Download CT of Coronary Artery Anomalies (CAA)

COURSE LEARNING
OBJECTIVES
CT of
Coronary Artery
A Anomalies
(CAA)
Teresa Swenson, A.S., R.T.(R)(CT)
CT Research Manager
Department of Radiology
University of Florida College of Medicine-Jacksonville
Review:
• Definition and classifications of CAA
• The associated symptoms and clinical
significance of the different forms of CAA
• CT imaging techniques to enhance
visualization of CAA
• Imaging cases with CAA
Relationship: Siemens Medical Solutions , Inc. (Research
Support)
WHAT IS A CAA?
Definition:
A CAA is a congenital malformation most
often related to the origin or location of the
coronary artery. Anomalies of the
coronary arteries may be associated with
other cardiac pathology including valvular
lesions and congenital heart disease (e.g.
TOF or TGA)
PREVALANCE OF CAA
• CAA constitute 1-3 % of all congenital
malformations of the heart
• CAA present in more than 30% of sudden
nontraumatic deaths in young people. [1]
Reference: [1] Eckart RE, Scoville SL, Campbell CL, et al.: Sudden death in young adults: a 25-year review of autopsies in
military recruits.
Ann intern Med 2004, 141:829-834
WHAT CAUSES CAA?
WHAT ARE THE SYMPTOMS OF
CAA
• There is no known cause of the vast
majority of congenital heart defects
including CAA
• Adult symptoms can include: chest pain,
dizziness, syncope and heart failure
symptoms.
• Maternal transmission of some types,
familial clustering, Klinefelter’s syndrome
and trisomy 18 have all been suggested or
linked in some capacity to CAA. [2]
• Pediatric symptoms can include:
irritability, poor feeding, poor growth,
difficulty breathing, wheezing, sweating,
gray or pale skin and heart failure
Reference: [2] Ohnesorge, B.M., Flohr, T., Becker, C., Knez, A., Reiser, M.F. (2007). Multi-slice and Dual-source CT in Cardiac
Imaging.
NewYork: Springer-Verlag Berlin Heidelberg.
DIAGNOSING OF CAA
INVASIVE TESTS
NON-INVASIVE TESTS
CARDIAC
CATHETERIZATION/CORONARY
ANGIOGRAPHY
CHEST RADIOGRAPHY
EKG
CARDIAC CTA
MRI/MRA
NUCLEAR IMAGING
CLASSIFICATION OF CORONARY ARTERY
ANOMALIES
Reference: Congenital Heart Dis. 2009; 4:239-251
SUBDIVISIONS OF COURSE
ANOMALIES
Clinically significant
(“Malignant”)
Clinically insignificant
(“Non-malignant”)
Associated with an increased risk of
myocardial ischemia or sudden death
and mostly show a course between
the pulmonary artery and aorta, these
types of anomalies require surgical
intervention
These types of anomalies are usually
considered not “life threatening” and
may be managed medically
ANOMALOUS LOCATION OF THE
CORONARY OSTIUM
ANOMALIES OF COURSE AND
ORIGIN
HIGH OSTIUM OR “HIGH TAKEOFF”
High Ostium or “High take-off”
1.Refers to an unusually high origin of either
the RCA or the LAD artery from the
ascending aorta a point that is located at
least 1cm above the sino-tubular junction
in adults.
2.This type of anomaly is without any
hemodynamic significance unless acutely
angled; however, may be difficult to
cannulate during cardiac catheterization.
Reference: The British Journal of Radiology, 82, (2009), 254-261
ANOMALOUS ORIGIN FROM THE
OPPOSITE SINUS
INTER-ARTERIAL (MALIGNANT) COURSE OF
ANOMALOUS CORONARY ARTERY
Inter-Arterial (Malignant) Course
1.When either the left or right coronary
artery originates from the opposite
coronary sinus and takes a course
between the aorta and the PA.
2.This course is the most likely to be
associated with an adverse outcome,
including death.
ANOMALOUS ORIGIN FROM THE
OPPOSITE SINUS
TRANSSEPTAL COURSE
Transseptal Course
1.Where the LMC or LAD runs anteriorly and
inferiorly into the septum (subpulmonic)
and has an intramyocardial course approx.
to the level of the upper to mid sternum.
2.Considered a relatively benign course
ANOMALOUS ORIGIN FROM THE
OPPOSITE SINUS
Retroaortic Course
1.A retroaortic course is the most frequently
encountered anomalous course.
2.This type of course is considered benign
or non-malignant.
RETROAORTIC COURSE OF AN CAA
ANOMALOUS ORIGIN FROM THE
OPPOSITE SINUS
PREPULMONIC COURSE
Prepulmonic Course
1.In the prepulmonic course, usually the
LMC, LAD, or LCX, courses anterior to the
PA or RVOT.
2.This anomaly is often seen in patients
TOF.
ANOMALOUS ORIGIN FROM THE PA
ANOMALOUS ORIGIN OF THE CORONARY
ARTERY FROM THE PA
ALCAPA (Anomalous origin of the left
coronary artery from the pulmonary artery)
also known as Bland-White-Garland
syndrome
1.The ALCAPA syndrome is a rare anomaly
that affects 1 of every 300,000 live births.
2.Two types of ALCAPA syndrome: the
infant and adult types, each has different
manifestations and outcomes.
Reference: RadioGraphics 2009;
29:553-565
ANOMALOUS ORIGIN OF THE CORONARY
ARTERY FROM THE PA
ALCAPA
Reference: Radiographics2009;29:553-565
ANOMALIES OF INTRINSIC CORONARY
ARTERY ANATOMY
CORONARY ARTERY ANEURYSM
1. Is defined as coronary artery dilation
more than 1.5 times that of the adjacent
normal segment and may be focal or
diffuse.
2. Can be non-atherosclerotic or
atherosclerotic in origin.
3. Worldwide, Kawasaki disease is the most
common cause of coronary artery
aneurysms, whereas atherosclerotic
disease is the most common etiology in
the US.[4]
CORONARY ANEURYSM
Reference: [4] Kayalar, N., Burkhart, H., Dearani, J., Cetta, F., Schaff, H. Congenital Coronary Anomalies and Surgical TreatmentCongenit Heart Dis.
2009;4:239-251
MYOCARDIAL BRIDGING
©2004 by Radiological Society of North America
MYOCARDIAL BRIDGING
1. Occurs when a short segment of the
coronary artery enters the myocardium
and courses for a variable length before
coursing back to the epicardial surface of
the heart.
2. Myocardial bridging is considered a
relatively
benign finding; however, this
may rarely cause severe ischemia.
Reference: Tech Vasc Interventional Rad. 2006; 9:210-217
MYOCARDIAL BRIDGING
Reference: Radiology 2009, 252 (3)
ANOMALIES OF TERMINATION
CONGENITAL CORONARY ARTERY
FISTULA
CONGENITAL CORONARY ARTERY
FISTULA
1. This represents an abnormal connection
between a coronary artery and the PA,
coronary sinus, or cardiac chamber.
2. Fistulae represent a left-to-right or a leftto-left shunt, depending on where their
exit site is. This may also result in
dilation of the coronary artery to varying
degrees depending on the shunt volume.
Reference: The British Journal of Radiology, 82, (2009), 254-261
TREATMENTS FOR CAA
• Medical: Depending on the type of CAA
involved, medications can be utilized,
oxygen therapy and activity limitations
• Surgical: Depending on the type of CAA
involved, different surgical techniques may
be utilized for repair
THE END!