Role of mdc tin coronary artery part 4 (anomalous coronary arteries) dr ahmed esawy Magnetic Resonance Imaging in Coronary Artery Disease MULTISCLICE CTcoronary artery angiography Coronary artery segments Coronary artery anatomy Coronary artery stenosis Coronary artery calcification score Coronary artery stricture Coronary artery aneurysm Coronary artery pos operative changes Coronary artery by pass Coronary artery stent Coronary artery bridge Artifacts recognition and management 1/ Fundamental CT artifacts Scanner hardware failure Partial volume artifacts Beam hardening artifacts Metal related artifacts Coronary artery angiography pitfalls Artifact Cardiac motion Pulmonary motion Body motion Beam hardening Metallic object A Artifacts recognition and management 1/ Fundamental CT artifacts Scanner hardware failure Partial volume artifacts Beam hardening artifacts Metal related artifacts rtifacts recognition and management 1/ Fundamental CT artifacts Scanner hardware failure Partial volume artifacts Beam hardening artifacts Metal related artifacts 2/ Artifacts specific to cardiac CT Slab misalignment Tube modulation artifacts Cardiac motion Patient motion

1. Dr/AHMED ESAWY

2. Anomalous Coronary
Arteries
Dr/AHMED ESAWY

3. Dr. Ahmed Esawy
MBBS M.Sc. MD
Dr/AHMED ESAWY

4. Dr/AHMED ESAWY

5. 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

6. RCA
LCA
Dr/AHMED ESAWY

7. 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
Dr/AHMED ESAWY

8. 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
Dr/AHMED ESAWY

9. Anomalous Coronary Anatomy
~60% cases involve the circumflex
~40% involve the LM or RCA
Dr/AHMED ESAWY

10. Anomalous Circumflex Artery
Anomalous circumflex:
Either off R sinus or branches off RCA
ALMOST ALWAYS RETROCARDIAC BENIGN
Dr/AHMED ESAWY

11. Anomalous Circumflex:
Retroaortic BENIGN
Normal Anatomy
Dr/AHMED ESAWY

12. Retroaortic Anomalous
Circumflex
Ao
Dr/AHMED ESAWY

13. 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.
Dr/AHMED ESAWY

14. 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
Dr/AHMED ESAWY

15. Normal Anatomy
Anomalous RCA:
InterarterialISCHEMIA!!
Dr/AHMED ESAWY

16. Anomalous RCA:
Retroaortic BENIGN
Normal Anatomy
Dr/AHMED ESAWY

17. Dr/AHMED ESAWY

18. WHICH??
Dr/AHMED ESAWY

19. L sinus of Valslava
R AV groove
Dr/AHMED ESAWY

20. L sinus of Valslava
R AV groove
INTERARTERIAL ISCHEMIA!!!
Dr/AHMED ESAWY

21. 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

22. 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)
Dr/AHMED ESAWY

23. 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
Dr/AHMED ESAWY

24. Malignant right coronary artery
Dr/AHMED ESAWY

25. 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.
Dr/AHMED ESAWY

26. 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
Dr/AHMED ESAWY

27. • 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

28. 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

29. Normal Anatomy
Anomalous LCA:
InterarterialISCHEMIA!!
Dr/AHMED ESAWY

30. Normal Anatomy Anom LCA: Retroaortic
Anom LCA: Anterior Anom LCA: IntramuralDr/AHMED ESAWY

31. Normal Anatomy Anom LCA: Retroaortic
Anom LCA: Anterior Anom LCA: Intramural
BENIGN!!
Dr/AHMED ESAWY

32. Dr/AHMED ESAWY

33. WHICH??
Dr/AHMED ESAWY

34. R sinus of Valsalva
Behind aorta to L AV groove Dr/AHMED ESAWY

35. R sinus of Valsalva
RETROAORTIC BENIGN!!
Behind aorta to L AV groove
Dr/AHMED ESAWY

36. Dr/AHMED ESAWY

37. WHICH??
Dr/AHMED ESAWY

38. Ao
RVOT
R sinus of Valsalva
Dr/AHMED ESAWY

39. Ao
RVOT
R sinus of Valsalva
INTERARTERIAL ISCHEMIA!!!
Dr/AHMED ESAWY

40. 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

41. 47 year old woman with atypical chest pain:
Anomalous LCA from RT coronary sinus
Dr/AHMED ESAWY

42. 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

43. 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.
Dr/AHMED ESAWY

44. 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.
Dr/AHMED ESAWY

45. 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

46. “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
Dr/AHMED ESAWY

47. Myocardial bridge over LAD
Diastole Systole
Dr/AHMED ESAWY

48. 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