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CARDIAC AND CORONARY ARTERY ANATOMY NO DISCLOSURES NASCI MEETING, ORLANDO FLORIDA 2009 KOSTAKI G. BIS, MD, FACR DEPARTMENT OF RADIOLOGY WILLIAM BEAUMONT HOSPITAL Royal Oak, Michigan Axial Anatomy of Heart ASCENDING AORTA MAIN PULMONARY ARTERY BIFURC’ BIFURC’N OBJECTIVES SVC CARDIAC ANATOMYANATOMY- VARIOUS IMAGING PLANES NORMAL, VARIANT and SOME ANOMALOUS ANATOMY OF CORONARY ARTERIES AND SUBJACENT VEINS IMPORTANT FOR CORRECT IMAGE INTERPRETATION AND PATIENT CARE Axial Anatomy of Heart R- SUPERIOR PULMONARY VEIN L- SUPERIOR PULMONARY VEIN DESCENDING AORTA Axial Anatomy of Heart PULMONARY VALVE LAD LEFT ATRIAL APPENDAGE INFLOW L- SUPERIOR PULMONARY VEIN 1 Axial Anatomy of Heart SVC INFLOW RVOT Axial Anatomy of Heart RIGHT ATRIAL APPENDAGE L- MAIN ORIGIN INFLOW R- SUPERIOR PULMONARY VEIN L-MAIN CEPHALAD INTERATRIAL SEPTUM Axial Anatomy of Heart Axial Anatomy of Heart RCA LAD SASA-NODE BRANCH NONNON-CORONARY CUSP LCx Axial Anatomy of Heart AORTIC VALVE INFLOW L- INFERIOR PULMONARY VEIN Axial Anatomy of Heart INFLOW R-INFERIOR PULMONARY VEIN LVOT MITRAL VALVE 2 Axial Anatomy of Heart Axial Anatomy of Heart INTERVENTRICULAR SEPTUM RCA LAD RV LV RA INTERATRIAL SEPTUM ANTEROLATERAL PAPILLARY MUSCLE LA LCx Axial Anatomy of Heart TRICUSPID VALVE PLANE IVC INFLOW INFLOWINFLOWCORONARY SINUS CORONARY SINUS Axial Anatomy of Heart DISTAL RCA Axial Anatomy of Heart Axial Anatomy of Heart POSTEROMEDIAL PAPILLARY MUSCLES SUPRAHEPATIC IVC 3 Axial Anatomy of Heart Axial Anatomy of Heart-MRI PDA IMAGING PLANES (SET-UP) RAO CARDIAC ANATOMYANATOMY-(4D MIPs) MIPs) (VERTICAL LONG AXISAXIS-RAO) RAO LAO CARDIAC AND CORONARY ARTERY ANATOMYANATOMY-(3D(3D-MIPs) (VERTICAL LONG AXISAXIS-RAO) CARDIAC ANATOMYANATOMY-(CINE MRI) (VERTICAL LONG AXISAXIS-RAO) 4 CARDIAC ANATOMYANATOMY-(4D(4D-MIPs) (HORIZONTAL LONG AXIS, 4 CHAMBER) CARDIAC AND CORONARY ARTERY ANATOMYANATOMY-(3D(3D-MIPs) (HORIZONTAL LONG AXIS) HLA CARDIAC ANATOMYANATOMY-(CINE MRI) CARDIAC ANATOMYANATOMY-(CINE MRI) (HORIZONTAL LONG AXIS) (HORIZONTAL LONG AXIS) CARDIAC ANATOMYANATOMY-(4D(4D-MIPs) (SHORT AXISAXIS-LAO) CARDIAC AND CORONARY ARTERY ANATOMYANATOMY-(3D(3D-MIPs) (SHORT AXISAXIS-LAO) LAO 5 CARDIAC ANATOMYANATOMY-(CINE MRI) (SHORT AXISAXIS-LAO) 1717-MYOCARDIAL SEGMENT MODEL Above schematic is for RCA dominance. Note: With left dominance, LCx supplies the inferior septum and inferior distributions CARDIAC ANATOMYANATOMY-(CINE MRI) (INLET(INLET-OUTLET, 33-CHAMBER, “PARASTERNAL LONG AXIS” AXIS”) BASE MIDDLE APEX ADDITIONAL VIEWSVIEWS-(CINE MRI) CORONARY DOMINANCE Determined by blood supply to inferior wall PDA, PLB and AVAV-node branches help define dominance LVOT RVOT Direct coronal Oblique coronal AORTIC ROOT Oblique axial 6 RIGHT DOMINANCE (80-85%) DOMINANT RCA ANATOMYANTERIOR SCHEMATIC RCA gives rise to PDA, PLB and AVAV-node branches PDA supplies inferior septum PLB supplies inferior wall DOMINANT RCA ANATOMY RCA ANATOMY RCA proximal – From ostium to one half the distance to the acute margin of the heart. RCA middle– middle– RCA from above segment to the acute margin of heart. RCA distal - From the acute margin to the origin of the PDA. Report of the AdAd-Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery. Circulation 1975; 51:551:5-40. CONUS BRANCH VARIATIONS CONUS BRANCH FROM LAD 50% Conus Branch Supplies RVOT 50% 7 SASA-NODE BRANCH VARIATIONS 55% RV (ACUTE) MARGINAL BRANCHES SUPPLY ANTERIOR RV FROM RCA FROM LCx 45% PDA and PLB VARIATIONVARIATIONRCA DOMINANCE SINGLE PDA and PLB AVAV-NODE BRANCH RIGHT DOMINANCE HIGH PDA TAKETAKE-OFF DUAL PDA and PLB PDA Usually distal to PDA LEFT DOMINANCE (15-20%) PDA and PLB arise from LCx and supply inferior wall and inferior septum AVAV-Node branch usually distal to PDA LAO SCHEMATICSCHEMATICDOMINANT LEFT CORONARY ANATOMY 8 DOMINANT LCx ANATOMY DOMINANT LCx ANATOMY AVGA= AVAV-groove artery of LCx DOMINANT LCx ANATOMYANATOMYDual PDA CO-DOMINANCE (5%) PDA ARISES FROM RCA LAO SCHEMATICSCHEMATICDOMINANT LEFT CORONARY ANATOMY PLB ARISES FROM LCx LEFT MAIN BIFURCATION LMLM5-10 mm 9 LEFT MAIN TRIFURCATIONTRIFURCATIONRAMUS INTERMEDIUS BRANCH VARIATION RAMUS INTERMEDIUS BRANCH VARIATION Single RI RI DISTRIBUTIONDISTRIBUTIONAS DIAGONAL OR OBTUSE MARGINAL Dual RI MOST COMMON LCA VARIATION LAD ANATOMY LAD proximal – Proximal to and including origin of the first major septal perforator. LAD middle – Distal to origin of first major septal perforator and extending to point where the LAD forms an angle (RAO view). This is often, but not always, close to the origin of the second diagonal. If this angle or diagonal is not identifiable, this segment ends one half the distance from the first major septal perforator to the apex. LAD apical – Beginning at the end of the previous segment and extending to or beyond the apex. LAD ANATOMY RAO Report of the AdAd-Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery. Circulation 1975; 51:551:5-40. SEPTAL PERFORATOR BRANCH VARIATION NUMBERED IN SEQUENCE S1, S2, S3… S3….. SUPPLY VENTRICULAR SEPTUM DIAGONAL BRANCH ANATOMY NUMBERED IN SEQUENCE D1, D2, D3… D3….. SUPPLY ANTERIOR WALL 10 LCX ANATOMY NONNON-DOMINANT LCx ANATOMY LCx proximal – From it’ it’s origin off LCA to and including origin of obtuse marginal. LCx distal – The LCx distal to the origin of the obtuse marginal and running along or close to left (posterior) AV groove. Report of the AdAd-Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery. Circulation 1975; 51:551:5-40. DOMINANT LCx ANATOMY AXIALAXIAL-ANTERIOR LAO Cardiac Veins OBTUSE MARGINAL BRANCHES NUMBERED IN SEQUENCE : OM1, OM2, OM3… OM3….. SUPPLY LATERAL WALL Cardiac Veins PDA and MIDDLE CARDIAC VEIN 11 SMALL CARDIAC VEIN ANTERIOR INTERVENTRICULAR VEIN AND GREAT CARDIAC VEIN AIV AIV AIV GCV GCV CAUDALCAUDAL-TOTO-CRANIAL ACQUISITION TRIPLE R/O PROTOCOL CORONARY SINUS ANATOMY STANDARD CRANIALCRANIALTOTO-CAUDAL ACQUISITION What is an Anomaly? Normal Norma – the anatomy seen in >99% of the population6 DOMINANT LCx NONNONDOMINANT LCx Variant – unusual anatomy seen in >1% of the population Anomaly – unusual and uncommon anatomy seen in <1% of the population Coronary Artery Anomalies Anomalies of Origin High takeoff Multiple ostia Single coronary artery Anomalous origin of the coronary artery from the pulmonary artery* Origin of coronary artery from the opposite or noncoronary sinus with an anomalous course (either retroaortic, interarterial,* prepulmonic, septal (subpulmonic). Anomalies of Course Myocardial bridging* Duplication of arteries Anomalies of termination Coronary artery fistulas* Coronary arcade Extracardiac termination *-Potentially hemodynamically significant or malignant abnormalities Anomalies of Course – Myocardial Bridging Myocardial bridging - When a coronary artery runs intramurally within the myocardium instead of epicardially. epicardially. Encased segment called tunneled artery. Superficial bridge (75%) (no deviation into myocardium) Deep Bridge (25%) (Dips, ie U-shaped, into myocardium) 12 SUPERFICIAL AND DEEP MYOCARDIAL BRIDGE DEEP MYOCARDIAL BRIDGE SungSung-Min Ko Int J Cardiovasc Im, Im, 2007 Deep Superficial Anomalies of Course – Myocardial Bridging Additional Facts – Myocardial Bridging Usually asymptomatic with good prognosis. Has been associated with arrhythmia, unstable angina, myocardial infarction and sudden death. When symptoms occur they often don’ don’t manifest until the third decade of life. Incidence ranges from 0.50.5-2.5% in angiographic studies to 1515-85% in pathologic series and thus, may be considered an anatomic variant rather than a true anomaly. MB predisposes artery to atherosclerosis proximal to bridge. 5.7% incidence on CTA (Sung(Sung-Min Ko, Ko, et.al. Int J Cardiovasc Im Oct. 2007) Anomalies of Origin Large multicenter studies needed for incidence and link between MB and chest pain. ANOMALOUS RCARCAINTERARTERIAL COURSE A coronary artery that arises from the opposite or noncoronary cusp can take any one of four common courses: 1. interarterial (between aorta and pulmonary artery) 2. retroaortic 3. prepulmonic 4. septal (subpulmonic (subpulmonic)) The course taken by the anomalous artery is critically important as the retroaortic, retroaortic, prepulmonic and septal courses are considered benign while the interarterial course can be associated with sudden cardiac death. 13 Left Main Arising from Right Coronary Cusp with Interarterial Course Left Main Arising from Right Coronary Cusp with Interarterial Course Rt. Ant. PA Lt. Non Ao Ao Rt. Lt. Axial MIP and Volume rendered images show the Left main Coronary artery originating from the right coronary cusp and coursing between the aorta and pulmonary artery. The schematic diagram depicts a similar situation. Left Main Arising from Right Coronary Cusp with Interarterial Course Anterior 3D Volume rendered images demonstrate the left main coronary artery arising from the right coronary cusp with interarterial course. The image on the right has had the pulmonary artery digitally removed by changing the window. Left Main Arising from Right Coronary Cusp with Septal Course LM The anomalous left main can be seen descending inferiorly. This septal or subpulmonic course has not been associated with sudden death. PA A second case demonstrating an anomalous origin of the left main coronary artery from the right coronary cusp with interarterial course. MIP images in various projections display the anomaly, however, the sagittal MIP image on the right confirms the interarterial course ANOMALOUS LM ORIGINORIGINSeptal (Subpulmonic) Subpulmonic) Course FROM RIGHT CORONARY CUSP COURSECOURSE-BETWEEN RVOT AND AORTIC ROOT SINGLE CORONARY ARTERY LADLADVENTRAL TO RVOTRVOTPrepulmonic LCxLCxPOSTERIOR TO AORTIC ROOTROOTRetroaortic 14 Anomalous Left Coronary Artery Originating From the Pulmonary Artery Anomalous Left Coronary Artery Originating From the Pulmonary Artery Left main coronary artery is seen originating from the posterior pulmonary artery. Note the large size of both the left main, LAD and the right coronary artery. SAME CASE AS PREVIOUS SLIDE: ALCAPA with large right coronary artery. The RCA is hypertrophied as it is providing collateral flow to the left coronary bed. Note the intramyocardial collateral vessels on the MIP image on the right. Anomalous Pulmonary Artery Origin of Either the RCA or LCA Anomalous Pulmonary Artery Origin of Either the RCA or LCA Also known as ALCAPA or BlandBland-WhiteWhiteGarland syndrome. A rare congenital defect that represents only 0.250.25-0.5% of all congenital cardiac defects. Usually an isolated defect, but can be associated with other anomalies such as ASD, VSD and aortic coarctation in approximately 5% of cases. Anomalies of Termination – Coronary Artery Fistula Usually congenital and accounts for 0.20.2-0.4% of congenital cardiac anomalies. Most are clinically and hemodynamically insignificant and are found incidentally. Approximately 60% of coronary artery fistulas originate from the right coronary artery. Symptoms usually present at 11-2 months of age when LCA pressures rise and PA pressures decrease causing left to right shunting. Without treatment, approximately 90% of infants will die in the first year of life. Survival beyond infancy occurs when there are abundant intercoronary collaterals or the LCA supplies relatively less area of the myocardium. Anomalies of Termination – Coronary Artery Fistula Coronary artery can communicate with either a chamber of the heart (coronary-cameral fistula) or a segment of the systemic or pulmonary circulation (coronary arteriovenous fistula). Stealing of blood to the low pressure systemic circulation leaves myocardium at risk for ischemia. In response, the coronary dilates and may progress to frank aneurysm which can ulcerate, thrombose or rupture. 15 Anomalies of Termination – Coronary Arteriovenous Fistula Anomalies of Termination – Coronary Arteriovenous Fistula Ao A complex fistula is seen between the left main coronary artery and the pulmonary artery. Note the tortuous vessels and the contrast spill into the PA (arrows). Anomalies of Termination – Coronary Arteriovenous Fistula Another example of a complex coronary artery fistula, this one associated with a coronary artery aneurysm (arrows). The fistula is from the LAD and continues beyond the aneurysm as a serpiginous vessel over the main pulmonary artery. (Coronary AnatomyAnatomy-Swine Model) SELECTIVE CTA AORTIC ROOT CTA XX-RAY ANGIO EXEX-VIVO SAME CASE AS PRVIOUS SLIDE: Complex coronary artery fistula from the LAD to the pulmonary artery with aneurysm (arrows). CONCLUSION MULTIDETECTOR CTA THE END THANK YOU kbis@ kbis@beaumont. beaumont.edu High Temporal and Spatial Resolution 2D2D-MPR, 3D and 4D4D-MIP and VR Techniques Detailed Depiction of Cardiac and Coronary Anatomy 16