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CARDIAC AND CORONARY CARDIAC AND CORONARY ARTERY ANATOMYARTERY ANATOMY
NASCI MEETING, ORLANDO FLORIDA 2009NASCI MEETING, ORLANDO FLORIDA 2009
KOSTAKI G. BIS, MD, FACRKOSTAKI G. BIS, MD, FACRDEPARTMENT OF RADIOLOGYDEPARTMENT OF RADIOLOGY
WILLIAM BEAUMONT HOSPITALWILLIAM BEAUMONT HOSPITALRoyal Oak, MichiganRoyal Oak, Michigan
NO DISCLOSURESNO DISCLOSURES
OBJECTIVESOBJECTIVES
CARDIAC ANATOMYCARDIAC ANATOMY-- VARIOUS IMAGING PLANESVARIOUS IMAGING PLANESNORMAL, VARIANT and SOME ANOMALOUS ANATOMY NORMAL, VARIANT and SOME ANOMALOUS ANATOMY OF CORONARY ARTERIES AND SUBJACENT VEINSOF CORONARY ARTERIES AND SUBJACENT VEINS
IMPORTANT FOR CORRECT IMAGE INTERPRETATION AND IMPORTANT FOR CORRECT IMAGE INTERPRETATION AND PATIENT CAREPATIENT CARE
Axial Anatomy of HeartAxial Anatomy of Heart
SVCSVC
ASCENDING ASCENDING AORTAAORTA
DESCENDING DESCENDING AORTAAORTA
RR-- SUPERIOR SUPERIOR PULMONARY PULMONARY VEINVEIN
LL-- SUPERIORSUPERIORPULMONARY PULMONARY VEINVEIN
MAINMAINPULMONARYPULMONARYARTERY BIFURCARTERY BIFURC’’NN
Axial Anatomy of HeartAxial Anatomy of Heart
LEFT ATRIALLEFT ATRIALAPPENDAGEAPPENDAGE
Axial Anatomy of HeartAxial Anatomy of Heart
LADLAD
INFLOW INFLOW LL-- SUPERIORSUPERIORPULMONARYPULMONARYVEINVEIN
PULMONARYPULMONARYVALVEVALVE
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Axial Anatomy of HeartAxial Anatomy of Heart
RVOTRVOT
LL--MAINMAIN
SVC SVC INFLOWINFLOW
INFLOWINFLOWRR-- SUPERIORSUPERIORPULMONARYPULMONARYVEINVEIN
Axial Anatomy of HeartAxial Anatomy of Heart
RIGHTRIGHTATRIALATRIALAPPENDAGEAPPENDAGE
CEPHALADCEPHALADINTERATRIALINTERATRIALSEPTUMSEPTUM
LL-- MAINMAINORIGINORIGIN
Axial Anatomy of HeartAxial Anatomy of Heart
RCARCA
LADLAD
LCxLCx
NONNON--CORONARYCORONARYCUSPCUSP
Axial Anatomy of HeartAxial Anatomy of Heart
SASA--NODENODEBRANCHBRANCH
INFLOWINFLOWLL-- INFERIORINFERIORPULMONARYPULMONARYVEINVEIN
Axial Anatomy of HeartAxial Anatomy of Heart
AORTIC VALVEAORTIC VALVE
Axial Anatomy of HeartAxial Anatomy of Heart
LVOTLVOT
MITRAL VALVEMITRAL VALVE
INFLOWINFLOWRR--INFERIORINFERIORPULMONARYPULMONARYVEINVEIN
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Axial Anatomy of HeartAxial Anatomy of Heart
RCARCA LADLAD
LCxLCx
Axial Anatomy of HeartAxial Anatomy of Heart
INTERATRIALINTERATRIALSEPTUMSEPTUM
ANTEROLATERALANTEROLATERALPAPILLARYPAPILLARYMUSCLEMUSCLE
RVRV
RARA
LALA
LVLV
INTERVENTRICULARINTERVENTRICULARSEPTUMSEPTUM
Axial Anatomy of HeartAxial Anatomy of Heart
INFLOWINFLOW--CORONARY CORONARY SINUSSINUS
TRICUSPIDTRICUSPIDVALVEVALVEPLANEPLANE
Axial Anatomy of HeartAxial Anatomy of Heart
CORONARYCORONARYSINUSSINUS
IVCIVCINFLOWINFLOW
Axial Anatomy of HeartAxial Anatomy of Heart
POSTEROMEDIALPOSTEROMEDIALPAPILLARYPAPILLARYMUSCLESMUSCLES
DISTALDISTALRCARCA
SUPRAHEPATICSUPRAHEPATICIVCIVC
Axial Anatomy of HeartAxial Anatomy of Heart
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Axial Anatomy of HeartAxial Anatomy of Heart
PDAPDA
Axial Anatomy of HeartAxial Anatomy of Heart--MRIMRI
IMAGING PLANES (SETIMAGING PLANES (SET--UP)UP)
LAOLAO
RAORAO
CARDIAC ANATOMYCARDIAC ANATOMY--(4D (4D MIPsMIPs))(VERTICAL LONG AXIS(VERTICAL LONG AXIS--RAO)RAO)
RAORAO
CARDIAC AND CORONARY CARDIAC AND CORONARY ARTERY ANATOMYARTERY ANATOMY--(3D(3D--MIPs)MIPs)(VERTICAL LONG AXIS(VERTICAL LONG AXIS--RAO)RAO)
CARDIAC ANATOMYCARDIAC ANATOMY--(CINE MRI)(CINE MRI)(VERTICAL LONG AXIS(VERTICAL LONG AXIS--RAO)RAO)
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CARDIAC ANATOMYCARDIAC ANATOMY--(4D(4D--MIPs)MIPs)(HORIZONTAL LONG AXIS, 4 CHAMBER)(HORIZONTAL LONG AXIS, 4 CHAMBER)
HLAHLA
CARDIAC AND CORONARY CARDIAC AND CORONARY ARTERY ANATOMYARTERY ANATOMY--(3D(3D--MIPs)MIPs)
(HORIZONTAL LONG AXIS)(HORIZONTAL LONG AXIS)
CARDIAC ANATOMYCARDIAC ANATOMY--(CINE MRI)(CINE MRI)(HORIZONTAL LONG AXIS)(HORIZONTAL LONG AXIS)
CARDIAC ANATOMYCARDIAC ANATOMY--(CINE MRI)(CINE MRI)(HORIZONTAL LONG AXIS)(HORIZONTAL LONG AXIS)
CARDIAC ANATOMYCARDIAC ANATOMY--(4D(4D--MIPs)MIPs)(SHORT AXIS(SHORT AXIS--LAO)LAO)
LAOLAO
CARDIAC AND CORONARY CARDIAC AND CORONARY ARTERY ANATOMYARTERY ANATOMY--(3D(3D--MIPs)MIPs)
(SHORT AXIS(SHORT AXIS--LAO)LAO)
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CARDIAC ANATOMYCARDIAC ANATOMY--(CINE MRI)(CINE MRI)(SHORT AXIS(SHORT AXIS--LAO)LAO)
1717--MYOCARDIAL SEGMENT MODELMYOCARDIAL SEGMENT MODEL
Above schematic is for RCA dominance.Above schematic is for RCA dominance.Note: With left dominance, Note: With left dominance, LCxLCx supplies the inferior septum and inferior supplies the inferior septum and inferior
distributionsdistributions
BASEBASE
MIDDLEMIDDLE
APEXAPEX
CARDIAC ANATOMYCARDIAC ANATOMY--(CINE MRI)(CINE MRI)(INLET(INLET--OUTLET, 3OUTLET, 3--CHAMBER, CHAMBER, ““PARASTERNAL LONG AXISPARASTERNAL LONG AXIS””))
ADDITIONAL VIEWSADDITIONAL VIEWS--(CINE MRI)(CINE MRI)
LVOT RVOT AORTIC ROOTLVOT RVOT AORTIC ROOTDirect coronalDirect coronal Oblique coronalOblique coronal Oblique axialOblique axial
CORONARY DOMINANCECORONARY DOMINANCE
Determined by blood supply to inferior Determined by blood supply to inferior wallwallPDA, PLB and AVPDA, PLB and AV--node branches help node branches help define dominancedefine dominance
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RIGHT DOMINANCE (80RIGHT DOMINANCE (80--85%)85%)
RCA gives rise to PDA, PLB and AVRCA gives rise to PDA, PLB and AV--node node branchesbranchesPDAPDA supplies inferior septumsupplies inferior septumPLBPLB supplies inferior wallsupplies inferior wall
DOMINANT RCA ANATOMYDOMINANT RCA ANATOMY--ANTERIOR SCHEMATICANTERIOR SCHEMATIC
DOMINANT RCA ANATOMYDOMINANT RCA ANATOMY RCA ANATOMYRCA ANATOMY
RCA proximalRCA proximal –– From From ostiumostiumto one half the distance to the to one half the distance to the acute margin of the heart.acute margin of the heart.RCA middleRCA middle–– RCA from above RCA from above segment to the acute margin segment to the acute margin of heart.of heart.RCA distalRCA distal -- From the acute From the acute margin to the origin of the margin to the origin of the PDA.PDA.Report of the AdReport of the Ad--Hoc Committee for Hoc Committee for Grading of Coronary Artery Disease, Grading of Coronary Artery Disease, Council on Cardiovascular Surgery. Council on Cardiovascular Surgery. Circulation 1975; 51:5Circulation 1975; 51:5--40.40.
CONUS BRANCH VARIATIONSCONUS BRANCH VARIATIONS
50%50%
50%50%
ConusConus BranchBranchSupplies RVOTSupplies RVOT
CONUS BRANCH FROM LADCONUS BRANCH FROM LAD
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SASA--NODE BRANCH VARIATIONSNODE BRANCH VARIATIONS
55%55%
45%45%
FROMFROMRCARCA
FROMFROMLCxLCx
RV (ACUTE) MARGINAL BRANCHESRV (ACUTE) MARGINAL BRANCHESSUPPLY ANTERIOR RVSUPPLY ANTERIOR RV
PDA and PLB VARIATIONPDA and PLB VARIATION--RCA DOMINANCERCA DOMINANCE
SINGLE PDASINGLE PDAand PLBand PLB
DUAL PDADUAL PDAand PLBand PLB
HIGH PDAHIGH PDATAKETAKE--OFFOFF
AVAV--NODE BRANCH NODE BRANCH --RIGHT DOMINANCERIGHT DOMINANCE
Usually distal to PDAUsually distal to PDAPDAPDA
LEFT DOMINANCE (15LEFT DOMINANCE (15--20%)20%)
PDA and PLBPDA and PLB arise from arise from LCxLCx and supply and supply inferior wall and inferior septum inferior wall and inferior septum AVAV--Node branch usually distal to PDANode branch usually distal to PDA
LAO SCHEMATICLAO SCHEMATIC--DOMINANT LEFT CORONARY DOMINANT LEFT CORONARY
ANATOMYANATOMY
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DOMINANT DOMINANT LCxLCx ANATOMYANATOMY
AVGA= AVAVGA= AV--groove artery of groove artery of LCxLCx
DOMINANT DOMINANT LCxLCx ANATOMYANATOMY
DOMINANT DOMINANT LCxLCx ANATOMYANATOMY--Dual PDADual PDA COCO--DOMINANCE (5%)DOMINANCE (5%)
PDA ARISES FROM RCAPDA ARISES FROM RCA PLB ARISES FROM PLB ARISES FROM LCxLCx
LAO SCHEMATICLAO SCHEMATIC--DOMINANT LEFT CORONARY DOMINANT LEFT CORONARY
ANATOMYANATOMYLEFT MAIN BIFURCATIONLEFT MAIN BIFURCATION
LMLM--55--10 mm10 mm
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LEFT MAIN TRIFURCATIONLEFT MAIN TRIFURCATION--RAMUS INTERMEDIUS BRANCH RAMUS INTERMEDIUS BRANCH
VARIATIONVARIATION
MOST COMMON LCA VARIATIONMOST COMMON LCA VARIATION
RAMUS INTERMEDIUS BRANCH RAMUS INTERMEDIUS BRANCH VARIATIONVARIATION
RI DISTRIBUTIONRI DISTRIBUTION--AS DIAGONAL ORAS DIAGONAL OROBTUSE MARGINALOBTUSE MARGINAL
Single RISingle RI
Dual RIDual RI
LAD ANATOMYLAD ANATOMYLAD proximalLAD proximal –– Proximal to and including Proximal to and including origin of the first major origin of the first major septalseptal perforator.perforator.LAD middleLAD middle –– Distal to origin of first major Distal to origin of first major septalseptal perforator and extending to point perforator and extending to point where the LAD forms an angle (RAO where the LAD forms an angle (RAO view). This is often, but not always, close view). This is often, but not always, close to the origin of the second diagonal. If this to the origin of the second diagonal. If this angle or diagonal is not identifiable, this angle or diagonal is not identifiable, this segment ends one half the distance from segment ends one half the distance from the first major the first major septalseptal perforator to the perforator to the apex.apex.LAD apicalLAD apical –– Beginning at the end of the Beginning at the end of the previous segment and extending to or previous segment and extending to or beyond the apex.beyond the apex.
Report of the AdReport of the Ad--Hoc Committee for Grading of Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Coronary Artery Disease, Council on Cardiovascular Surgery. Circulation 1975; 51:5Surgery. Circulation 1975; 51:5--40.40.
RAORAO
LAD ANATOMYLAD ANATOMY
SEPTAL PERFORATOR BRANCH SEPTAL PERFORATOR BRANCH VARIATIONVARIATION
NUMBERED IN SEQUENCENUMBERED IN SEQUENCES1, S2, S3S1, S2, S3……....
SUPPLY VENTRICULAR SUPPLY VENTRICULAR SEPTUMSEPTUM
DIAGONAL BRANCH ANATOMYDIAGONAL BRANCH ANATOMY
NUMBERED IN SEQUENCENUMBERED IN SEQUENCED1, D2, D3D1, D2, D3……....
SUPPLY ANTERIORSUPPLY ANTERIORWALLWALL
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LCX ANATOMYLCX ANATOMY
LCxLCx proximalproximal –– From itFrom it’’s s origin off LCA to and origin off LCA to and including origin of including origin of obtuse marginal.obtuse marginal.LCxLCx distaldistal –– The The LCxLCxdistal to the origin of the distal to the origin of the obtuse marginal and obtuse marginal and running along or close to running along or close to left (posterior) AV left (posterior) AV groove.groove.Report of the AdReport of the Ad--Hoc Committee for Hoc Committee for Grading of Coronary Artery Disease, Grading of Coronary Artery Disease, Council on Cardiovascular Surgery. Council on Cardiovascular Surgery. Circulation 1975; 51:5Circulation 1975; 51:5--40.40.
NONNON--DOMINANT DOMINANT LCxLCx ANATOMYANATOMY
AXIALAXIAL--ANTERIORANTERIOR LAOLAO
DOMINANT DOMINANT LCxLCx ANATOMYANATOMY
OBTUSE MARGINAL BRANCHES OBTUSE MARGINAL BRANCHES NUMBERED IN SEQUENCE : OM1, OM2, OM3NUMBERED IN SEQUENCE : OM1, OM2, OM3……....
SUPPLY LATERAL WALLSUPPLY LATERAL WALL
Cardiac VeinsCardiac Veins
Cardiac VeinsCardiac Veins PDA and MIDDLE CARDIAC VEINPDA and MIDDLE CARDIAC VEIN
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SMALL CARDIAC VEINSMALL CARDIAC VEIN ANTERIOR INTERVENTRICULAR ANTERIOR INTERVENTRICULAR VEIN AND GREAT CARDIAC VEINVEIN AND GREAT CARDIAC VEIN
CAUDALCAUDAL--TOTO--CRANIALCRANIALACQUISITIONACQUISITIONTRIPLE R/O PROTOCOLTRIPLE R/O PROTOCOL
STANDARD CRANIALSTANDARD CRANIAL--TOTO--CAUDALCAUDALACQUISITIONACQUISITION
GCVGCVGCVGCV
AIVAIVAIVAIV AIVAIV
CORONARY SINUS ANATOMYCORONARY SINUS ANATOMY
DOMINANTDOMINANTLCxLCx
NONNON--DOMINANTDOMINANTLCxLCx
What is an Anomaly?What is an Anomaly?NormaNormal –– the anatomy seen in >99% of the anatomy seen in >99% of the populationthe population66
Variant –– unusual anatomy seen in >1% unusual anatomy seen in >1% of the populationof the population
AnomalyAnomaly –– unusual and uncommon unusual and uncommon anatomy seen in <1% of the populationanatomy seen in <1% of the population
Coronary Artery AnomaliesCoronary Artery AnomaliesAnomalies of Origin
High takeoffMultiple ostiaSingle coronary arteryAnomalous origin of the coronary artery from the
pulmonary artery*Origin of coronary artery from the opposite or
noncoronary sinus with an anomalous course (either retroaortic, interarterial,* prepulmonic, septal (subpulmonic).
Anomalies of CourseMyocardial bridging*Duplication of arteries
Anomalies of terminationCoronary artery fistulas*Coronary arcadeExtracardiac termination
*-Potentially hemodynamically significant or malignant abnormalities
Anomalies of Course Anomalies of Course –– Myocardial Myocardial BridgingBridging
Myocardial bridgingMyocardial bridging -- When a coronary When a coronary artery runs artery runs intramurallyintramurally within the within the myocardium instead of myocardium instead of epicardiallyepicardially..
Encased segment called tunneled artery.Encased segment called tunneled artery.
SuperficialSuperficial bridge (75%) (no deviation into bridge (75%) (no deviation into myocardium) myocardium)
DeepDeep Bridge (25%) (Dips, Bridge (25%) (Dips, ieie UU--shaped, into shaped, into myocardium)myocardium)
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SUPERFICIAL AND DEEP SUPERFICIAL AND DEEP MYOCARDIAL BRIDGEMYOCARDIAL BRIDGE
SungSung--Min Min KoKo IntInt J J CardiovascCardiovasc ImIm, 2007, 2007
SuperficialSuperficial
DeepDeep
DEEP MYOCARDIAL BRIDGEDEEP MYOCARDIAL BRIDGE
Anomalies of Course Anomalies of Course –– Myocardial Myocardial BridgingBridging
Usually asymptomatic with good prognosis. Has Usually asymptomatic with good prognosis. Has been associated with arrhythmia, unstable angina, been associated with arrhythmia, unstable angina, myocardial infarction and sudden death.myocardial infarction and sudden death.
Incidence ranges from 0.5Incidence ranges from 0.5--2.5% in angiographic 2.5% in angiographic studies to 15studies to 15--85% in pathologic series and thus, may 85% in pathologic series and thus, may be considered an anatomic variant rather than a true be considered an anatomic variant rather than a true anomaly.anomaly.
5.7% incidence on CTA 5.7% incidence on CTA (Sung(Sung--Min Min KoKo, et.al. , et.al. IntInt J J CardiovascCardiovasc ImImOct. 2007)Oct. 2007)
Additional Facts Additional Facts –– Myocardial BridgingMyocardial Bridging
When symptoms occur they often donWhen symptoms occur they often don’’t t manifest until the third decade of life.manifest until the third decade of life.
MB predisposes artery to atherosclerosis MB predisposes artery to atherosclerosis proximal to bridge.proximal to bridge.
Large multicenter studies needed for Large multicenter studies needed for incidence and link between MB and chest incidence and link between MB and chest pain.pain.
Anomalies of OriginAnomalies of Origin
A coronary artery that arises from the opposite or A coronary artery that arises from the opposite or noncoronary cusp can take any one of four common noncoronary cusp can take any one of four common courses:courses:
1. interarterial (between aorta and pulmonary artery)1. interarterial (between aorta and pulmonary artery)2. 2. retroaorticretroaortic3. 3. prepulmonicprepulmonic4. septal (4. septal (subpulmonicsubpulmonic))
The course taken by the anomalous artery is The course taken by the anomalous artery is critically important as the critically important as the retroaorticretroaortic, , prepulmonicprepulmonicand septal courses are considered benign while the and septal courses are considered benign while the interarterial course can be associated with sudden interarterial course can be associated with sudden cardiac death.cardiac death.
ANOMALOUS RCAANOMALOUS RCA--INTERARTERIAL COURSEINTERARTERIAL COURSE
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Left Main Arising from Right Coronary Left Main Arising from Right Coronary Cusp with Interarterial CourseCusp with Interarterial Course
Rt.
Non Lt.
Rt.
Lt.
Ant.
Rt.
Non Lt.
Rt.Rt.
Non Lt.
Rt.
Lt.
Ant.
Axial MIP and Volume rendered images show the Left main Coronary artery originating from the right coronary cuspand coursing between the aorta and pulmonary artery. Theschematic diagram depicts a similar situation.
PA
Ao
Left Main Arising from Right Coronary Left Main Arising from Right Coronary Cusp with Interarterial CourseCusp with Interarterial Course
A second case demonstrating an anomalous origin of the left main coronary artery from the right coronary cusp with interarterial course. MIP images in various projections display the anomaly, however, the sagittal MIP image on the right confirmsthe interarterial course
Ao
PA
Left Main Arising from Right Coronary Left Main Arising from Right Coronary Cusp with Interarterial CourseCusp with Interarterial Course
Anterior 3D Volume rendered images demonstrate the left main coronary artery arising from the right coronary cusp with interarterial course. The image on the right has had the pulmonary artery digitally removed by changing the window.
ANOMALOUS LM ORIGINANOMALOUS LM ORIGIN--SeptalSeptal ((SubpulmonicSubpulmonic) Course) Course
FROM RIGHT CORONARY CUSPFROM RIGHT CORONARY CUSPCOURSECOURSE--BETWEEN RVOT AND AORTIC ROOTBETWEEN RVOT AND AORTIC ROOT
Left Main Arising from Right Coronary Left Main Arising from Right Coronary Cusp with Septal CourseCusp with Septal Course
The anomalous left main can be seendescending inferiorly. This septal or subpulmonic course has not been associated with sudden death.
LM
SINGLE CORONARY ARTERYSINGLE CORONARY ARTERYLADLAD--VENTRAL TO RVOTVENTRAL TO RVOT--PrepulmonicPrepulmonic
LCxLCx--POSTERIOR TO AORTIC ROOTPOSTERIOR TO AORTIC ROOT--RetroaorticRetroaortic
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Anomalous Left Coronary Artery Anomalous Left Coronary Artery Originating From the Pulmonary Originating From the Pulmonary
ArteryArtery
Left main coronary artery is seen originating from the posterior pulmonary artery. Note the large size of both the left main, LAD and the right coronary artery.
Anomalous Left Coronary Artery Anomalous Left Coronary Artery Originating From the Pulmonary Originating From the Pulmonary
ArteryArtery
SAME CASE AS PREVIOUS SLIDE: ALCAPA with large right coronary artery. The RCA is hypertrophied as it is providing collateral flow to the left coronary bed. Note the intramyocardial collateral vessels on the MIP image on the right.
Anomalous Pulmonary Artery Anomalous Pulmonary Artery Origin of Either the RCA or LCAOrigin of Either the RCA or LCA
Also known as ALCAPA or BlandAlso known as ALCAPA or Bland--WhiteWhite--Garland syndrome.Garland syndrome.
A rare congenital defect that represents A rare congenital defect that represents only 0.25only 0.25--0.5% of all congenital cardiac 0.5% of all congenital cardiac defects.defects.
Usually an isolated defect, but can be Usually an isolated defect, but can be associated with other anomalies such as associated with other anomalies such as ASD, VSD and aortic coarctation in ASD, VSD and aortic coarctation in approximately 5% of cases.approximately 5% of cases.
Anomalous Pulmonary Artery Anomalous Pulmonary Artery Origin of Either the RCA or LCAOrigin of Either the RCA or LCA
Symptoms usually present at 1Symptoms usually present at 1--2 months of 2 months of age when LCA pressures rise and PA age when LCA pressures rise and PA pressures decrease causing left to right pressures decrease causing left to right shunting.shunting.
Without treatment, approximately 90% of Without treatment, approximately 90% of infants will die in the first year of life.infants will die in the first year of life.
Survival beyond infancy occurs when there Survival beyond infancy occurs when there are abundant intercoronary collaterals or the are abundant intercoronary collaterals or the LCA supplies relatively less area of the LCA supplies relatively less area of the myocardium.myocardium.
Anomalies of Termination Anomalies of Termination ––Coronary Artery FistulaCoronary Artery Fistula
Usually congenital and accounts for 0.2Usually congenital and accounts for 0.2--0.4% 0.4% of congenital cardiac anomalies.of congenital cardiac anomalies.
Most are clinically and Most are clinically and hemodynamicallyhemodynamicallyinsignificant and are found incidentally.insignificant and are found incidentally.
Approximately 60% of coronary artery Approximately 60% of coronary artery fistulas originate from the right coronary fistulas originate from the right coronary artery.artery.
Anomalies of Termination Anomalies of Termination ––Coronary Artery FistulaCoronary Artery Fistula
Coronary artery can communicate with Coronary artery can communicate with either a chamber of the heart (coronary-cameral fistula) or a segment of the systemic or pulmonary circulation (coronary arteriovenous fistula).
Stealing of blood to the low pressure systemic circulation leaves myocardium at risk for ischemia.
In response, the coronary dilates and may progress to frank aneurysm which can ulcerate, thrombose or rupture.
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Anomalies of Termination Anomalies of Termination ––Coronary Arteriovenous FistulaCoronary Arteriovenous Fistula
A complex fistula is seen between the left main coronary artery and the pulmonaryartery. Note the tortuous vessels and the contrast spill into the PA (arrows).
Ao
Anomalies of Termination Anomalies of Termination ––Coronary Arteriovenous FistulaCoronary Arteriovenous Fistula
Another example of a complex coronary artery fistula, this one associated with a coronary artery aneurysm (arrows). The fistula is from the LAD and continues beyond the aneurysm as a serpiginous vessel over the main pulmonary artery.
Anomalies of Termination Anomalies of Termination ––Coronary Arteriovenous FistulaCoronary Arteriovenous Fistula
SAME CASE AS PRVIOUS SLIDE:Complex coronary artery fistula from the LAD to the pulmonary artery with aneurysm (arrows).
(Coronary Anatomy(Coronary Anatomy--Swine Model)Swine Model)SELECTIVE CTA AORTIC ROOT CTA XSELECTIVE CTA AORTIC ROOT CTA X--RAY ANGIO EXRAY ANGIO EX--VIVOVIVO
CONCLUSIONCONCLUSION
MULTIDETECTOR CTAMULTIDETECTOR CTA
High Temporal and Spatial ResolutionHigh Temporal and Spatial Resolution2D2D--MPR, 3D and 4DMPR, 3D and 4D--MIP and VR MIP and VR TechniquesTechniquesDetailed Depiction of Cardiac and Coronary Detailed Depiction of Cardiac and Coronary Anatomy Anatomy
THE ENDTHE ENDTHANK YOUTHANK YOU
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