DOI:10.2214/AJR.07.2830
AJR 2008; 190:934-946
© American Roentgen Ray Society
Nonatherosclerotic Cardiovascular Findings on MDCT Coronary Angiography: A Selection of Abnormalities
Mark T. T. Takaki1,
Theodore J. Dubinsky1,
Bill H. Warren1,
Lee Mitsumori1 and
William P. Shuman1
1 All authors: Department of Radiology, Body Imaging Section, University of
Washington Medical Center, 325 Ninth Ave., Box 359728, Seattle, WA
98104.
Received July 6, 2007;
accepted after revision October 20, 2007.
Address correspondence to T. J. Dubkinsky
(tdub{at}u.washington.edu).
Abstract
OBJECTIVE. Improvements in MDCT coronary angiography allow imaging
of the coronary arteries that rivals invasive coronary angiography. Recent
studies have shown high sensitivity and specificity in detecting coronary
artery disease. But in the course of interpretation, other significant
abnormalities may be encountered in addition to atherosclerotic plaques.
CONCLUSION. We present a selection of nonatherosclerotic
cardiovascular findings that were detected with coronary CT angiography
performed on a 64-MDCT scanner.
Keywords: cardiac imaging • coronary arteries • CT angiography • MDCT • nonatherosclerotic disease
Introduction
MDCT coronary angiography (CTA) is a new and rapidly emerging noninvasive
imaging technique. Improvements in spatial and temporal resolution, ECG
gating, and postprocessing software allow fast, motion-free imaging of the
coronary arteries that rivals invasive coronary angiography
[1]. Recent studies have shown
high sensitivity and specificity in detecting coronary artery disease
[2]. But in the course of
interpretation, other significant abnormalities may be encountered in addition
to atherosclerotic plaques. We present a selection of nonatherosclerotic
cardiovascular findings that were detected with coronary CTA obtained on a
64-MDCT scanner. Images were acquired at 0.625-mm thickness at pitches ranging
from 0.2 to 0.24 with 0.35-second rotation time. A timing bolus was obtained
at the aortic root, and a triphasic injection of 50 mL of Visipaque
(iodixanol, GE Healthcare) was followed by a mixture of 30 mL of Visipaque and
20 mL of saline followed by a 50-mL saline flush. Scanning was performed using
a dual-head projector at 5 mL/s for all three phases. Selected cases were
derived from our first 200 studies.
Coronary Artery Anomalies
MDCT coronary angiography is now acknowledged as an accurate diagnostic
tool in depicting coronary artery anomalies
[3]. Because conventional
angiography detects only 53% of these abnormalities, coronary CTA may be
superior to conventional coronary angiography in defining the origins and
proximal paths of these anomalous vessels
[4]. Congenital anomalies of
the coronary arteries are not rare, affecting approximately 0.3–1.0% of
the general population [5].
Variants of the origins and courses of the proximal segments are the most
frequently encountered.
In terms of clinical importance, recognized hemodynamically significant
coronary artery anomalies are anomalous origins arising from the pulmonary
artery, interarterial courses that indicate malignancy between the aorta and
pulmonary artery (Figs. 1A,
1B, and
1C), coronary artery fistulas
(Figs. 2A and
2B), and occasional myocardial
bridges (Figs. 3A and
3B)
[3]. Hemodynamically
insignificant or courses that indicate benignity of the coronary arteries are
retroaortic (Figs. 4 and
5), prepulmonic, and
subpulmonic [3] (Figs.
6A and
6B).
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Fig. 1A —MDCT angiography images in 67-year-old woman with acute
coronary syndrome. Volume-rendered image shows interarterial course of
proximal right coronary artery (RCA) arising from left coronary sinus.
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Fig. 1B —MDCT angiography images in 67-year-old woman with acute
coronary syndrome. Caudal projection of volume-rendered image emphasizes
interarterial or malignant course of anomalous RCA (arrow).
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Fig. 2A —MDCT angiography images in 48-year-old man with incidentally
noted myocardial bridge that was thought not to be symptomatic. Curved
multiplanar reformation shows long segment of myocardial bridging
(arrow) of mid left anterior descending artery (LAD).
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Fig. 2B —MDCT angiography images in 48-year-old man with incidentally
noted myocardial bridge that was thought not to be symptomatic. Axial image
shows intramyocardial course of mid LAD (arrow).
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Fig. 3A —MDCT angiography images in 54-year-old woman with episode of
chest pain and syncope. Volume-rendered images show coronary artery fistula
from left circumflex artery to coronary sinus (arrows).
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Fig. 3B —MDCT angiography images in 54-year-old woman with episode of
chest pain and syncope. Volume-rendered images show coronary artery fistula
from left circumflex artery to coronary sinus (arrows).
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Fig. 4 —29-year-old man with repaired tetralogy of Fallot. Axial MDCT
angiography image reveals retroaortic course of proximal left main coronary
artery arising from right coronary sinus. Accessory left anterior descending
artery is arising from left cusp as well (arrow).
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Fig. 5 —58-year-old man with incidentally noted anomalous left
circumflex artery (LCX). Curved multiplanar reformation of MDCT angiography
image shows retroaortic course of proximal LCX arising from right coronary
sinus (arrow). CIRC = circumflex artery.
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Fig. 6A —MDCT angiography images in 43-year-old man with incidentally
noted anomalous origin of left circumflex artery (LCX). Curved multiplanar
reformation (A) and coronal oblique (B) images show subpulmonic
course of proximal LCX arising from right coronary sinus
(arrows).
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Fig. 6B —MDCT angiography images in 43-year-old man with incidentally
noted anomalous origin of left circumflex artery (LCX). Curved multiplanar
reformation (A) and coronal oblique (B) images show subpulmonic
course of proximal LCX arising from right coronary sinus
(arrows).
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Several pathophysiologic mechanisms have been described to explain the
symptoms related to the interarterial malignant course. The two most popular
explanations relate to stress exercise contributing to intermittent narrowing
or occlusion during diastole: The first explanation is that increased cardiac
output causes a flaplike closure of the vessel at the anomalous origin, and
the second is that the interarterial segment is extrinsically compressed
between the aorta and pulmonary artery during systole
[6].
Coronary artery fistulas are found in 0.1–0.2% of patients who
undergo coronary angiography
[7]. The right coronary artery
is slightly more affected than the left
[8]. Drainage is much more
commonly into the right than the left heart
[9]. The mechanism for ischemia
is a hemodynamic steal phenomenon, in which blood flow is diverted from the
portion of the myocardium supplied by the abnormally connected coronary artery
[10].
The prevalence of myocardial bridging is 0.5–4.9% on angiography.
However, the reported prevalence of intramuscular coronary arteries varies
between 5% and 86% at autopsy. Intramuscular coronary arteries can cause
technical problems during coronary bypass surgery, including inadvertent
perforation of the right ventricle. However, on CT a prevalence as high as
30.5% has been reported [11].
Most myocardial bridges are located in mid left anterior descending coronary
artery (LAD) and the distal LAD. Three patterns of bridging LAD have been
describ ed: superficial septal (29.4%), deep septal (41.1%), and right
ventricular (29.5%) types. Myocardial bridging has been associated with plaque
formation proximal to the narrowing at the bridge entrance site, although
plaque does not seem to form in the bridged segment itself
[12]. The most common bridged
segment involved with atherosclerotic disease is the mid LAD
[13]. The mechanism for
ischemia is secondary to compression of the tunneled segment during systole
[14]. However, most cases of
myocardial bridging are asymptomatic.
Coronary Artery Aneurysms and Dissections
Coronary artery aneurysms have been observed in 5% of patients undergoing
coronary angiography [15]. The
main causes are atherosclerotic, congenital, and mycotic–embolic
diseases [16]. Most aneurysms
are small and thick-walled and have a low risk of spontaneous rupture
[16] (Figs.
7A and
7B). Aneurysms may be fusiform
or saccular in configuration. This is in distinction to ectasia, in which the
vessel may be dilated but is elongated as well and hence has a tortuous
appearance. Ectasia tends to occur in association with atherosclerotic
disease. Giant aneurysms are rare and usually congenital in origin. Another
cause of giant aneurysms is Kawasaki's disease (Figs.
8A and
8B). In general, 24.6% of
patients with acute Kawasaki's disease develop coronary artery aneurysms, of
which approximately 50% regress
[15]. The clinical
significance of giant aneurysms is the strong potential to develop ischemic
heart disease [17].
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Fig. 7A —MDCT angiography images in 24-year-old man with congenital
aortic stenosis. Curved multiplanar reformations reveal small saccular
aneurysm arising from proximal left main artery (arrows).
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Fig. 7B —MDCT angiography images in 24-year-old man with congenital
aortic stenosis. Curved multiplanar reformations reveal small saccular
aneurysm arising from proximal left main artery (arrows).
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In the recent literature, a few cases have been reported of spontaneous
coronary artery dissection depicted on coronary CTA. A coronary dissection
usually appears as a narrowing or occlusion of the true lumen secondary to
intramural hematoma formation, in contrast to the intimal flap seen in an
aortic dissection [1] (Figs.
9A and
9B).
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Fig. 9A —MDCT angiography images in 25-year-old man who awoke with
chest pain. Curved multiplanar reformations reveal spontaneous left anterior
descending artery (LAD) dissection presenting as eccentric stenosis of mid LAD
(arrows).
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Fig. 9B —MDCT angiography images in 25-year-old man who awoke with
chest pain. Curved multiplanar reformations reveal spontaneous left anterior
descending artery (LAD) dissection presenting as eccentric stenosis of mid LAD
(arrows).
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Cardiac Tumors
Most intracardiac masses observed at echocardiography are found to actually
be thrombi (Figs. 10A and
10B). The most commonly
encountered tumors of the heart are pericardial, with most being a metastasis
from breast or lung cancer or lymphoma. These present as focal or diffuse
areas of pericardial thickening with enhancement. True primary intracardiac
tumors are extremely rare. Benign tumors constitute 77% of the primary cardiac
tumors [18]. The most common
primary cardiac tumor is the myxoma, which accounts for 24.4% of the benign
tumors [18]. Myxomas are
usually found in the left atrium and develop in or near the fossa ovale of the
atrial septum. A characteristic CT finding is inhomogeneity, which is a
reflection of the presence of hemorrhage, necrosis, fibrosis, and
calcifications [17] (Figs.
11A and
11B).
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Fig. 10A —MDCT angiography images in 44-year-old woman with acute
monocytic leukemia and left atrial thrombus. Volume-rendered image shows left
atrial mass (arrow) without calcifications. Inset shows plane of
reconstruction.
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Congenital Heart Disease
At our institution, MRI is typically preferred over CT for imaging of
complex congenital heart disease (CHD) because of its lack of radiation. When
we detect CHD on MDCT, it is usually incidental or clinically unknown in the
adult patient. Our examples of these include a high membranous ventricular
septal defect (VSD) (Fig. 12),
bicuspid aortic valve (BAV) (Figs.
13A and
13B), and patent ductus
arteriosus (PDA) (Figs. 14A
and 14B).
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Fig. 13A —MDCT angiography images in 31-year-old man with heart murmur.
Maximum-intensity-projection (A) and axial (B) images show
noncalcified bicuspid aortic valve with poststenotic dilation of ascending
thoracic aorta (arrows). Note minimal left ventricular
hypertrophy.
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Fig. 13B —MDCT angiography images in 31-year-old man with heart murmur.
Maximum-intensity-projection (A) and axial (B) images show
noncalcified bicuspid aortic valve with poststenotic dilation of ascending
thoracic aorta (arrows). Note minimal left ventricular
hypertrophy.
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Fig. 14A —MDCT angiography images in 59-year-old woman with patent
ductus arteriosus (PDA) and Eisenmenger's syndrome. Axial (A) and
sagittal (B) oblique reconstructions show PDA (arrows) and
enlarged main pulmonary artery. Contrast dilution is evidence for jet from
PDA.
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Fig. 14B —MDCT angiography images in 59-year-old woman with patent
ductus arteriosus (PDA) and Eisenmenger's syndrome. Axial (A) and
sagittal (B) oblique reconstructions show PDA (arrows) and
enlarged main pulmonary artery. Contrast dilution is evidence for jet from
PDA.
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Studies have shown that the incidence of CHD is as high as 20 in 1,000 live
births [19]. More than 400,000
cases exist in the United States, and approximately 150,000 are unrecognized
[20].
The most common CHD is an isolated VSD, with an incidence of 2–5%
[19]. VSDs are classified by
their appearance from the ventricular lumen as either perimembranous,
muscular, or doubly committed juxtaarterial defects
[21].
BAV is another common CHD, varying in incidence from 0.4% to 2.2%
[19]. The incidence is higher
with Turner's syndrome, coarctation of the aorta, and VSD. In initially
asymptomatic patients, BAV becomes clinically significant as the left
ventricular outflow is reduced. The pattern of valve calcification is
distinctive, characterized by a partial or complete ring with or without
calcification of the central raphe, which usually develops by the age of 30
years [22]. The blood flow jet
through the stenotic valve causes dilation of the ascending thoracic
aorta.
Another common lesion is a PDA, which is a persistent communication between
the proximal descending aorta and left pulmonary artery. A PDA almost always
closes by the fourth to seventh day of life in the term infant. Attention has
been drawn to the silent PDA that is not heard at auscultation but is
incidentally detected by echocardiography and is estimated to occur in 1 per
500–1,000 individuals
[23].
Occasionally, we image complex CHD using MDCT. In the adult patient, these
anomalies are usually surgically repaired, which adds to the difficulty in
interpretation because of the alterations in the anatomy. So far, our
institution has three cases of repaired CHD: tetralogy of Fallot (TOF) (Figs.
15A and
15B), transposition of the
great vessels (TGV) (Figs.
16A,
16B, and
16C), and truncus arteriosus
(Figs. 17A,
17B, and
17C).
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Fig. 16A —MDCT angiography images in 39-year-old man with repaired
transposition of great vessels after Mustard-Senning procedure. Axial image
shows portion of left atrium isolated by atrial baffle placed during
Mustard-Senning procedure (arrow).
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Fig. 16B —MDCT angiography images in 39-year-old man with repaired
transposition of great vessels after Mustard-Senning procedure. Coronal image
shows aorta arising from anterior right ventricle (arrow).
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Fig. 16C —MDCT angiography images in 39-year-old man with repaired
transposition of great vessels after Mustard-Senning procedure. Coronal image
reveals contrast-enhanced superior vena cava (arrow) and nonenhancing
inferior vena cava (arrow) flow into left atrium and subsequently
into left ventricle as result of a baffle procedure.
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The most common cyanotic CHD is TOF. The features of a TOF are an
overriding aorta, VSD, pulmonic stenosis, and right ventricular hypertrophy.
Surgical corrective procedures include the Blalock-Taussig operation
(end-to-side anastomosis of the subclavian artery to the pulmonary artery),
Potts operation (side-to-side anastomosis of the descending aorta to the left
pulmonary artery), and Waterston operation (side-to-side anastomosis of the
ascending aorta to the right pulmonary artery)
[24]. The long-term
complications associated with these procedures are pulmonary hypertension,
left ventricular volume overload, and pulmonary artery tortuosity
[25].
Another common cyanotic CHD is TGV. Complete TGV consists of
atrioventricular and ventriculoarterial concordance. Without an atrial septal
defect (ASD), VSD, or PDA, the systemic and pulmonary circulations do not
intermix, which is incompatible with life. The initial approach to repair TGV
was the atrial switch procedure, called the Mustard-Senning operation
[26]. This involves the
creation of an atrial "baffle" to direct systemic venous blood
flow across the mitral valve into the left ventricle and pulmonary venous
blood flow across the tricuspid valve into the right ventricle. After this
procedure, the ventricle continues to act as the systemic ventricle. The
associated complications include atrial baffle leakage, baffle obstruction,
atrial arrhythmias, right ventricular dysfunction, and sudden death
[25]. The atrial switch has
been substituted for the arterial switch (Jatene operation), which has a
better long-term outcome
[27].
Truncus arteriosus is an uncommon form of CHD. Truncus arteriosus is a
single arterial trunk that arises from the ventricle, which supplies the
pulmonary and systemic circulation and the coronary arteries. A complete
surgical repair involves closing the VSD and separating out the main pulmonary
artery and attaching a valve conduit to the right ventricular outflow tract
[28]. The long-term
complications include conduit stenosis or regurgitation, aortic root dilation,
branch pulmonary artery stenosis or residual VSD, ventricular dysfunction,
truncal valve stenosis or regurgitation, arrhythmias, and pulmonary
hypertension [26].
Postoperative Complications
A rare complication of coronary artery bypass grafting is a pseudoaneurysm
of a saphenous vein graft (Figs.
18A and
18B). The mechanism of
formation is unclear. Most are asymptomatic and discovered as an incidental
finding 5 years after coronary artery bypass grafting
[29]. Often, these are
mistaken as a mediastinal mass on chest radiography. If symptomatic, saphenous
vein graft pseudoaneurysms may cause angina, acute myocardial infarction, and
sudden death [30,
31].
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Fig. 18A —MDCT angiography images in 60-year-old man with history of
coronary artery bypass grafting who presented with large mediastinal mass.
Sagittal (A) and volume-rendered (B) images reveal giant
thrombosed saphenous vein graft pseudoaneurysm (arrows). LIMA = left
internal mammary artery.
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Fig. 18B —MDCT angiography images in 60-year-old man with history of
coronary artery bypass grafting who presented with large mediastinal mass.
Sagittal (A) and volume-rendered (B) images reveal giant
thrombosed saphenous vein graft pseudoaneurysm (arrows). LIMA = left
internal mammary artery.
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The final case is a left atrioventricular iatrogenic fistula after mitral
valve replacement (Fig. 19).
The patient presented 6 days after his operation with symptomatic atrial
fibrillation. He subsequently underwent echocardiography, which revealed an
abnormal communication between the left atrium and left ventricle. Cardiac CT
was performed for confirmation and surgical planning.
Conclusion
Familiarity with the imaging appearances of unusual cardiovascular findings
is important during the interpretation of MDCT coronary angiography. As the
number of studies continues to increase with this fast-growing imaging
technique, more of these types of abnormalities will be encountered.
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Abstract
Introduction
