Radiodiagnosis

1. ROLE OF CT ANGIOGRAPHY IN
DIAGNOSIS OF CORONARY Anomalies
Prepared by :-
GHADA SHETA
Radiodiagnosis Resident – Kasr Alaini

2. INTRODUCTION
 Variations in coronary anatomy are often recognized in
association with structural forms of congenital heart disease.
Understanding the pathophysiology is important in guiding
management because variations in coronary anatomy are
common. Because of considerable heterogeneity of coronary
vessels, what is considered atypical, abnormal, anomalous,
accessory, ectopic, variant, or significant is often unclear. The
terms anomalous or abnormal are used to define any variant
form observed in less than 1% of the general population.
 Importantly, coronary artery anomalies are cause of sudden
death in young athletes in the absence of additional heart
abnormalities .
 Despite being a disease of infancy , most of cases are discoved
so late ….

3. HOW TO SUSPECT ?!!
Pediatric CAD usually presents in infancy at age 2-3 months as
cardiogenic shock (Poor feeding,Dyspnea,Wheezing,Periods
of pallor, Failure to thrive)
OR angina (Irritability, Diaphoresis)
or later in childhood or adolescence as an activity-related
phenomenon, syncope, or chest pain.
Unfortunately, in a significant number of patients, symptoms
may not be evident before a sudden catastrophic,
presumably dysrhythmic, event.

4. HOW TO DIAGNOSE?!!
• In the initial evaluation of a critically ill infant,
include an assessment of acid-base status and
rule out systemic sepsis(as the most
common& fatal cause of shock).
• CXR
• Echocardiography
• MRI
• CT angiography

5. CXR
• Radiographic features of anomalous coronary
arteries are similar to those of CHF, including
cardiomegaly, pulmonary venous congestion,
interstitial edema, and left atrial enlargement
especially if accompanied with other heart
anomalies .

6. Echocardiography
• By routine evaluation of coronary arteries, chances for
identification of coronary variants are increased.
• in patients sustaining myocardial injury, Echo
demonstrates a hypocontractile, dilated, poorly
functioning ventricle. Global or regional areas of
myocardial dysfunction may be present. Mitral valve
insufficiency from papillary muscle dysfunction is often
demonstrable and may be recoverable.
• Associated congenital heart defects were found in 53%
of individuals with coronary anomalies.

7. MRI
• Newer MRI sequences have improved image quality
with better anatomical definition.
• Black-blood imaging enables visualization of the lumen
and aortic wall.
• Three-dimensional reconstruction provides optimal
anatomical information.
• MRI does not use radiation and enables adequate
definition of the origin of the coronary vessels . But is
limited by time of acquisition and gating requirements
for cardiac study and may suboptimally define the
distal course and extent of a coronary anomaly.

8. CT Angiography
THE ROAD MAP
Multidetector computed tomography with
(ECG)-gating has a faster volume coverage
and higher spatial and temporal resolution
and is a noninvasive and accurate technique
that can be used to show these kinds of
anomalies.

9. REQUIREMENTS
• Multidetector Spiral Computed Tomography using 64
detectors.
• ECG monitor (As the best image quality for CCTA is
typically obtained at the specific phase of the R-R
interval (usually mid- to end-diastole), the tube current
(and thus dose) can be reduced in the phases where
image quality is not optimal. This is the most common
method to reduce radiation dose.
• Contrast media ( omnipaque) “dose in infants &
children is 2ml / kg “ given by an injector .
• Expert operator & Radiologist .

10. Patient Preparation
• No history of contrast allergy or renal impairement .
• Avoid eating solid food 4 hours before the study and increase fluid intake
prior to the study.
• Beta-blocker administration to lower the heart rate (with single-source CT
scanners below 65 bpm…Dual-source CT up to 90 bpm) and decrease
motion artifact.
• Sublingual nitroglycrein to dilate the coronary arteries
• Breathing exercise: Breath-hold for the time necessary to complete a CCTA
study. A Valsalva maneuver should be avoided, as this can decrease inflow
into the right atrium and decrease contrast enhancement.Respiratory
motion artifact can be recognized on the lung windows and is most
prominent on coronal and sagittal images.
• Calcium score : performing a nonenhanced calcium scoring study before a
CCTA is to decide whether to proceed with CCTA in patients with extensive
coronary calcium…There is no established calcium score cutoff value
above which CCTA will not be diagnostic, but a score of 1000 is often used

11. Beta Blockers
Metoprolol
An oral dose of 50-100 mg can be administered 60-90 minutes before
the study … if not effective in lowering HR to the desired level, 5mg
doses of IV metoprolol can be administered at 3- to 5-minute
intervals, up to a total dose of 15-30 mg.
Contraindications :-
• Systolic blood pressure < 100 mm Hg (in adults)
• Asthma or (COPD) on beta2 -agonist inhaler
• Second- or third-degree atrioventricular block , Sick sinus syndrome
• Decompensated heart failure
• Phyochromocytoma (can be given in combination with an alpha
blocker .
• Allergy to beta blockers
Diltiazem or verapamil used for patients in whom BB is contraindicated

12. Coronary anatomy
 Left Main or left coronary artery (LCA)
Left anterior descending (LAD)
• diagonal branches (D1, D2)
• septal branches
Circumflex (Cx)
• Obtuse marginal branches (M1,M2)
In 15% of cases a third branch arises in between the LAD and the
Cx, known as the ramus intermedius
 Right coronary artery
Acute marginal branch (AM)
Posterior descending artery (PDA)
AV node branch

14. Left Anterior Descending (LAD) :
The LAD travels in the anterior interventricular groove and continues
up to the apex of the heart.
The LAD supplies the anterior part of the septum with septal
branches and the anterior wall of the left ventricle with diagonal
branches.
The LAD supplies most of the left ventricle and also the AV-bundle.
Circumflex (Cx):
The Cx lies in the left AV groove between the left atrium and left
ventricle and supplies the vessels of the lateral wall of the left
ventricle.
These vessels are known as obtuse marginals (M1, M2...), because
they supply the lateral margin of the left ventricle and branch off
with an obtuse angle.

15. Right Coronary Artery (RCA)
• The right coronary artery arises from the anterior sinus of Valsalva and
courses through the right atrioventricular (AV) groove between the right
artium and right ventricle to the inferior part of the septum.
• In 50-60% the first branch of the RCA is the small conus branch, that
supplies the right ventricle outflow tract.
• In 20-30% the conus branch arises directly from the aorta.
• In 60% a sinus node artery arises as second branch of the RCA, that runs
posteriorly to the SA-node (in 40% it originates from the Cx).
• The next branches are some diagonals that run anteriorly to supply the
anterior wall of the right ventricle.
 The large acute marginal branch (AM) comes off with an acute angle and
runs along the margin of the right ventricle above the diaphragm.
 The RCA continues in the AV groove posteriorly and gives off a branch to
the AV node.
 In 65% of cases the posterior descending artery (PDA) is a branch of the
RCA (right dominant circulation).
It supplies the inferior wall of the left ventricle and inferior part of the
septum.

18. ALCAPA
Bland–White–Garland syndrome
• anomalous origin of the LCA from the
pulmonary artery
• ALCAPA results in the left ventricular
myocardium being perfused by relatively
desaturated blood under low pressure,
leading to myocardial ischemia

19. multiple collateral circulations between the RCA and LCA

20. Interarterial LCA
.
anomalous origin of the LCA from the right sinus
of Valsalva and coursing between the aorta
and pulmonary artery.

21. Interarterial RCA

22. Single coronary artery
Cx originates from the left aortic sinus. Acute marginal branch
&PDA originate from LCx. RCA origin from right aortic sinus is
absent. Calcified plaque is visible at proximal LAD..

23. Others
• Cx from RCA
• LAD from RCA

24. • Separate origin of
left circumflex artery (LCx)
and left anterior descending
artery (LAD) from left aortic sinus
• Separate origin of RCA and
conal artery from right aortic sinus

25. • High takeoff the LCA from
Lt coronary sinus
• High takeoff the RCA from
Anterior coronary sinus

26. Myocardial bridging
o Myocardial bridging is most commonly
observed of the LAD
o The depth of the vessel under the
myocardium is more important that the length
of the myocardial bridging.
o There is debate, whether some of these
myocardial bridges are hemodynamically
significant.

27. end-systolic period (B) and the end-diastolic period (C) demonstrate typical milking
effect by systolic compression of the tunneled segment (circle). There is a stenosis of
proximal LAD

28. Duplication
• This finding may constitute valuable data for
the interventional cardiologist and must be
reported in order to prevent any confusion
during catheter angiography of the coronary
arteries.
Duplicated LCADuplicated RCA

29. Fistula
LAD giving rise to a large septal branch that
terminates in the right ventricle

30. Extracardiac termination
Abnormal feeding artery from RCA and LAD which form a
plexus on the left side of the pulmonary trunk (circle in A, C)
and directly drains into pulmonary trunk

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