Presentation
Low to moderate atypical chest pain, admitted with NSTEMI, strong family history of CAD. Inability to probe the right coronary artery during cardiac catheterization.
Patient Data
Technique
patient premedication: beta blocker and nitrates
acquisition method: step and shoot (prospective acquisition - 100 KV)
contrast injection protocol: triphasic injection
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image reconstruction:
standard with and without edge correction
dual-energy maps (see next study)
Findings
anomalous origin of the right coronary artery from the left coronary sinus with an interarterial course
left coronary arterial dominance due to the anomalous origin of the right coronary artery, in addition the apical segment of the LAD encircles the cardiac apex
Plaque burden:
calcium score: ~90
segment involvement score (SIS): 3 segments
Right coronary artery (RCA): anomalous origin from the left coronary sinus
separate origin, take-off level above the commissure, sharp angle with acute take-off <45°, slit-like narrowing of the ostial segment indicating an aortic intramural course
calcified plaque in the proximal segment followed by an occlusion (~4-5 cm) of the distal portion of the proximal segment and the proximal portion of the medial segment
contrast filling of the distal segment and the posterior descending artery (PDA) via collaterals
Left main (LM): unremarkable
Left anterior descending artery (LAD): gives off one diagonal branch
two small non-stenotic calcified plaques in the proximal segment and the diagonal branch
Ramus intermedius: strong, branches out
Circumflex artery (CX): ends in one strong marginal branch (OM)
two small non-stenotic calcified plaques
There is no thinning of the inferior wall myocardium visible on the CT.
Impression
anomalous origin of the right coronary artery from the left coronary sinus with an interarterial/intramural course
left coronary dominance
coronary artery disease with occlusion of the proximal and medial segment of the right coronary artery
CADRADS5/P1/E
Recommendations
cardiac MRI for evaluation of viability
coronary revascularization (e.g. bypass surgery)
risk factor modification and optimal medical therapy
Exam courtesy: Yvonne Kühn (imaging technologist)
MonoE 40
virtual monoenergetic or monochromatic images synthesized at a level of 80 keV
reconstructions with a window setting C:200 W:600
Z-effective
the effective atomic number Zeff calculated by dual-energy analysis
slightly increased signal in the inferoseptal segments
Iodine no water
obtained by subtracting water from contrast-enhanced images
reconstructions with a window setting C:10 W:24
Impression
A good question would be if that increased signal in the inferior and inferoseptal segments corresponded to myocardial edema.
Subsequent clinical course
The patient received an urgent referral to a major cardiac center for revascularization before he was able to receive a cardiac MRI at our institution.
The preoperative cardiac MRI at that institution was reported to show myocardial edema in basal and midventricular inferior and inferoseptal segments with subendocardial perfusion deficit and narrow subendocardial late gadolinium enhancement (transmurality <25%) and no signs of microvascular obstruction.
The coronary intervention was complex but ultimately consisted of antegrade wiring of the right coronary artery and pre-dilation of the occluded segment followed by the implantation of two drug-eluting stents.
The patient was discharged soon thereafter on oral reocclusion prophylaxis.
Case Discussion
An anomalous origin of the right coronary artery from the left coronary sinus and an interarterial and probably intramural course is a coronary anomaly with a high risk of hemodynamic significance.
In this case, the patient also had coronary artery disease with an occluded section of the proximal and medial segment of the right coronary artery.
Fortunately, the remaining medial and distal segments and the posterior descending artery were perfused via collaterals from the left coronary territory.
An intramural course of an anomalous originating coronary artery is suggested by the following features 1-3:
acute take-off angle
slit-like opening
separate origin of the anomalous coronary artery
Co-author: Dr Frank-Peter Held (cardiologist)
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