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CARDIAC AND CORONARY ARTERY ANATOMY NASCI MEETING, SEATTLE WASHINGTON 2010 KOSTAKI G. BIS, MD, FACR DEPARTMENT OF RADIOLOGY WILLIAM BEAUMONT HOSPITAL Royal Oak, Michigan NO DISCLOSURES OBJECTIVES CARDIAC ANATOMY- 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 ASCENDING AORTA MAIN PULMONARY ARTERY BIFURC’N SVC R- SUPERIOR PULMONARY VEIN L- SUPERIOR PULMONARY VEIN DESCENDING AORTA Axial Anatomy of Heart Pectinate Muscles Transverse Pericardial Sinus Oblique Pericardial Sinus LEFT ATRIAL APPENDAGE Axial Anatomy of Heart PULMONARY VALVE Transverse Pericardial Sinus Oblique Pericardial Sinus LAD INFLOW L- SUPERIOR PULMONARY VEIN Axial Anatomy of Heart Pectinate Muscle SVC INFLOW INFLOW R- SUPERIOR PULMONARY VEIN Muscular Infundibulum (Conus) RVOT L-MAIN Axial Anatomy of Heart RIGHT ATRIAL APPENDAGE L- MAIN ORIGIN CEPHALAD INTERATRIAL SEPTUM Axial Anatomy of Heart RCA LAD NON-CORONARY CUSP LCx Axial Anatomy of Heart SA-NODE BRANCH INFLOW L- INFERIOR PULMONARY VEIN Axial Anatomy of Heart AORTIC VALVE Crista Terminalis Shares fibrous continuity with Mitral valve Axial Anatomy of Heart Outflow portion of Interventricular Septum INFLOW R-INFERIOR PULMONARY VEIN LVOT MITRAL VALVE Axial Anatomy of Heart RCA LAD LCx Crista Terminalis Axial Anatomy of Heart INTERVENTRICULAR SEPTUM RV LV RA INTERATRIAL SEPTUM ANTEROLATERAL PAPILLARY MUSCLE LA Chordae Tendinae Axial Anatomy of Heart TRICUSPID VALVE PLANE INFLOWCORONARY SINUSvia Thebesian valve Axial Anatomy of Heart Moderator Band- part of right bundle branch Eustachian Valve IVC INFLOW CORONARY SINUS Axial Anatomy of Heart Pericardial Fat Epicardial Fat DISTAL RCA SUPRAHEPATIC IVC POSTEROMEDIAL PAPILLARY MUSCLES Axial Anatomy of Heart Axial Anatomy of Heart PDA Axial Anatomy of Heart-MRI Crista Term IMAGING PLANES (SET-UP) RAO LAO CARDIAC ANATOMY-(4D MIPs) (VERTICAL LONG AXIS-RAO) RAO CARDIAC AND CORONARY ARTERY ANATOMY-(3D-MIPs) (VERTICAL LONG AXIS-RAO) AVI CARDIAC ANATOMY-(CINE MRI) (VERTICAL LONG AXIS-RAO) AVI CARDIAC ANATOMY-(4D-MIPs) (HORIZONTAL LONG AXIS, 4 CHAMBER) HLA CARDIAC AND CORONARY ARTERY ANATOMY-(3D-MIPs) (HORIZONTAL LONG AXIS) AVI CARDIAC ANATOMY-(CINE MRI) (HORIZONTAL LONG AXIS) AVI CARDIAC ANATOMY-(CINE MRI) (HORIZONTAL LONG AXIS) AVI CARDIAC ANATOMY-(4D-MIPs) (SHORT AXIS-LAO) LAO CARDIAC AND CORONARY ARTERY ANATOMY-(3D-MIPs) (SHORT AXIS-LAO) AVI CARDIAC ANATOMY-(CINE MRI) (SHORT AXIS-LAO) AVI 17-MYOCARDIAL SEGMENT MODEL Above schematic is for RCA dominance. Note: With left dominance, LCx supplies the inferior septum and inferior wall. Apical segment 17- Has most variable blood supply (LAD, RCA or LCx) BASE MIDDLE APEX CARDIAC ANATOMY-(CINE MRI) (INLET-OUTLET, 3-CHAMBER, “PARASTERNAL LONG AXIS”) AVI ADDITIONAL VIEWS-(CINE MRI) LVOT RVOT Direct coronal Oblique coronal AORTIC ROOT Oblique axial AVI CORONARY DOMINANCE Determined by blood supply to inferior wall PDA, PLB and AV-node branches help define dominance RIGHT DOMINANCE (80-85%) RCA gives rise to PDA, PLB and AV-node branches PDA supplies inferior septum PLB supplies inferior wall DOMINANT RCA ANATOMYANTERIOR SCHEMATIC DOMINANT RCA ANATOMY AV-NODE BRANCH RIGHT DOMINANCE PDA Usually distal to PDA RCA ANATOMY RCA proximal – From ostium to one half the distance to the acute margin of the heart. RCA 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 Ad-Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery. Circulation 1975; 51:5-40. CONUS BRANCH VARIATIONS 50% Conus Branch Supplies RVOT 50% Forms circle of Vieussens = Anastomosis with LAD circ’n CONUS BRANCH FROM LAD SA-NODE BRANCH VARIATIONS 55% 45% FROM RCA FROM LCx RV (ACUTE) MARGINAL BRANCHES SUPPLY ANTERIOR RV PDA and PLB VARIATIONRCA DOMINANCE SINGLE PDA and PLB DUAL PDA and PLB HIGH PDA TAKE-OFF NORMAL ANATOMY Aortic Root Injection - CTA- 3D MIP’s of Normal Dominant RCA RCA PDA PLB Cardiac AngiographyRCA DOMINANT RCA ANATOMY- Aortic Root Injection PROXIMAL RCA ANATOMY: SA-NODAL BRANCHES PROXIMAL RCA ANATOMY: CONUS & RV MARGINALS DISTAL RCA ANATOMY: DUAL PDA & PLB SINGLE PDA AND PLB PDA PDA PLB conus PLB RV marginals PDA PLB LEFT DOMINANCE (15-20%) PDA and PLB arise from LCx and supply inferior wall and inferior septum AV-Node branch usually distal to PDA LAO SCHEMATICDOMINANT LEFT CORONARY ANATOMY DOMINANT LCx ANATOMY AVGA= AV-groove artery of LCx DOMINANT LCx ANATOMY DOMINANT LCx ANATOMYDual PDA CO-DOMINANCE (5%) PDA ARISES FROM RCA PLB ARISES FROM LCx LAO SCHEMATICDOMINANT LEFT CORONARY ANATOMY LEFT MAIN BIFURCATION LM5-10 mm LEFT MAIN TRIFURCATIONRAMUS INTERMEDIUS BRANCH VARIATION RI RI RI RI MOST COMMON LCA VARIATION RAMUS INTERMEDIUS BRANCH VARIATION Single branching RI RI DISTRIBUTIONAS DIAGONAL OR OBTUSE MARGINAL Dual RI 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. Report of the Ad-Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery. Circulation 1975; 51:5-40. RAO LAD ANATOMY SEPTAL PERFORATOR BRANCH VARIATION NUMBERED IN SEQUENCE S1, S2, S3….. SUPPLY: VENTRICULAR SEPTUM and …. AV bundle and Proximal bundle branch DIAGONAL BRANCH ANATOMY NUMBERED IN SEQUENCE D1, D2, D3….. SUPPLY ANTERIOR WALL LCX ANATOMY LCx proximal – From 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 Ad-Hoc Committee for Grading of Coronary Artery Disease, Council on Cardiovascular Surgery. Circulation 1975; 51:5-40. NON-DOMINANT LCx ANATOMY SUPPLIES: LATERAL WALL and variable portion of anterolateral papillary muscle AXIAL-ANTERIOR LAO DOMINANT LCx ANATOMY OBTUSE MARGINAL BRANCHES NUMBERED IN SEQUENCE : OM1, OM2, OM3….. SUPPLIES: LATERAL WALL, INFERIOR WALL and INFERIOR SEPTUM and variable portion of anterolateral papillary and Posteriomedial papillary muscle NORMAL ANATOMY- Aortic Root Injection CTA- 3D MIP’s of Normal LEFT MAIN Bifurcation, LAD with D1 and LCx CTA- 3D MIP’s of S1 and S2 Cardiac AngiographyLAD LM S1, S2 D1 LAD AVGA D1 LCx NORMAL ANATOMY Aortic Root Injection - CTA- 3D MIP’s of Normal Cardiac Non-dominant LCx, AVGA and OM1 AngiographyLCx OM1 AVGA AVGA Proximal LCx OM1 Cardiac Veins Cardiac Veins PDA and MIDDLE CARDIAC VEIN SMALL CARDIAC VEIN ANTERIOR INTERVENTRICULAR VEIN AND GREAT CARDIAC VEIN AIV AIV GCV GCV AIV CORONARY SINUS ANATOMY DOMINANT LCx NONDOMINANT LCx What is an Anomaly? Normal Norma – the anatomy seen in >99% of the population6 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. Encased segment called tunneled artery. Superficial bridge (75%) (no deviation into myocardium) Deep Bridge (25%) (Dips, ie U-shaped, into myocardium) SUPERFICIAL AND DEEP MYOCARDIAL BRIDGE Sung-Min Ko Int J Cardiovasc Im, 2007 Deep Superficial DEEP MYOCARDIAL BRIDGE Anomalies of Course – Myocardial Bridging Usually asymptomatic with good prognosis. Has been associated with arrhythmia, unstable angina, myocardial infarction and sudden death. Incidence ranges from 0.5-2.5% in angiographic studies to 15-85% in pathologic series and thus, may be considered an anatomic variant rather than a true anomaly. 5.7% incidence on CTA (Sung-Min Ko, et.al. Int J Cardiovasc Im Oct. 2007) Anomalies of Origin 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) The course taken by the anomalous artery is critically important as the retroaortic, prepulmonic and septal courses are considered benign while the interarterial course can be associated with sudden cardiac death. ANOMALOUS RCAINTERARTERIAL COURSE Left Main Arising from Right Coronary Cusp with Interarterial Course Rt. Ant. PA Ao 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. Lt. Rt. Non Lt. Left Main Arising from Right Coronary Cusp with Interarterial Course Ao 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 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. ANOMALOUS LM ORIGINSeptal (Subpulmonic) Course FROM RIGHT CORONARY CUSP COURSE-BETWEEN RVOT AND AORTIC ROOT 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. 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. Anomalous Left Coronary Artery Originating From the Pulmonary 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 Symptoms usually present at 1-2 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 Usually congenital and accounts for 0.2-0.4% 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. 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. 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. CONCLUSION MULTIDETECTOR CTA High Temporal and Spatial Resolution 2D-MPR, 3D and 4D-MIP and VR Techniques Detailed Depiction of Cardiac and Coronary Anatomy THANK YOU [email protected]
