Download CARDIAC AND CORONARY ARTERY ANATOMY NO DISCLOSURES

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
ƒ CARDIAC ANATOMYANATOMY- VARIOUS IMAGING PLANES
ƒ 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
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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
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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
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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)
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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
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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
ƒ Determined by blood supply to inferior
wall
ƒ PDA, PLB and AVAV-node branches help
define dominance
LVOT
RVOT
Direct coronal
Oblique coronal
AORTIC ROOT
Oblique axial
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RIGHT DOMINANCE (80-85%)
DOMINANT RCA ANATOMYANTERIOR SCHEMATIC
ƒ RCA gives rise to PDA, PLB and AVAV-node
branches
ƒ PDA supplies inferior septum
ƒ PLB supplies inferior wall
DOMINANT RCA ANATOMY
RCA ANATOMY
ƒ RCA proximal – From ostium
to one half the distance to the
acute margin of the heart.
ƒ RCA middle–
middle– RCA from above
segment to the acute margin
of heart.
ƒ 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%
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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%)
ƒ PDA and PLB arise from LCx and supply
inferior wall and inferior septum
ƒ AVAV-Node branch usually distal to PDA
LAO SCHEMATICSCHEMATICDOMINANT LEFT CORONARY
ANATOMY
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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
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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
ƒ LAD proximal – Proximal to and including
origin of the first major septal perforator.
ƒ 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.
ƒ 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
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LCX ANATOMY
NONNON-DOMINANT LCx ANATOMY
ƒ LCx proximal – From it’
it’s
origin off LCA to and
including origin of
obtuse marginal.
ƒ 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
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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?
ƒ Normal
Norma – the anatomy seen in >99% of
the population6
DOMINANT
LCx
NONNONDOMINANT
LCx
ƒ Variant – unusual anatomy seen in >1%
of the population
ƒ 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
ƒ Myocardial bridging - When a coronary
artery runs intramurally within the
myocardium instead of epicardially.
epicardially.
ƒ Encased segment called tunneled artery.
ƒ Superficial bridge (75%) (no deviation into
myocardium)
ƒ Deep Bridge (25%) (Dips, ie U-shaped, into
myocardium)
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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
ƒ Usually asymptomatic with good prognosis. Has
been associated with arrhythmia, unstable angina,
myocardial infarction and sudden death.
ƒ When symptoms occur they often don’
don’t
manifest until the third decade of life.
ƒ 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.
ƒ MB predisposes artery to atherosclerosis
proximal to bridge.
ƒ 5.7% incidence on CTA (Sung(Sung-Min Ko,
Ko, et.al. Int J Cardiovasc Im
Oct. 2007)
Anomalies of Origin
ƒ Large multicenter studies needed for
incidence and link between MB and chest
pain.
ANOMALOUS RCARCAINTERARTERIAL COURSE
ƒ 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))
ƒ 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.
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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
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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
ƒ Also known as ALCAPA or BlandBland-WhiteWhiteGarland syndrome.
ƒ A rare congenital defect that represents
only 0.250.25-0.5% of all congenital cardiac
defects.
ƒ 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
ƒ Usually congenital and accounts for 0.20.2-0.4%
of congenital cardiac anomalies.
ƒ Most are clinically and hemodynamically
insignificant and are found incidentally.
ƒ Approximately 60% of coronary artery
fistulas originate from the right coronary
artery.
ƒ Symptoms usually present at 11-2 months of
age when LCA pressures rise and PA
pressures decrease causing left to right
shunting.
ƒ Without treatment, approximately 90% of
infants will die in the first year of life.
ƒ 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
ƒ 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).
ƒ Stealing of blood to the low pressure systemic
circulation leaves myocardium at risk for ischemia.
ƒ In response, the coronary dilates and may progress
to frank aneurysm which can ulcerate, thrombose or
rupture.
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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
ƒ kbis@
kbis@beaumont.
beaumont.edu
ƒ High Temporal and Spatial Resolution
ƒ 2D2D-MPR, 3D and 4D4D-MIP and VR
Techniques
ƒ Detailed Depiction of Cardiac and Coronary
Anatomy
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