angina, congestive heart failure, myocardial infarction, cardiomyopathy, ventricular aneurysms, or sudden cardiac death (SCD). In fact, it is the second leading cause of SCD among young athletes and requires more studies to handle such patients efficiently. To illustrate the many possible manifestations of this unusual diagnosis, we present a series of five cases. We have also reviewed the different varieties of this rare congenital anomaly and discussed the latest diagnostic tests and treatment plans.

Donor heart selection: Evidence-based guidelines for providers

The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review.

Congenital absence of the right coronary artery: A case report

BACKGROUND

As a rare anomaly, congenital absence of the right coronary artery (RCA) occurs during the development of coronary artery. Patients with congenital absence of the RCA often show no clinical symptoms, and this disease is considered benign. The left coronary artery gives blood supply to the whole myocardium. The prevalence of congenital absence of the RCA is approximately 0.024%-0.066%. There are few cases reported as for this disease. In this work, a patient, with congenital absence of the RCA diagnosed by coronary angiography (CAG), was described.

CASE SUMMARY

A 41-year-old man arrived at our hospital for treatment, due to the repeated palpitations for a duration of one year. Considering the possibility of coronary heart disease, the patient underwent CAG that indicated the congenital absence of the RCA. Unfortunately, the patient refused to accept computed tomography coronary angiography (CTCA), to further confirm the congenital absence of the RCA.

CONCLUSION

Single coronary artery is a rare type of coronary artery abnormality, which usually has no obvious clinical manifestations and is considered as a benign disease. CAG is the main means by which congenital absence of the RCA can be diagnosed, and the disease can also be further confirmed by CTCA.

TAVR in a Patient With Anomalous Origin and Course of the Left Main Coronary Artery

In patients with anomalous coronary arteries with high-risk features, corrective cardiac surgery should be considered. We report the first case of transcatheter aortic valve replacement using a self-expanding Evolut valve, in a patient with a single coronary artery arising from the right coronary cusp and an intramural course of the left main. (Level of Difficulty: Intermediate.).

Incidental Vascular Findings in Computed Tomography Performed in the Qualification for the TAVI Procedure

Transcatheter aortic valve implantation (TAVI) or transcatheter aortic valve replacement (TAVR) is now a very widespread treatment method for symptomatic and severe aortic stenosis as an alternative for patients at intermediate or high risk of surgery or contraindications to surgery. The key role of imaging examinations before TAVI is to assess the morphology of the aortic valve, the routes of surgical access, and non-cardiac and extravascular structures. The objective of this article is to present and discuss the importance of selected accidental vascular findings in computed tomography examinations of the heart and large vessels performed in the TAVI qualification procedure: persistent left superior vena cava (SVC) with absent right SVC, right aortic arch, ectopic right coronary artery ostium, and left superior pulmonary vein draining into left brachiocephalic vein.

Case report: Transcatheter closure of a giant and tortuous right coronary artery to right ventricle fistula in an infant

Congenital coronary artery fistulas (CAFs) are an uncommon congenital anomaly. While most patients are asymptomatic, life-threatening events including sudden death, myocardial ischemia, heart failure, infective endocarditis, and rupture of aneurysm may occur. Surgical ligation was once the standard choice of management of CAFs in the past. However, transcatheter closure of CAFs has become an emerging alternative to surgery in patients with suitable anatomy. We reported a 7-month-old infant with a giant and tortuous CAF that originated from the distal right coronary artery and drained into the right ventricle, and was successfully treated by transcatheter closure with an Amplatzer ductus occluder.

A comprehensive analysis of the intramural segment in interarterial anomalous coronary arteries using computed tomography angiography

Aims

An anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) with an interarterial course can be assessed using computed tomography angiography (CTA) for the presence of high-risk characteristics associated with sudden cardiac death. These features include a slit-like ostium, acute angle take-off, proximal luminal narrowing, and an intramural segment. To date, no robust CTA criteria exist to determine the presence of an intramural segment. We aimed to deduct new CTA parameters to distinguish an intramural course of interarterial ACAOS.

Methods and results

Twenty-five patients with an interarterial ACAOS (64% female, mean age 46 years, 88% right ACAOS) from two academic hospitals were evaluated. Inclusion criteria were the availability of a preoperative CTA scan (0.51 mm slice thickness) and peroperative confirmation of the intramural segment. Using multiplanar reconstruction of the CTA, the distance between the lumen of the aorta and the lumen of the ACAOS [defined as ‘interluminal space’ (ILS)] was assessed at 2 mm intervals along the intramural segment. Analysis showed a mean ILS of 0.69 ± 0.15 mm at 2 mm from the ostium. At the end of the intramural segment where the ACAOS becomes non-intramural, the mean ILS was significantly larger (1.27 ± 0.29 mm, P < 0.001). Interobserver agreement evaluation showed good reproducibility (intraclass correlation coefficient 0.77, P < 0.001). Receiver operator characteristic analysis demonstrated that at a cut-off ILS of <0.95 mm, an intramural segment can be diagnosed with 100% sensitivity and 84% specificity.

Conclusion

The ILS is introduced as a novel and robust CTA parameter to identify an intramural course of interarterial ACAOS. An ILS of <0.95 mm is indicative of an intramural segment.

An Extremely Rare Presentation of Four Coronary Anomaly Patterns Originating from the Right Coronary Sinus

Background. “Coronary anomaly” is defined as the coronary feature or pattern seen in <1% of the population. The most common CAAs are anomalies of origin, specifically having a separate LCX and LAD origin with an incidence of 0.41%. The second most common anomaly is the LCX arising from the RCA (0.37%). Treatment options include CABG, coronary unroofing, reimplantation, or medical therapy. Case Presentation. We present the case of an 85-year-old male who presents with an acute coronary syndrome who was found to have an extremely rare combination of different coronary anomaly patterns including left main coronary artery (LMCA) atresia, small LAD arising posteriorly from the right coronary cusp, anomalous left circumflex artery arising from the RCA, and an anomalous LAD arising from the left circumflex artery which is originating from the RCA. Conclusions. To the best of our knowledge, this is the first case report to describe four coronary anomalies in a single patient. When CAAs are diagnosed, it is of utmost importance for cardiologists to do further imaging and workup that might include a stress test to be able to offer patients the best management options.

Antemortem diagnosis of anomalous origin of the left coronary artery from the pulmonary artery in a dog

Background

In both humans and animals, anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary artery anomaly. In veterinary medicine, ALCAPA is reported to be discovered only during autopsy or necropsy, and diagnostic methods and prognosis remain poorly understood in dogs.

Case presentation

A 6-month-old Kaninchen Dachshund was diagnosed with functional mitral valve regurgitation and ALCAPA. Echocardiography identified anomalous vessels in the left ventricular wall and abnormal origin of the left coronary artery from the pulmonary artery.

Further evaluation with coronary computed tomographic angiography demonstrated the left coronary artery arising from the posterior aspect of the main pulmonary artery together with the characteristic findings of ALCAPA. The right coronary artery was found to be dilated and tortuous. Furthermore, dilated coronary collateral arteries within the ventricular septum and along the epicardial surface were observed. The dog underwent surgery, but the origin of the anomalous artery could not be ligated, and it died from pulmonary edema 5 months after surgery.

Conclusion

Anomalous origin of the left coronary artery from the pulmonary artery is overlooked in clinical practice due to its rarity. Coronary computed tomographic angiography was useful to definitively diagnose ALCAPA in a low-invasive manner. Antemortem diagnosis of ALCAPA was shown to be possible in dogs for the first time, and presence of unexplained mitral valve regurgitation should raise concern to this anomaly.

A Single Coronary Artery Originating from the Right Coronary Sinus with a Typical Course of the Right Coronary Artery and the Interarterial Course of the Left Main, Left Anterior Descending, and Left Circumflex as an Example of a Rare Case of High-Risk Coronary Anomaly

In the typical course of the coronary arteries, the right coronary artery comes from the right coronary sinus and descends in the right atrioventricular groove. The left coronary artery trunk begins from the left coronary sinus. It crosses the pulmonary trunk and divides into left anterior descending and left circumflex arteries. Anatomical differences of the coronary arteries can be observed in 0.3–5.6% of the population. The interarterial course of coronary branches between the aorta and the pulmonary trunk is a malignant anomaly of the coronary arteries. Such abnormalities have been associated with an increased risk of sudden cardiac death. We present a rare case of coronary arteries anomaly involving the presence of a single right coronary artery and the interarterial course of its atypical branches documented by computed tomography angiography (CTA). In summary, the accurate assessment of the anatomical topography of coronary anomalies, possible in CTA, is necessary in the analysis of the risk of sudden cardiac death and its prevention.

Coronary computed tomography angiography in children

Imaging the coronary arteries of children, with their faster heart rates, small vessel size and common inability to lie still or breath-hold, has been a major challenge. With numerous advances in technology, CT examinations can now be performed quickly, often with children free-breathing and with much lower radiation doses than previously. This has led to increased use in children. Care must be taken with technique and choice of electrocardiogram (ECG)-gating technique to obtain adequate imaging for a diagnosis while keeping radiation dose as low as reasonably achievable (ALARA). In this paper, we discuss techniques and tips for CT imaging of the coronary arteries in children, including use of dual-source- and ultrawide-detector CT scanners.

Left circumflex artery fistula to left atrium: a rare case report

Coronary artery fistulas are rare congenital anomalies of coronary termination. There are 3 types: (1) cameral coronary fistulas, (2) pulmonary coronary fistulas, and (3) bronchial coronary fistulas. Left circumflex coronary artery to left atrial fistula are exceptional. Imaging, especially the CT angiogram, must establish an anatomical classification of the fistula for therapeutic purposes, by specifying its origin, its path, its size and its termination.

We report a rare case of the left circumflex coronary artery to left atrial fistula in a 31 year old man, which is an uncommon presentation of coronary termination anomalies. The CT coronary angiogram must describe the origin segment of the fistula and the drainage site which have therapeutic consequences.

Imaging Features of Complications after Coronary Interventions and Surgical Procedures

Coronary artery interventions and surgical procedures are used in the treatment of coronary artery disease and some congenital heart diseases. Cardiac and noncardiac complications can occur at variable times after these procedures, with the clinical presentation ranging from asymptomatic to devastating symptoms. Invasive coronary angiography is the reference standard modality used in the evaluation of coronary arteries, with intravascular US and optical coherence tomography providing high-resolution information regarding the vessel wall. CT is the mostly commonly used noninvasive imaging modality in the evaluation of coronary artery intervention complications and allows assessment of the stent, lumen of the stent, lumen of the coronary arteries, and extracoronary structures. MRI is limited to the evaluation of the proximal coronary arteries but allows comprehensive evaluation of the myocardium, including ischemia and infarction. The authors review the clinical symptoms and pathophysiologic and imaging features of various complications of coronary artery interventions and surgical procedures. Complications of percutaneous coronary interventions are discussed, including restenosis, thrombosis, dissection of coronary arteries or the aorta, coronary wall rupture or perforation, stent deployment failure, stent fracture, stent infection, stent migration or embolism, and reperfusion injury. Complications of several surgical procedures are reviewed, including coronary artery bypass grafting, coronary artery reimplantation procedure (for anomalous origin from opposite sinuses or the pulmonary artery or as part of surgical procedures such as arterial switching surgery and the Bentall and Cabrol procedures), coronary artery unroofing, and the Takeuchi procedure. Online supplemental material is available for this article. ^©RSNA, 2021.

Cardiac-CT with the newest CT scanners: An incoming screening tool for competitive athletes?

Competitive athletes of all skill levels are at risk of sudden cardiac death (SCD) due to certain heart conditions. Prior to engagement in high-intensity athletics, it is necessary to screen for these conditions in order to prevent sudden cardiac death. Cardiac-CT angiography (CCTA) is a reliable tool to rule out the leading causes of SCD by providing an exceptional overview of vascular and cardiac morphology. This allows CCTA to be a powerful resource in identifying cardiac anomalies in selected patients (i.e. unclear symptoms or findings at ECG or echocardiography) as well as to exclude significant coronary artery disease (CAD). With the advancement of technology over the last few years, the latest generations of computed tomography (CT) scanners provide better image quality at lower radiation exposures. With the amount of radiation exposure per scan now reaching the sub-millisievert range, the number of CT examinations it is supposed to increase greatly, also in the athlete's population. It is thus necessary for radiologists to have a clear understanding of how to make and interpret a CCTA examination so that these studies may be performed in a responsible and radiation conscious manner especially when used in the younger populations. Our work aims to illustrate the main radiological findings of CCTAs and highlight their clinical impact with some case studies. We also briefly describe critical features of state-of-the-art CT scanners that optimize different acquisitions to obtain the best quality at the lowest possible dose.

Virtual endoluminal aortic root views determined at coronary CT angiography - an important tool for improving anomalous coronary artery visualization and surgical planning

Anomalous origin of the coronary arteries, though uncommon, is of great clinical concern. It can be the cause of sudden cardiac death and abnormal cardiac hemodynamics. Advances in electrocardiographically (ECG)-gated multi-detector CT have increased diagnostic accuracy in detecting anomalous origin of coronary arteries and their interarterial and intramural courses. Recent advances in multi-detector CT image processing software have allowed the creation of virtual endoluminal views of the aortic root and improved assessment of the intramural course (the length and relationship to the intercoronary commissure) of the coronary artery, which is of considerable surgical importance. We review our experience with virtual endoluminal imaging in our first 19 cases of interarterial coronary artery anomalies (17 cases of interarterial with intramural segment and 2 cases of purely interarterial course) diagnosed preoperatively and proven surgically.

Multimodality Assessment of Anomalous Aortic Origin of the Right Coronary Artery Presenting With Cardiac Arrest

Anomalous aortic origin of coronary artery (AAOCA) can range from benign anatomic variants to those presenting with sudden cardiac arrest. This unique case of right AAOCA demonstrates detailed anatomic findings from cardiac computed tomography and the effects of transient acute coronary ischemia by cardiac magnetic resonance. (Level of Difficulty: Advanced.)

Noninvasive imaging of congenital cardiovascular defects

Advances in the treatment have drastically increased the survival rate of congenital heart disease (CHD) patients. Therefore, the prevalence of these patients is growing. Imaging plays a crucial role in the diagnosis and management of this population as a key component of patient care at all stages, especially in those patients who survived into adulthood. Over the last decades, noninvasive imaging techniques, such as cardiac magnetic resonance (CMR) and cardiac computed tomography (CCT), progressively increased their clinical relevance, reaching stronger levels of accuracy and indications in the clinical surveillance of CHD. The current review highlights the main technical aspects and clinical applications of CMR and CCT in the setting of congenital cardiovascular abnormalities, aiming to address a state-of-the-art guidance to every physician and cardiac imager not routinely involved in the field.

Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve in Patients with Anomalous Origin of the Right Coronary Artery from the Left Coronary Sinus

Objective

To examine the fractional flow reserve derived from computed tomographic angiography (CT-FFR) in patients with anomalous origin of the right coronary artery from the left coronary sinus (R-ACAOS) with an interarterial course, assess the relationship of CT-FFR with the anatomical features of interarterial R-ACAOS on coronary computed tomographic angiography (CCTA), and determine its clinical relevance.

Materials and Methods

Ninety-four patients with interarterial R-ACAOS undergoing CCTA were retrospectively included. Anatomic features (proximal vessel morphology [oval or slit-like], take-off angle, take-off level [below or above the pulmonary valve], take-off type, intramural course, % proximal narrowing area, length of narrowing, minimum luminal area [MLA] at systole and diastole, and vessel compression index) on CCTA associated with CT-FFR ≤ 0.80 were analyzed. Receiver operating characteristic analysis was performed to describe the diagnostic performance of CT-FFR ≤ 0.80 in detecting interarterial R-ACAOS.

Results

Significant differences were found in proximal vessel morphology, take-off level, intramural course, % proximal narrowing area, and MLA at diastole (all p < 0.05) between the normal and abnormal CT-FFR groups. Take-off level, intramural course, and slit-like ostium (all p < 0.05) predicted hemodynamic abnormality (CT-FFR ≤ 0.80) with accuracies of 0.69, 0.71, and 0.81, respectively. Patients with CT-FFR ≤ 0.80 had a higher prevalence of typical angina (29.4% vs. 7.8%, p = 0.025) and atypical angina (29.4% vs. 6.5%, p = 0.016).

Conclusion

Take-off level, intramural course, and slit-like ostium were the main predictors of abnormal CT-FFR values. Importantly, patients with abnormal CT-FFR values showed a higher prevalence of typical angina and atypical angina, indicating that CT-FFR is a potential tool to gauge the clinical relevance in patients with interarterial R-ACAOS.

Early Outcomes of Transconal Repair of Transseptal Anomalous Left Coronary Artery From Right Sinus

BACKGROUND

Anomalous aortic origin of the left coronary artery (AAOCLA) with an extended transseptal course behind the right ventricular outflow tract (RVOT) is a rare variant that poses challenges not addressed by current surgical techniques. We utilized a novel transconal approach in 7 consecutive patients.

METHODS

A retrospective review was made of a prospectively collected database for consecutive patients undergoing transconal unroofing of transseptal AAOLCA. Surgical repair entails transection of the RVOT, unroofing the septal course of the AAOLCA, followed by RVOT extension with a rectangular strip of autologous pericardium. Preoperative characteristics, operative details, and postoperative course were abstracted.

RESULTS

All 7 patients identified were symptomatic. Median age was 48 years (range, 12 to 62). The AAOLCA with transseptal course was confirmed by computed tomography angiography. Three patients had provocative testing demonstrating anterolateral ischemia. Four patients underwent cardiac catheterization with intravascular ultrasound and indexed fractional flow reserve, confirming flow-limiting lesion. Importantly, 3 patients had negative provocative noninvasive testing for ischemia. Median postoperative hospital length of stay was 6 days (range, 4 to 12). No mortality or major complications occurred during a median follow-up of 0.75 years. Postoperative evaluation demonstrated anatomically patent unroofed AAOLCA with improved indexed fractional flow reserve compared with preoperative (0.59 ± 0.16 vs 0.90 ± 0.03, P = .05).

CONCLUSIONS

Complete unroofing of AAOLCA with transseptal course repaired with posterior extension of RVOT is an effective technique with excellent early outcome. Multimodality provocative testing is critical to evaluate these lesions as individual studies may be misleading. Intravascular ultrasound with indexed fractional flow reserve is clinically useful to confirm the hemodynamic significance of specific lesions.

Transthoracic echocardiography features of adult-type anomalous left coronary artery from the pulmonary artery before and after surgery: highlights from observational study in a single center of China

To review the imaging characteristics of adult-type anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) and evaluate the post-operative echocardiographic features. The transthoracic echocardiography (TTE) records and invasive coronary angiography (ICA), coronary computed tomography angiography (CTA) or operative findings of thirty adult patients with final diagnosis of ALCAPA were reviewed at our center. The diagnostic reliability of TTE was determined by comparing its results with that of ICA/CTA, and the echocardiographic features of the patients during early visit and post-operative follow-up were summarized. The coincidence rate of TTE and ICA/CTA diagnosing ALCAPA was 96.3% (26/27), and one case was misdiagnosed as coronary artery fistula. All patients showed abnormal left coronary ostium arising from the pulmonary trunk with retrograde coronary artery flow, 20 patients had enlarged right coronary artery (RCA), and 20 showed abundant inter-coronary septal coronary collaterals. Left ventricle (LV) abnormalities such as wall thinning, abnormal wall motion, papillary muscle fibrosis, mitral valve (MV) prolapse and moderate-severe mitral regurgitation (MR) were respectively observed in 4, 7, 10, 8 and 10 patients. Three patients showed ventricular septal defect, patent foramen ovale and tetralogy of Fallot respectively. Post-operative data was available for 12 patients, and showed that the diameter of RCA, size of left atrium (LA) and LV were decreased after surgery compared to the respective pre-operative values. Furthermore, inter-coronary septal coronary collaterals lessened in 8 of these patients. Although 6 patients showed residual mild MR, moderate or severe MR was not observed, and the ejection fraction (EF) also showed no obvious changes before and after surgery. TTE is a non-invasive diagnostic tool for adult-type ALCAPA, and can indicate abnormal coronary origin, collateral arteries and other associated malformations. Some of the structural and hemodynamic parameters of adult-type ALCAPA were improved after surgery.

Coronary Computed Tomography Angiography in the Clinical Workflow of Athletes With Anomalous Origin of Coronary Arteries From the Contralateral Valsalva Sinus

PURPOSE

This study aimed to assess the role of coronary computed tomography-angiography (CCTA) in the workflow of competitive sports eligibility in a cohort of athletes with anomalous origin of the left-coronary artery (AOLCA)/anomalous origin of the right-coronary artery (AORCA) in an attempt to outline relevant computed tomography features likely to impact diagnostic assessment and clinic management.

MATERIALS AND METHODS

Patients with suspected AOLCA/AORCA at transthoracic echocardiography or with inconclusive transthoracic echocardiography underwent CCTA to rule out/confirm and characterize the anatomic findings: partially interarterial course or full-INT, high-take-off, acute-take-off-angle (ATO), slit-like origin, intramural course (IM), interarterial-course-length, and lumen-reduction/hypoplasia (HYPO).

RESULTS

CCTA identified 28 athletes: 6 AOLCA (3 males; 20.3±11.0 y) and 22 AORCA (18 males; 29.1±16.5 y). Symptoms were present only in 13 athletes (46.4%; 10 AORCA). Four patients (3 AORCA) had abnormal rest electrocardiogram, 11 (40.7%; 9 AORCA) had abnormal stress-electrocardiogram. The INT course was observed in 15 athletes (53.6%): 6/6 AOLCA and 9/22 AORCA (40.9%). Slit-like origin was present in 7/22 AORCA (31.8%) and never in AOLCA. Suspected IM resulted in 3 AOLCA (50%), always with HYPO/ATO, and in 6/22 AORCA (27.3%) with HYPO. No statistically significant differences were found between asymptomatic/symptomatic patients in the prevalence of partially INT/INT courses, high-take-off/ATO, and slit-like ostium. A slightly significant relationship between suspected proximal-IM (r=0.47, P<0.05) and proximal-HYPO of anomalous vessel (r=0.65, P<0.01) resulted in AORCA and was confirmed on AOLCA/AORCA pooled analysis (r=0.58, P<0.01 for HYPO). All AOLCA/AORCA athletes were disqualified from competitive sports and warned to avoid vigorous physical efforts. Surgery was recommended to all AOLCA athletes and to 13 AORCA (3 asymptomatic), but only 6 underwent surgery. No major cardiovascular event/ischemic symptoms/signs developed during a mean follow-up of 49.6±39.5 months.

CONCLUSION

CCTA provides essential information for safe/effective clinical management of athletes, with important prognostic/sport-activity implications.

A case report of right coronary artery agenesis diagnosed by computed tomography coronary angiography

INTRODUCTION

Single coronary artery is a rare condition characterized by the origin of a coronary that supplies the entire heart from a single coronary ostium.

PATIENT CONCERNS

A 45-year-old woman with an altered exercise testing was addressed to a computed tomography coronary angiography (CTCA) to rule out coronary artery disease (CAD).

DIAGNOSIS

CTCA examination showed the absence of the right coronary artery (RCA). The left anterior descending artery and the left circumflex artery (LCX) presented regular origin and course and LCX provided the posterior interventricular artery and the posterolateral artery.

INTERVENTIONS

As CTCA highlighted the absence of potentially life-threatening features related to coronary anomaly, no surgical treatment was advised.

OUTCOMES

The patient was dismissed, kept under pharmacological control and monitored over time.

CONCLUSION

CTCA is the first-choice imaging modality in patients with ECG abnormalities properly allowing the differential diagnosis between CAD and congenital heart disease.

Incidental Anomalous Left Coronary Artery in a Transplanted Heart

Anomalous coronary artery is an uncommon congenital cardiac anomaly that is often detected incidentally on coronary angiography. It has rarely been reported in the donor heart of patients who have undergone cardiac transplantation. Here, we report a case of a 72-year-old patient who received a second heart transplant and has been identified to have an anomalous left main coronary artery originating from the right coronary sinus on postoperative coronary angiography.

Four Coronary Arteries Separately Originating from the Right Sinus of Valsalva

An 82-year-old woman was admitted to our hospital with heart failure. Coronary angiography revealed one anatomically normal right coronary artery and three left coronary arteries (LCA-1, LSA-2, and LSA-3) separately originating from the right sinus of Valsalva, comprising multiple atherosclerotic lesions. LCA-1 became the obtuse marginal branch after branching off into the septal branches. LCA-2 was the main circumflex artery with an obstructive lesion. LCA-3 corresponded to the distal part of the anterior descending branch. The patient died 14 days after hospitalization. We describe the rarity of quadriostial origin, the unusual course, and the unusual branching of the coronary arteries.

Pseudo-Wellens syndrome, acute pancreatitis, and an anomalous coronary artery: a case report

Background

Chest pain associated with transient electrocardiogram changes mimicking an acute myocardial infarction have been described in acute pancreatitis. These ischemic electrocardiogram changes can present a diagnostic dilemma, especially when patients present with concurrent angina pectoris and epigastric pain warranting noninvasive or invasive imaging studies.

Case presentation

A 45-year-old African-American man with a history of alcohol use disorder presented to the emergency department of our institution with 36 hours of concurrent epigastric pain and left-sided chest pain radiating to his left arm and associated with nausea and dyspnea. On physical examination, he was afebrile; his blood pressure was elevated; and he had epigastric tenderness. His laboratory test results were significant for hypokalemia, normal troponin, and elevated serum lipase and amylase levels. Serial electrocardiograms for persistent chest pain showed ST-segment elevations with dynamic T-wave changes in the right precordial electrocardiogram leads, consistent with Wellens syndrome. He was immediately taken to the cardiac catheterization laboratory, where selective coronary angiography showed normal coronary arteries with an anomalous origin of the right coronary artery from the opposite sinus. Given his elevated lipase and amylase levels, the patient was treated for acute alcohol-induced pancreatitis with intravenous fluids and pain control. His chest pain and ischemic electrocardiogram changes resolved within 24 hours of admission, and coronary computed tomography angiography showed an interarterial course of the right coronary artery without high-risk features.

Conclusions

Clinicians may consider deferring immediate cardiac catheterization and attribute electrocardiogram changes to acute pancreatitis in patients presenting with angina pectoris and acute pancreatitis if confirmed by normal cardiac enzymes and elevated levels of lipase and amylase. However, when clinical signs and electrocardiogram findings are highly suggestive of myocardial ischemia/injury, immediate noninvasive coronary computed tomography angiography may be the best approach to make an early diagnosis.

Cardiac CT: why, when, and how : Update 2019

PURPOSE

The aim of this study was to review established and emerging techniques of cardiac computed tomography (CT) and their clinical applications with a special emphasis on new techniques, recent trials, and guidelines.

TECHNOLOGICAL INNOVATIONS

Cardiac CT has made great strides in recent years to become an ever more robust and safe imaging technique. The improvements in spatial and temporal resolution are equally important as the substantial reduction in radiation exposure, which has been achieved through prospective ECG-triggering, low tube voltage scanning, tube current modulation, and iterative reconstruction techniques. CT-derived fractional flow reserve and CT myocardial perfusion imaging are novel, investigational techniques to assess the hemodynamic significance of coronary stenosis.

ESTABLISHED AND EMERGING INDICATIONS

In asymptomatic patients at risk for coronary artery disease, CT coronary artery calcium scoring is useful to assess cardiovascular risk and guide the intensity of risk factor modification. Coronary CT angiography is an excellent noninvasive test to rule out obstructive coronary artery disease in patients with stable chest pain. In acute chest pain with normal ECG and normal cardiac enzymes, cardiac CT can safely rule out acute coronary syndrome although its benefit and role in this indication remains controversial. Cardiac CT is the established standard for planning transcatheter aortic valve implantation and-increasingly-minimally invasive mitral valve procedures.

PRACTICAL RECOMMENDATIONS

Our review makes practical recommendations on when and how to perform cardiac CT and provides templates for structured reporting of cardiac CT examinations.

Dual-source computed tomography coronary artery imaging in children

Computed tomography (CT) has a well-established diagnostic role in the assessment of coronary arteries in adults. However, its application in a pediatric setting is still limited and often impaired by several technical issues, such as high heart rates, poor patient cooperation, and radiation dose exposure. Nonetheless, CT is becoming crucial in the noninvasive approach of children affected by coronary abnormalities and congenital heart disease. In some circumstances, CT might be preferred to other noninvasive techniques such as echocardiography and MRI for its lack of acoustic window influence, shorter acquisition time, and high spatial resolution. The introduction of dual-source CT has expanded the role of CT in the evaluation of pediatric cardiovascular anatomy and pathology. Furthermore, technical advances in the optimization of low-dose protocols represent an attractive innovation. Dual-source CT can play a key role in several clinical settings in children, namely in the evaluation of children with suspected congenital coronary artery anomalies, both isolated and in association with congenital heart disease. Moreover, it can be used to assess acquired coronary artery abnormalities, as in children with Kawasaki disease and after surgical manipulation, especially in case of transposition of the great arteries treated with arterial switch operation and in case of coronary re-implantation.

Anomalous Origin of the Right Coronary Artery from the Left Main Coronary Artery in the Setting of Critical Bicuspid Aortic Valve Stenosis

Anomalous origin of the right coronary artery (ARCA) is an extremely rare cardiac pathology. The coronary artery can potentially course between the aorta and the pulmonary artery, putting the patient at risk for sudden cardiac death. Even rarer is an ARCA that arises from the left main coronary artery (LMCA). To our knowledge, this is the first case where an ARCA arising entirely from the LMCA is associated with critical bicuspid aortic valve stenosis.

A Cardiogenic Shock due to an Acute MI with LCA Arising from the Right Coronary Sinus Successfully Treated with PCI

Coronary artery anomalies (CAAs) are a diverse group of congenital anomalies with an incidence ranging from 0.17% in autopsy cases to 1.2% in patients undergoing coronary angiography. The left coronary artery (LCA) originating from the right coronary sinus is a very rare CAA with a frequency of 0.03%. We present a very rare case of a cardiogenic shock as a consequence of an acute anterolateral myocardial infarction by a totally occlusive lesion in the long left main stem with a complete LCA arising from the right coronary sinus in an 85-year-old female. This lesion was successfully treated with 2 drug-eluting stents. This is perhaps the first published case about cardiogenic shock due to an acute myocardial infarction associated with this type of coronary anomalies, and it presents a special challenge in the catheter laboratory.

Cross-sectional imaging of congenital pulmonary artery anomalies

Congenital pulmonary artery (PA) anomalies comprise a rare and heterogeneous spectrum of disease, ranging from abnormal origins to complete atresia. They may present in early infancy or more insidiously in adulthood, often in association with congenital heart disease such as tetralogy of Fallot or other syndromes. In recent years, cross-sectional imaging, including computed tomography (CT) and magnetic resonance imaging (MRI), has become widely utilized for the noninvasive assessment of congenital PA diseases, supplementing echocardiography and at times supplanting invasive angiography. In this article, modern CT and MRI techniques for imaging congenital PA disorders are summarized. The key clinical features, cross-sectional imaging findings, and treatment options for the most commonly encountered entities are then reviewed. Emphasis is placed on the ever-growing role of cross-sectional imaging options in facilitating early and accurate diagnosis and tailored treatment.

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 unusual presentation of anomalous left coronary artery from the pulmonary artery (ALCAPA) syndrome in a 70-year-old man: a case report

Background

We present a rare case of anomalous origin of the left coronary artery from the pulmonary artery syndrome in an elderly man, and we describe coronary computed tomographic angiographic imaging findings to improve diagnostic confidence for the evaluation of this uncommon coronary artery anomaly.

Case presentation

A 70-year-old Caucasian man came to our hospital with slight limitation of physical activity (New York Heart Association class II). He was asymptomatic for angina, syncope, and palpitations. Cardiac magnetic resonance imaging was performed after echocardiography because a hypertrophic cardiomyopathy was suspected; a plausible coronary artery anomaly was demonstrated as collateral evidence. Subsequently, coronary computed tomographic angiography showed the anomalous origin of left coronary artery from the pulmonary artery; the coronary vessels appeared markedly dilated and tortuous. Dilated intercoronary vessels along the epicardial surface of the heart and dilated bronchial arteries, corresponding to collateral pathways, were observed. Left ventricular hypertrophy, delayed subendocardial enhancement, and mitral insufficiency were better evaluated on magnetic resonance images. Invasive coronary angiography confirmed the main findings. Given the patient’s age and clinical performance, surveillance with medical management was considered appropriate, and surgical repair was avoided.

Conclusions

Confidence with the anatomic pattern and clinical significance of this anomalous condition is necessary to improve cardiac imaging evaluation ability. In our patient, coronary computed tomographic angiography proved to be a reliable imaging approach, superior to invasive coronary angiography in terms of diagnostic performance and patient safety.

Transseptal course of anomalous left main coronary artery originating from single right coronary orifice presenting as unstable angina

Transseptal course of coronary artery has often been described as a benign entity; however, this report and literature analysis provides growing evidence of high risk of serious cardiovascular events in this anomaly. We present a case of unstable angina in a patient with anomalous common origin of left and right coronary arteries from a single coronary ostium at the right sinus of Valsalva, with subsequent transseptal course of the left main artery, review of relevant literature, and discussion of possible management options.

Magnetic Resonance Imaging and Computed Tomography of Cardiac Masses and Pseudomasses in the Atrioventricular Groove

The atrioventricular (AV) groove constitutes the anatomic space separating the atria and ventricles. The AV groove is often difficult to visualize at echocardiography, and suspected lesions can be further assessed with cardiac computed tomography or magnetic resonance imaging. AV groove lesions may originate from within the AV groove or extend into this space from adjacent structures. The differential diagnosis for AV groove lesions is often wide, but a precise diagnosis can sometimes be made. This pictorial essay illustrates the magnetic resonance imaging and computed tomography appearance of common and uncommon AV groove lesions, and attempts to provide a logical framework for differential diagnosis when confronted with a known or suspected lesion at cross-sectional imaging.

Imaging of Cardiovascular Disease in Pregnancy and the Peripartum Period

OPINION STATEMENT

Cardiovascular disease is an important cause of morbidity and mortality during pregnancy and the postpartum period. During pregnancy, the cardiovascular system undergoes extensive hemodynamic, hormonal, and microstructural changes which may exacerbate a preexisting underlying cardiovascular condition or predispose to cardiovascular complications not typically seen in young healthy women. Such conditions include spontaneous coronary artery dissection, atherosclerotic coronary artery disease, and peripartum cardiomyopathy. When evaluating this patient population, the diagnostic strategy should be tailored to specifically assess this distinct disease spectrum. The choice of imaging techniques must also consider potential risks to both the mother and child; a unique challenge of diagnostic imaging during pregnancy. The risk of radiation from radiography, computed tomography, and nuclear medicine imaging; iodinated and gadolinium-based contrast media for computed tomography and magnetic resonance imaging respectively; and heat deposition from sonography are of special importance during pregnancy. A thorough understanding of pregnancy-specific cardiovascular complications and the capabilities and risks of available diagnostic imaging modalities is crucial to appropriately manage the pregnant patient.