Identification Of Coronary Anomalies Research Articles

P811 More than aortic measurements: evaluation with TTE and angioCT in bicuspid aortic valve yields useful information about valvular compromise

Abstract Background 2D transthoracic echocardiogram (TTE) is the technique of choice in the diagnosis of bicuspid aortic valve (BAV). Computed tomography (CT) is widely used in BAV to measure aortic diameters. However, in some cases CT or magnetic resonance (MRI) can add important information to TTE regarding valvular degeneration and morphotype. We designed the present prospective study to determine the agreement between TTE and gated CT in the assessment of aortic valve morphology, fibrosis, calcification and measurements of thoracic aorta. We also aimed to analyze the utility of CT in the evaluation of BAV patients, in addition to aortic measurements. Methods We included 30 consecutive patients with BAV (mean age 45 ± 15.7 years ; 73.3% men) who underwent both TTE and ECG-gated cardiac and aortic CT for valvular and aortic assessment in a follow-up protocol with a time interval between TTE and CT of 4 ± 2.6 months. We performed measurements of thoracic aorta at 6 levels (annulus, Valsalva sinus: VS, sinotubular junction, ascendent, arch and isthmus) with both techniques following guideline recommendations blinded to the results of the other technique. Several measurements of VS were performed in short-axis view (double-oblique method) (maximal diameter perpendicular to the valve opening, sinus to sinus, raphe to sinus, commissure to commissure) at systole and diastole with CT. Valve phenotype, presence of raphe, calcification scoring, aortic valve prolapse and fibrosis were also determined with both techniques and maximum aortic diameters were compared. An indexed aortic diameter > 21 mm/m2 was considered as aortic dilation and assimetryc root was defined when differences between CT measurements were ≥5mm. Results In 7 patients (23.3%) aortic diameter differences at Sinus by TTE and CT were ≥3mm. Concerning ascending aorta measurements, there was better agreement and only 2 cases (6.6%) showed differences ≥ 3mm. In 2 patients with severe calcification valve morphology was identified only with CT. There was good agreement between TTE and CT in calcium quantification in patients with valvular calcium score over 2000 AU (n = 5) and in those without calcification. However, TTE failed in identification of valvular fibrosis in 5 patients. 10 patients (30%) had aortic dilatation with CT and 7 according to TTE measurements. The 3 patients that were not identified as dilated in TTE had dilatation at the distal tubular portion. CT led to identification of coronary anomalies in 5 patients (16.7%), most of them anomalous high origin above the sinotubular junction. Conclusions Although TTE is the gold-standard in the diagnosis and follow-up of patients with BAV, CT was useful to confirm aortic measurements and to identify valvular fibrosis, assimetry, coronary anomalies and dilatation at the tubular portion. CT can add important information to TTE regarding valvular morphotype and aortic measurements, although radiation and cost should be evaluated. Abstract P811 Figure. Calcification agreement TTE and CT

Non-electrocardiographic-gated computed tomographic angiography can be used to diagnose coronary artery anomalies in Bulldogs with pulmonary valve stenosis.

Coronary artery anomalies have been reported in Bulldogs and present an increased risk when performing balloon valvuloplasty. Identification of coronary anomalies has been reported using multidetector-row computed tomographic (MDCT) angiography with electrocardiographic gating. However, the utility of non-electrocardiographic-gated 16-row computed tomographic for MDCT for the identification of coronary artery anatomy or anomalies to the authors' knowledge has not been fully investigated. The purpose of this study was to evaluate the feasibility of non-electrocardiographic-gated computed tomographic (CT) angiography to identify coronary anomalies in Bulldogs with pulmonary valve stenosis. In this prospective, observational study, Bulldogs with echocardiographically diagnosed pulmonary valve stenosis, an echocardiographically derived transpulmonic pressure gradient >70mmHg, and a clinician recommendation for balloon valvuloplasty were included. Anesthetized dogs underwent a 16-row MDCT non-electrocardiographic-gated CT angiography. A board-certified veterinary radiologist and board-certified veterinary cardiologist reviewed the CT angiography studies and identified the coronary artery anatomy. When normal coronary artery anatomy was detected on CT angiography, a right ventricular outflow tract fluoroscopic angiogram was performed and evaluated during levophase to confirm normal coronary anatomy prior to balloon valvuloplasty. Dogs with coronary anomalies noted on CT angiography were recovered from anesthesia and balloon valvuloplasty was not performed. All dogs (10/10; 100%) had interpretable images from the non-electrocardiographic-gated CT angiography. Coronary anomalies were identified in six dogs based on non-electrocardiographic-gated CT angiography, five with type R2A anomaly and one had a single left coronary ostium. Four dogs had normal coronary anatomy based on non-electrocardiographic-gated CT angiography. Balloon valvuloplasty was performed without incident in these four dogs. We conclude that non-electrocardiographic-gated CT angiography represents a noninvasive method for diagnosing coronary anomalies in Bulldogs with pulmonary valve stenosis.

Remote reading of coronary CTA exams using a tablet computer: utility for stenosis assessment and identification of coronary anomalies

The feasibility of remote reading of coronary CT examinations on tablet computers has not been evaluated. The purpose of this study is to evaluate the accuracy of coronary CT angiography reading using an iPad compared to standard 3D workstations. Fifty coronary CT angiography exams, including a spectrum of coronary artery disease and anatomic variants, were reviewed. Coronary CT angiography exams were interpreted by two readers independently on an iPad application (Siemens Webviewer) and a clinical 3D workstation at sessions 2weeks apart. Studies were scored per vessel for severity of stenosis on a 0-3 scale (0 none, 1 <50%, 2 ≥50-69%, 3 ≥70%). Coronary anomalies were recorded. A consensus read by two experienced cardiac imagers was used as the reference standard. Level of agreement with the reference for iPad and 3D workstations was compared. Multivariate logistic regression was used to analyze the relationship between agreement and display type and to adjust for inter-reader differences. For both readers, there was no significant difference in agreement with the reference standard for per-vessel stenosis scores using either the 3D workstation or the iPad. In a multivariable logistic regression analysis including reader, workstation, and vessel as co-variates, there was no significant association between workstation type or reader and agreement with the reference standard (p > 0.05). Both readers identified 100% of coronary anomalies using each technique. Reading of coronary CT angiography examinations on the iPad had no influence on stenosis assessment compared to the standard clinical workstation.

Multidetector Computed Tomography for Evaluation of Ischemic Etiology and a Post-Unroofing Procedure for an Anomalous Origin of the Right Coronary Artery From the Left Sinus of Valsalva

An anomalous origin of the right coronary artery (RCA) is a rare congenital anomaly. If it runs between the pulmonary artery and aorta, it may cause acute myocardial infarction (AMI) and sudden death.1-4) Identification of coronary anomalies is sometimes difficult by coronary angiography because of the lack of three-dimensional information. A 34-year old male patient presented with an inferior wall AMI. Coronary angiography showed that the RCA originated from the left sinus of Valsalva close to the left main coronary artery (Fig. 1). Coronary spasm was considered as the etiology of the AMI. Ten months after the first attack, the patient was readmitted due to an inferior wall AMI. Multidetector computed tomography (MDCT) showed that the RCA originated from the left sinus of Valsalva, and ran between the aortic root and the main pulmonary trunk (Fig. 2A). The axial image showed an acute-angled takeoff of the RCA from the ascending aorta and a small orifice of the RCA which was thought to be the main mechanism for the ischemia (Fig. 2B). Findings during surgery showed the RCA ostium with a small slit-like orifice that originated at the left sinus of Valsalva with an acute angle and the proximal portion of the RCA was located beside the commissure, between the right and left cusps, which were embedded in the aortic wall (Fig. 2C). After the operation, MDCT and coronary angiography showed good patency of the RCA and the patient was doing well and was free of symptoms (Fig. 2D and E). Our case showed that when a coronary anomaly, especially an anomalous origin of the RCA, is noted on coronary angiography, MDCT may provide important information about ischemic mechanisms. Fig. 1 Coronary angiography showed there were no significant lesions at LAD and LCX (A). However, RCA could not be found at its usual location. It originated from left sinus of Valsarva (white arrow) close to the left main coronary artery with diffuse minimal ... Fig. 2 MDCT showed RCA originated from left sinus of Valsalva (white arrow), separate from the left main coronary artery, and courses anteriorly between aortic root and main pulmonary trunk (A). The maximum intensity projection image showed an acute-angled takeoff ...