role of mdct multisclice ct tin coronary artery part 4 (anomalous coronary arteries) dr ahmed esawy
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Dr/AHMED ESAWY
Anomalous Coronary
Arteries
Dr/AHMED ESAWY
Dr. Ahmed Esawy
MBBS M.Sc. MD
Dr/AHMED ESAWY
Dr/AHMED ESAWY
Normal Anatomy
R and L coronary arteries arise from the R and L aortic sinuses (of Valsalva)
Usually within 1cm superior to aortic valve
Arteries originate orthogonal to aortic wall
Epicardial (extramural course) course
Dr/AHMED ESAWY
RCA LCA
Dr/AHMED ESAWY
Anomalous Coronary Arteries
Found in ~0.1%-1.3% of patients undergoing cardiac catheterization
Can be assoc w/ congenital heart dz or be isolated anomaly
Angio evaluation can be challenging; misdiagnosis in up to 50% of cases
Rare but important cause of CP, arrhythmia, MI & sudden cardiac death; TREATABLE
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Why Is It So Dangerous?
Not fully understood; many variants benign
But some variants w/ mortality rates >50%
Depends on course of anomalous artery: retroaortic & anterior courses benign
Dangerous: “interarterial” course b/w aorta & RVOT
Pathophysiolgy unclear: compression or kinking during systole vs. abnl narrowing of ostium
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Anomalous Coronary Anatomy
~60% cases involve the circumflex
~40% involve the LM or RCA
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Anomalous Circumflex Artery
Anomalous circumflex:
Either off R sinus or branches off RCA
ALMOST ALWAYS RETROCARDIAC BENIGN
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Anomalous Circumflex: Retroaortic BENIGN
Normal Anatomy
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Retroaortic Anomalous Circumflex
Ao
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Congenital origin of the circumflex artery from the right coronary sinus, it shows separate origin slightly infro-posterior to the origin of the right coronary artery.
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Anomalous Right Coronary
Anomalous RCA:
Either off L sinus or branches off single left coronary
Can be retroaortic but IN VAST MAJORITY (>90%) OF CASES INTERARTERIAL MALIGNANT
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Normal Anatomy
Anomalous RCA: InterarterialISCHEMIA!!
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Anomalous RCA: Retroaortic BENIGN
Normal Anatomy
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WHICH??
Dr/AHMED ESAWY
L sinus of Valslava
R AV groove
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L sinus of Valslava
R AV groove
INTERARTERIAL ISCHEMIA!!!
Dr/AHMED ESAWY
Malignant right coronary artery
• anomalous origin of a right coronary artery from the left coronary sinus with an inter-arterial course, between the aorta and the main pulmonary artery.
• This variant has been called malignant because of its association with sudden death, especially in young asymptomatic athletes
Dr/AHMED ESAWY
Maximum intensity projection of top of heart showing both right coronary artey (RCA) and left coronary artey (LCA) originating from left coronary sinus. RCA has a slit-like ostium and courses between pulmonary artery (PA) and aorta (A)
Volume rendered image of same showing anomalous, interarterial course of right coronary artey (RCA), between pulmonary artery (PA) and aorta (A)
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the origin of the RCA from the left aortic sinus and its course between the RVOT and aorta. The compression of the RCA during its interarterial course is well appreciated. The normal origin of the left main coronary artery is also seen
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Malignant right coronary artery
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CCT image obtained for young patient with chest pain. Arrow indicates anomalous origin and course of right coronary artery between aorta and pulmonary arterial trunk.
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Multislice computed tomographic angiogram of an anomalous right coronary artery (RCA) that originates from the left coronary sinus. The vessel's course between the aorta and pulmonary artery caused anginal symptoms in this patient.
Visualization of coronary artery anomalies
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• 24 years old male with chest pain on exertion, CT coronary angiography was done reveal an abnormal origin of the right coronary artery from the left posterior aortic sinus with inter aorto pulmonary course that is liable for compression during systole.
Dr/AHMED ESAWY
Anomalous Left Coronary
Anomalous LCA:
Either off R sinus or branches off single right coronary
Can be retroaortic, anterior or intramural but
IN MOST CASES (75%) INTERARTERIAL MALIGNANT
Dr/AHMED ESAWY
Normal Anatomy
Anomalous LCA: InterarterialISCHEMIA!!
Dr/AHMED ESAWY
Normal Anatomy Anom LCA: Retroaortic
Anom LCA: Anterior Anom LCA: Intramural Dr/AHMED ESAWY
Normal Anatomy Anom LCA: Retroaortic
Anom LCA: Anterior Anom LCA: Intramural
BENIGN!!
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Dr/AHMED ESAWY
WHICH??
Dr/AHMED ESAWY
R sinus of Valsalva
Behind aorta to L AV groove Dr/AHMED ESAWY
R sinus of Valsalva
RETROAORTIC BENIGN!!
Behind aorta to L AV groove
Dr/AHMED ESAWY
Dr/AHMED ESAWY
WHICH??
Dr/AHMED ESAWY
Ao
RVOT
R sinus of Valsalva
Dr/AHMED ESAWY
Ao
RVOT
R sinus of Valsalva
INTERARTERIAL ISCHEMIA!!!
Dr/AHMED ESAWY
LCX with an anomalous origin, arising at the origin of the RCA, as shown in an oblique transverse thin-slab maximumintensity projection image. The LCX follows a retro-aortic course to its normal position in the left atrioventricular groove (arrows). This is a benign variant that is not associated with ischemia
Dr/AHMED ESAWY
47 year old woman with atypical chest pain: Anomalous LCA from RT coronary sinus
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There is an anomalous origin of the LCA from the right sinus of Valsalva and the LCA courses between the aorta and pulmonary artery. This interarterial course can lead to compression of the LCA (yellow arrows) resulting in myocardial ischemia.
The other anomalies in the figure on the left are not hemodynamically significant.
Dr/AHMED ESAWY
Interarterial LCA On the left images of a patient with an anomalous origin of the LCA from the right sinus of Valsalva and coursing between the aorta and pulmonary artery. Sudden death is frequently observed in these patients.
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ALCAPA On the left images of a patient with an anomalous origin of the LCA from the pulmonary artery, also known as ALCAPA. ALCAPA results in the left ventricular myocardium being perfused by relatively desaturated blood under low pressure, leading to myocardial ischemia. ALCAPA is a rare, congenital cardiac anomaly accounting for approximately 0.25-0.5% of all congenital heart diseases. Approximately 85% of patients present with clinical symptoms of CHF within the first 1-2 months of life.
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Left to right shunt: septal branch of LAD teminates in right ventricle
Fistula On the image on the left we see a large LAD giving rise to a large septal branch that terminates in the right ventricle (blue arrow). Dr/AHMED ESAWY
“Myocardial Bridging”
Segment of coronary artery dives below epicardial surface, surrounded by myocardium
In some cases the buried segment significantly narrows during systole, thought to compromise coronary blood flow
Controversial as most coronary flow is during diastole
This finding is USUALLY BENIGN but isolated reports of clot at site of bridge leading to MI
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Myocardial bridge over LAD
Diastole Systole
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Myocardial bridging Myocardial bridging is most commonly observed of the LAD (figure). The depth of the vessel under the myocardium is more important that the lenght of the myocardial bridging. There is debate, whether some of these myocardial bridges are hemodynamically significant.
Dr/AHMED ESAWY