The Role of Computed Tomography Coronary Angiography in the Management of Coronary Anomalies

Abstract

Congenital abnormalities of coronary arteries are an uncommon cause of sudden cardiac death and are difficult to detect at coronary angiography. We describe two patients with acute coronary syndrome and non-occlusive coronary artery disease in which a 64-multidetector computed tomography (MDCT) coronary angiography showed the presence of a malignant coronary anomaly. Sixty-four-MDCT with the possibility of 3D reconstructions allows for easier diagnosis of coronary anomalies and provides essential details necessary for operative intervention. doi: 10.1111/jocs.12040 (J Card Surg 2013;28:33-36) Congenital abnormalities of coronary arteries may be found incidentally in 0.3% to 1% of healthy individuals. 1They are an uncommon but important cause of chest pain, myocardial ischemia, and syncope and, above all, they carry a high risk for sudden cardiac death (up to 30% of patients), particularly before 35 years of age. 2The detection and characterization of these anomalies is crucial for the management of these patients. We describe two cases of patients with angina but nonsignificant coronary artery disease at angiography in which the coronary anomaly was diagnosed using a 64-MDCT (Light Speed VCT, General Electrics, Milwaukee, WI). The usefulness of this non-invasive diagnostic tool in the diagnosis of the coronary anomalies is the subject of this clinical review. PATIENT 1A 66-year-old female with hypertension presented with sudden chest pain. The electrocardiogram (ECG) showed sinus rhythm with ST elevation in V2 and V3 leads. Blood tests revealed a slight increase of T-troponine (0.06 ng/mL-normal values 0.01 to 0.03 ng/mL). The patient underwent conventional coronary angiography (CCA) which revealed a myocardial bridge of the anterior descending artery and an anomalous origin of the right coronary artery (RCA), with no significant disease of the other epicardial vessels (Fig. 1a). Computed tomography coronary angiography (CTCA) confirmed the absence of significant atherosclerosis and the presence of a short intramyocardial path of the anterior descending coronary artery (Fig. 1c) and, in addition, revealed the aberrant origin of the RCA from the opposite coronary sinus (Fig. 1b). The patient, though informed about potential risks associated with this anomaly and available therapeutic options, refused any surgical intervention and agreed to long-term b-blocker medical therapy with a strict follow-up. She has remained asymptomatic at one-year follow-up. PATIENT 2A 49-year-old male presented with chest pain. ECG showed sinus rhythm with ST elevation in all the electrocardiographic leads; the echocardiogram was normal; blood T-troponine values were 0.05 ng/mL. The patient underwent coronary angiography that showed non-occlusive coronary artery disease and revealed an aberrant origin of the dominant RCA from the left Disclosures: none.

Surgical Management of Coronary Arteriovenous Fistula in Patients Presenting with Acute Coronary Syndrome—A Local University Hospital 6 Years Experience

“…In a comprehensive review of patients undergoing coronary angiographic studies the incidence of coronary anomalies was 110/1950 = 5.6%, absent left main in 13/1950 = 0.67% and coronary arteriovenous fistula (CAVF) in 17/1950 = 0.87% [6]. In recent years, cardiac computed tomography (CCT) has become the test of choice for diagnosis of coronary anomalies [7]. In patients with atherosclerotic coronary artery disease presenting with acute coronary syndrome, surgical coronary revascularization can be safely associated with ligation excision of the CAVF.…”

Comprehensive assessment of left anterior descending coronary artery to pulmonary artery fistula

“…CTCA is a well-proven non-invasive imaging modality that provides an excellent overview of the cardiac vascular anatomy and high-resolution imaging of both origin and termination of fistulous tracts, allowing its complete depiction. Compared with CCA, CTCA can provide a more accurate assessment of coronary fistulas in less time, administering less contrast medium and avoiding burden and complications of arterial puncture and vascular catheterization [5] . On the other hand, indisputable advantage of CCA is the opportunity to perform intra-operative therapeutic maneuvers.…”

Evaluation of myocardial infarction patients after coronary revasculation by dual-phase multi-detector computed tomography: Now and in future

“…In patients with acute coronary syndrome sowing ambiguous ST segment changes on electrocardiogram, MDCT adds diagnostic accuracy and helps to exclude pulmonary embolism, aortic dissection, and other thoracic disease [31] . For patients with complex coronary artery disease who require bypass surgery, the 3D-image reconstruction from MDCT also provides additional details to operators [32] . Furthermore, it has been reported that the myocardial viability assessment derived from MDCT after primary revascularization may help to predict the clinical outcome in patients with AMI [22] .…”