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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3676_Библиотеки_им_академика_М_И_Перельмана
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42
https://t.me/med1917
C. Smuclovisky
3.5 Case 3.5
3.5.1 History
A 57-year-old female with no past medical history presented to the emergency department complaining of chest pain.
3.5.2 Findings
There is no left circumflex coronary artery (LCX)
(Fig. 3.8a–c). No coronary artery disease (CAD).
Coronary circulation is right dominant.
3.5.3 Diagnosis
Congenital absence of the left circumflex coronary artery.
a
3.5.4 Discussion
It is uncommon to encounter a congenital
absent LCX, which needs to be differentiated
from an occluded artery. In right coronary
dominance, the LCX is typically of small or
moderate caliber.
3.5.5 Pearls and Pitfalls
There was no visualized LCX ostium to indicate
a stump from a thrombus. Flush coronary ostial
occlusion is uncommon without a stump. The
fact that the other coronary branches are large
and have no CAD is conclusive that this is a nor-
mal variant.
b
Fig. 3.8 (a, b) Axial
MIP. Absence of LCX
over the left
atrioventricular sulcus.
(c) Volume rendered
c
3 Coronary Anatomy
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43
3.6 Case 3.6
3.6.1 History
A 60-year-old female outpatient with atypical
chest pain. No previous cardiac history.
3.6.2 Findings
There is supra-annular anterior origin of the right
coronary artery (RCA) (Fig. 3.9a–c). There is a
small diverticulum arising from the right inferior
wall of the left atrium (Fig. 3.9d). No atherosclerotic coronary artery disease.
3.6.3 Diagnosis
Supra-annular origin of the RCA.
3.6.4 Discussion
Although, some may argue that this is a con-
genital anomalous origin of the coronary,
the RCA has no interarterial course, nar-
rowed ostium, acute angulation, or intramural
segment.
Diverticulum arising from the left atrium
are common and are usually small. They
mostly arise from the superior anterior wall
of the left atrium and are of no clinical
significance.
3.6.5 Pearls and Pitfalls
The findings are of no clinical significance.
Fig. 3.9 (a)
cMPR. Supra-annular
anterior origin of the
RCA. (b) VR. (c)
Coronal. (d) Axial.
Small diverticulum
(Arrow) arising from the
left atrium
a
b
c
d
44
ab
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C. Smuclovisky
3.7 Case 3.7
3.7.1 History
A 39-year-old male presented to ED with atypical chest pain. No previous cardiac history.
3.7.2 Findings
CCTA was read as a complete obstruction of the
mid-LAD with decreased perfusion to the anterior
wall and the cardiac apex (Fig. 3.10a–c). Cardiac
catherization showed an anatomic variation of the
left anterior descending coronary artery (LAD) without any significant obstructive disease (Fig. 3.10d).
3.7.3 Diagnosis
Anatomical variation of the left anterior descending artery.
3.7.4 Discussion
This anatomical variation of LAD was read as a
complete obstruction by a less experience reader.
Short LAD is a normal variant of coronary
anatomy.
The LAD is a short artery that extends into the
myocardial septum. The first diagonal branch is
long and large caliber and extends to the LV apex
in the anterior wall, essentially perfusing the territory of the expected LAD.
3.7.5 Pearls and Pitfalls
It is important to keep in mind the possibility of
an anatomical variation of the coronary arteries
and appropriately distinguish it from a cardiac
disease process.
It is important to distinguish an acute thrombus
in the LAD from a chronic total occlusion with a
hypertrophied branch serving as a collateral.
c
Fig. 3.10 (a) Volume
rendered. (b) olique
MIP. (c) cMPR. (d)
Coronary angiogram to
confirm short but patent
LAD
d
3 Coronary Anatomy
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45
In this case, there was no thrombus identified
in the LAD or atherosclerotic disease, which substantiates a normal anatomical variant.
Suggested Reading
Bastarrika Alemañ G, Alonso Burgos A, Azcárate
Agüero PM, et
variants, and anomalies of the origin and course of
the coronary arteries on multislice CT. Radiologia.
2008;50(3):197–206.
Genc B, Solak A, Sahin N, Gur S, Kalaycioglu S, Ozturk
V.
Assessment of the coronary venous system by using
cardiac CT.
Germans T, Nijveldt R, van Rossum AC. A more detailed
view calls for more detailed definition: description
of cardiac morphology with high-resolution CT and
MRI. AJR Am J Roentgenol. 2008;190(2):W169.
Kini S, Bis KG, Weaver L. Normal and variant
coronary arterial and venous anatomy on high-
resolution CT angiography. AJR Am J Roentgenol.
2007;188(6):1665–74.
Lacomis JM, Goitein O, Deible C, et al. Dynamic multidi-
mensional imaging of the human left atrial appendage.
Europace. 2007;9(12):1134–40.
Manghat NE, Rachapalli V, Van Lingen R, et al. Imaging
the heart valves using ECG-gated 64-detector row car-
diac CT.
Mao SS, Ahmadi N, Shah B, et al. Normal thoracic aorta
diameter on cardiac computed tomography in healthy
asymptomatic adults: impact of age and gender. Acad
Radiol. 2008;15(7):827–34.
al. Normal anatomy, anatomical
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Br J Radiol. 2008;81(964):275–90.
Medrano-Gracia P, Ormiston J, Webster M, Beier S, Ellis
C, Wang C, Young AA, Cowan BR.
a coronary artery atlast from CT angiography. Med
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2):513–20.
Poh AC, Juraszek AL, Ersoy H, et
irregularities of the left atrial roof as seen on coronary CT angiography. Int J Cardiovasc Imaging.
2008;24(7):729–34.
Sirineni GK, Stillman AE.
and MRI for coronary heart disease. J Thorac Imaging.
2007;22(1):107–13.
Stolzmann P, Scheffel H, Leschka S, et
values for quantitative left ventricular and left atrial
measurements in cardiac computed tomography. Eur
Radiol. 2008;18(8):1625–34.
Thilo C, Schoepf UJ, Gordon L, et
ment of coronary anatomy and myocardial perfusion
using a retractable SPECT camera combined with
64-slice CT: initial experience. Eur Radiol. 2008.
[Epub ahead of print].
Van de Veire NR, Schuijf JD, De Sutter J, et
invasive visualization of the cardiac venous system in coronary artery disease patients using
64-slice computed tomography. J Am Coll Cardiol.
2006;48(9):1832–8.
Van Werkhoven JM, Schuijf JD, Jukema JW, et
slice computed tomography coronary angiography:
anatomic vs functional assessment in clinical practice.
Minerva Cardioangiol. 2008;56(2):215–26.
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Understanding the heart: CT
Construction of
al. Endocardial
al. Reference
al. Integrated assess-
al. Non-
al. Multi-
Pediatric Cardiac CTA
https://t.me/med1917
Dianna M.E. Bardo
4
4.1 Introduction
The use of cardiac computed tomographic angiography (cardiac CTA) as a diagnostic modality
has increased because CT scanner technology
has improved. Modern CT scanners have an
increased number of detector rows allowing more
tissue to be scanned rapidly which reduces
motion artifact and need for sedation in children.
Iterative image reconstruction techniques reduce
image noise, enabling proactive reduction of
radiation dose and improved ECG-gating techniques are particularly important for accurate
detection of the high heart rates found in children. New multi-energy spectral CT technology
may become important in cardiac imaging
through enhancing our ability to differentiate tissue composition and enable detection of myocardial perfusion defects. To effectively utilize the
tools and technology available on the CT scanner, one must be committed to understanding the
physics of CT image acquisition and the use of
protocol parameters and image processing techniques designed for imaging with a radiation
dose as low as reasonably achievable (ALARA)
in children and young adults with acquired and
congenital heart disease (CHD).
D.M.E. Bardo, MD, FSCCT, FNASCI
Department of Radiology, Phoenix Children’s
Hospital, Phoenix, AZ, USA
e-mail: dbardo@phoenixchildrens.com
Patients with CHD have a heart defect which
has been present from birth and is most often discovered in the first year of life. In developed
countries, steady progress in repairing or palliating congenital heart defects since the midtwentieth century has led to there being more
adults living with CHD than there are children
living with CHD.
When examining cross-sectional images in
patients with CHD, it is important to begin with
standardized or routine search pattern of intraand extra-cardiac connections. Look for the anatomic differences in the shape of the ventricles,
shape of atrial appendages, hepatic, pulmonary
and venae cavae connections, and aortic and pulmonary valve and artery connections, and position of the chambers in relation to one another
(Table 4.1).
Position of the RV and LV and the cardiac
apex in the thorax is determined through a process of looping of the cardiac tube which occurs
in the embryological period. Normally, the cardiac tube loops to the right or D-loop which positions the RV anterior and to the right of the LV
and the cardiac apex to the left. An abnormal leftward or L-loop of the cardiac tube the right ventricle is positioned to the left of the LV and the
cardiac apex may be is rotated into the right thorax. Position of the heart relates to visceroatrial
situs or the relative position of the cardiac atria
and the abdominal viscera. Normal situs exists
when abdominal, cardiothoracic, and bronchopulmonary anatomy is normally arranged in the
© Springer International Publishing AG 2018
C. Smuclovisky (ed.), Coronary Artery CTA, https://doi.org/10.1007/978-3-319-66988-5_4
47
48
D.M.E. Bardo
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Table 4.1 Normal intra- and extra-cardiac connections and structural features
Structure Connections Identifying structural features
Left ventricle (LV) Inflow: from left atrium (LA)
Right ventricle (RV) Inflow: from right atrium (RA)
Left atrium (LA) Inflow: from pulmonary veins (PVn)
Right atrium (RA) Inflow: from superior vena cava
Aortic valve (AV) and
ascending aorta (AAo)
Pulmonary valve (PV)
and main pulmonary
artery (MPA)
Pulmonary veins (PVn) Inflow: from pulmonary capillary
Superior vena cava
(SVC)
Inferior vena cava
(IVC)
Hepatic veins (HV) Inflow: from mesenteric veins to
Mitral valve (MV) Separates the LA and LV MV—bileaflet valve separates the LA and the
Tricuspid valve (TV) Separates the RA and RV TV—trileaflet valve separates the RA and the
through mitral valve (MV)
Outflow: through aortic valve (AV)
to ascending aorta (AAo)
through tricuspid valve (TV)
Outflow: through pulmonic valve
(PVn) to main pulmonary artery
(MPA)
Outflow: to LA
(SVC), inferior vena cava (IVC),
and hepatic veins (HV)
Outflow: to RA
Inflow: from LV
Outflow: to coronary arteries and
aortic arch
Inflow: from RV
Outflow: to right and left branch
pulmonary arteries (RPA) and
(LPA)
bed
Outflow: to LA
Inflow: from jugular, subclavian,
and other veins of the head and
upper extremities
Outflow: to RA
Inflow: from femoral, renal, and
other veins of the lower body
Outflow: to RA
portal veins
Outflow: to RA
Papillary muscles—anterior and posterior muscles
in the LV—chordae tendinae extend from tip of
each papillary muscle to leaflets of the mitral
valve
Moderator band—near RV apex a muscular band
courses from the base of the anterior papillary
muscle in the RV toward the intraventricular
septum—trabeculation are more prominent than in
then LV
Left atria appendage—a narrow muscular “pouch”
extending from the left atrium
Right atrial appendage—a broad based coneshaped extension of the right atrium
AV—trileaflet valve with right, left, and
noncoronary cusps within the sinuses of
Valsalva—lies posterior and to the right of the
pulmonary valve (PV)
AAo—tubular segment above the sinuses of
Valsalva proximal to the aortic arch
PV—trileaflet valve with right, left, and anterior
cusps—lies anterior and to the left of the AV
MPA—tubular artery above the PV, bifurcates to
right and left pulmonary artery branches
PVns—right and left superior and inferior veins
and occasionally a right middle pulmonary vein
join the LA—left-sided veins often form a
common confluence prior to meeting the LA
SVC—the major venous drainage pathway of the
upper body—typically R sided—a persistent L
SVC if present drains to the coronary sinus—there
may or may not be a bridging brachiocephalic vein
when both R SVC and L SVC are present
IVC—the major venous drainage pathway of the
lower extremities and lower body—typically R
sided and courses through the liver and along
with the RA—may be interrupted in some forms
of CHD—if interrupted, the azygous vein
continues drainage to the SVC
HV—drain liver parenchyma to the RA—venous
drainage from the liver contains a factor which
prohibits the formation of arterial venous
malformations (AVMs)in the lungs—when hepatic
factor is present (as in normal systemic/pulmonary
blood flow) pulmonary AVMs do not form)
LV—in transposition the MV remains associated
with the LV
RV—in transposition the TV remains associated
with the RV
4 Pediatric Cardiac CTA
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49
usual manner may be found in patients with
CHD, but it is more often that CHD is seen in
patients in whom the visceral and atrial anatomy
is inverted or ambiguous (Table 4.2).
Noting connections between the key structural
components of the heart and the cardiothoracic
vasculature and visceroatrial situs, other key anatomic relationships, the relative position or relationship of the aortic and pulmonary valves, and
the origins and proximal course of the coronary
Table 4.2 Basics of visceroatrial situs
Situs solitus Situs inversus Situs ambiguous
Visceralatrial anatomy
Right atrium (RA)
Liver
Left atrium (LA)
Stomach
Spleen
Trilobed lung
Early origin of the upper
lobe bronchus from the
right main bronchus
Bilobed lung
Distal origin of the upper
lobe bronchus from the
left main bronchus
Eparterial bronchial
position
Hyparterial bronchial
position
Normal Reverse of normal Heterotaxy
On the right On the left Two distinct forms of
On the left On the right
Right-sided trilobed lung
Right main bronchus
with early origin of the
upper lobe bronchus
Left-sided bilobed lung
Distal origin of the left
upper lobe bronchus
Right pulmonary artery
(RPA) lies in front of the
right bronchus
RPA crosses above the
main bronchus
arteries, allows thorough assessment of mild and
complex forms of CHD (Tables 4.3 and 4.4).
With this basic knowledge and an organized anatomic search pattern approach to identify anatomy
in cross-sectional images of CHD patients, the collection of the following 25 cases or group of cases
reinforce principles which may be applied in daily
practice. Each case or group of cases also provides
detailed findings of the most common forms of
simple and complex CHD.
heterotaxy or situs ambiguous
are recognized as most
common:
Left-sided trilobed lung
Left main bronchus with
early origin of the upper
lobe bronchus
Right-sided bilobed lung
Distal origin of the right
upper lobe bronchus
Left pulmonary artery
(LPA) lies in front of the
left bronchus
LPA crosses above the
main bronchus
Right isomerism (asplenia)
• bilateral trilobed lungs
• bilateral right-sided
bronchi
• large symmetric liver
• absence of the spleen
• total anomaly of the
pulmonary venous return
Left isomerism (polysplenia)
• bilateral bilobed lungs
• interruption of the IVC
(with lower body venous
flow returning to the heart
via azygous vein
continuation to the SVC)
• multiple spleens
• pulmonary veins drain
to the right and the left
atria
Heterotaxy exists as
combinations of one or more
of the above features—when
reporting or discussing a case
describe findings
independently and use the
term heterotaxy.
50
D.M.E. Bardo
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Table 4.3
Structure Normal position Leaflet nomenclature Abnormal position
Aortic valve (AV) Lies posterior and to the
Pulmonary valve (PV) Lies anterior and to the
Table 4.4 Coronary arteries in CHD
Structure Coronary artery origin, branches, and course Key anatomy
Left coronary artery (LM) LM arises from the left sinus of the AV,
Right coronary artery
(RCA)
Features of the aortic valve and pulmonary valve
right of the PV
left of the AV
courses under the LAA—bifurcates to the left
anterior descending (LAD) and left circumflex
(LCx) coronary arteries
LAD remains epicardial and courses along the
intraventricular septum with diagonal and
septal branches
LCx courses in the left atrioventricular groove
with obtuse marginal (OM) branches
RCA arises from the right sinus of the AV,
remains epicardial as it courses in the right
atrioventricular groove with acute marginal
(AM), conus, posterior descending (PDA),
and often a posterolateral (PL) branches
PDA is a terminal branch which most often
arises from the RCA (80%) and courses in the
posterior intraventricular groove
Trileaflet valve with right,
left, and noncoronary cusps
within the sinuses of
Valsalva—The noncoronary
cusp always lies adjacent to
the intra-atrial septum—even
if there is a coronary artery
arising from that cusp
Trileaflet valve with right,
left, and anterior cusps—lies
anterior and to the left of the
AV
The artery which supplies the PDA
is referred to as the dominant
coronary artery; most often the RCA
The LM and RCA should arise at a
nearly 90° orientation from the sinus
of Valsalva
An anomalous coronary artery origin
can arise from another sinus, the
AAo, or the MPA
Anomalous coronary arteries may
course in the wall of the AAo,
between the AAo and the MPA,
behind the AAo and anterior to the
atria, over the right ventricle outflow
tract, or through the myocardium at
the base of the heart
D-TGA—AV lies
anterior and to the right
of the PV
L-TGA—AV lies
anterior and to the left of
the PV
DORV—AV lies
side-by-side and R of the
PV
In TGA, the coronary
artery origins are
described as from the
R-facing, L-facing, and
non-facing sinuses of the
AV—depending on
whether they are adjacent
to or not adjacent to the
PV
4 Pediatric Cardiac CTA
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51
4.2 Azygous Continuation
an Interrupted IVC
of
Embryological development of the venous drainage of the gut, abdominal viscera, and lower
extremities progresses through several stages,
beginning in the fifth week of gestation as parallel anterior and posterior cardinal and subcardinal veins which extend the length of the embryo,
less than 10 mm in length. Supracardinal veins
join the cardinal and subcardinal veins and transverse anastomoses are formed. Communication
with the heart is achieved through formation of
the intrahepatic segment of the inferior vena cava
(IVC) as the right subcardinal vein joins the
hepatocardiac canal. The right superior cardinal
vein becomes the superior vena cava (SVC). The
left superior cardinal vein usually regresses;
when it persists drainage continues to the coronary sinus [1].
The dorsally positioned azygous venous system is formed from the cranial portion of the
supracardinal veins, becoming the azygous vein
on the right and the hemiazygous vein on the left.
In the normal situation each of these veins is
small caliber, but when the intrahepatic segment
of the IVC fails to develop, the azygous vein caliber is enlarged as a larger volume of venous
return to the heart must flow through the azygous
vein, to the SVC, to the right atrium.
As development of the heart, its arterial and
venous connections as well as abdominal visceral
formation develop simultaneously during these
early embryological weeks, it is not uncommon
to have associated other cardiac, pulmonary, and
abdominal organ anomalies.
Heterotaxy, a term used to generically describe
the presence of cardiothoracic and abdominal
situs abnormalities, is often found when the intrahepatic segment of the IVC is interrupted. Not
uncommonly, left-sided structures are dominant
or there is bilateral left-sidedness (left isomerism), manifested as polysplenia or multiple
splenic structures which may be located in either
or both upper abdominal quadrants or throughout
the peritoneal cavity. Other frequently associated
abnormalities include complete or partial abdominal situs inversus with horizontal position of the
liver, absence of the gallbladder, and malrotation
of the bowel. Anomalies of cardiovascular connections, anomalous pulmonary venous drainage, atrial (ASD) and ventricular (VSD) septal
defects or malalignment, bilateral SVCs, and cardiac malposition dominate the cardiothoracic
anomalies. Bilateral left-sided lungs (2 lobes
each) with hyparterial bronchi and bilateral leftsided atria are often present [2, 3].
4.2.1 Clinical Presentation
Patients with interruption of the intrahepatic IVC
and azygous continuation may be discovered in
utero with an abnormal structural exam, present
as a newborn due to structural congenital heart
disease, or may remain asymptomatic and therefore undiscovered prior to imaging performed for
other indications.
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D.M.E. Bardo
4.2.2 Case 4.1
See Fig. 4.1.
4.2.3 Case 4.2
See Figs. 4.2, 4.3, and 4.4.
Fig. 4.2 An arterial phase contrast enhanced axial image
of the upper abdomen shows the large caliber azygous
vein (AZ) and absence of the intrahepatic segment of the
IVC. In the right upper quadrant, a low attenuation structure is a spleen (bracket); numerous other splenic nodules
were located in the right upper quadrant on caudal images.
The descending aorta (DAo) is on the left of midline
Fig. 4.1 On the first day of life, this newborn who was
known to have situs inversus had an umbilical venous
catheter (UVC) (V) and umbilical arterial catheter (UAC)
(A) placed prior to a chest and abdomen radiograph. The
cardiac apex (arrow) and gastric air bubble (S) are on the
right and the liver shadow is on the left. The tip of the
UVC is more cephalad than expected, within the lumen of
the left-sided hemiazygous vein in this patient found to
have situs inversus and an interrupted IVC and hemiazygous continuation to the hemiazygous arch which drained
to the SVC. In this situation, situs inversus, the L SVC
drains to the morphologic right atrium and a persistent R
SVC (if present) would drain to the coronary sinus. This
patient does not have a persistent R SVC
Fig. 4.3 A coronal view of the chest from the contrast
enhanced CT shows the extension of the enlarged azygous
vein (AZ) nearly to the level of the aortic arch. The azygous vein and descending aorta (DAo) caliber are similar
and pulmonary vasculature is enlarged
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