Category: Cardiac

Cardiac #6

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75-year-old patient:
Medical history:
* Previous left anterior descending artery (LAD) stenosis and iatrogenic left coronary artery (LCA) dissection.
* Underwent coronary artery bypass grafting (CABG) complicated by subsequent graft thrombosis.
* Stress myocardial perfusion imaging performed to assess myocardial ischemia/viability (first row stress perfusion imaging, second row dark blood late gadolinium enhancement imaging).

What is the diagnosis?

Subendocardial scar in LAD territory basal/midventricular with perfusion defect/inducible ischemia in LAD territory surpassing the area of infarction.

Explanation:

Stress myocardial perfusion depicts reversible ischemia in the LAD coronary artery territory anteroseptal/anterior (perfusion at rest not shown). Dark blood-LGE imaging depicts subendocardial scar in LAD territory especially basal, but smaller in extension than the inducible ischemia, indicating potential suitability of revascularization.
Standard dose of adenosine is 140 mcg/kg/min for at least 3 min.

References:

– Patel, A, Salerno, M, Kwong, R. et al. Stress Cardiac Magnetic Resonance Myocardial Perfusion Imaging: JACC Review Topic of the Week. JACC. 2021 Oct, 78 (16) 1655–1668. https://doi.org/10.1016/j.jacc.2021.08.022.
– Shehata ML, Basha TA, Hayeri MR, Hartung D, Teytelboym OM, Vogel-Claussen J. MR myocardial perfusion imaging: insights on techniques, analysis, interpretation, and findings. Radiographics. 2014 Oct;34(6):1636-57. doi: 10.1148/rg.346140074. PMID: 25310421.

Cardiac #4

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Clinical Data: A 53-year-old patient with myocardial infarction (STEMI) and cardiac decompensation (Pulmonary-to-systemic flow ratio Qp:Qs of 3.9)

What is the most likely diagnosis?

What is the most diagnosis?

Post-myocardial infarction ventricular septal defect/rupture (VSD/VSR).

Explanation

Ventricular septal defect/rupture is a rare but life-threatening complication after myocardial infarction. Generally, patients with VSR present with a transmural infarction. The defect results in left-to-right shunting and right ventricular pressure and volume overload. The rupture site can expand abruptly, resulting in sudden hemodynamic collapse in previously stable patients. Surgical closure is the definitive treatment for post-infarction VSD; however, the optimal timing of surgery remains controversial. Percutaneous closure devices have also been applied with success.

References

– Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. GUSTO-I (Global Utilization of Streptokinase and TPA for Occluded Coronary Arteries) Trial Investigators. Circulation 2000;101:27-32.
– Menon V, Webb JG, Hillis LD, et al. Outcome and profile of ventricular septal rupture with cardiogenic shock after myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries in cardiogenic shocK? J Am Coll Cardiol 2000;36:1110-6.
– O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA,
Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61(4):e78-e140. doi: 10.1016/j.jacc.2012.11.019. Epub 2012 Dec 17. PMID: 23256914.

Cardiac #3

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Clinical Data: 70-year-old male, asymptomatic, incidental finding on chest X-ray

What are the findings:

What are the findings:

Enlargement of the left coronary artery (LAD) and right coronary artery (RCA) with peripheral thrombus
within both vessels diagnostic of coronary artery aneurysms.

What is the most likely diagnosis:

What is the most likely diagnosis?

Coronary artery aneurysm:

Definition: coronary dilatation which exceeds the diameter of normal adjacent segments or the diameter of the patient’s largest coronary vessel by 1.5 times
Etiology: Atherosclerosis, genetic, autoimmune/inflammatory, infectious
Clinical Presentation: mostly clinically silent
Complications: local thrombosis > distal embolization and myocardial infarction; aneurysm rupture > cardiac tamponade; myocardial stenosis
Treatment: percutaneous or surgical

Cardiac #2

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Clinical Data: Young adult with chest pain.

What do you see?

What do you see?

Intra-arterial course of the right coronary artery (RCA). RCA arises from left coronary sinus (not depicted) and passes between aorta and pulmonary trunk.

List at least three other potentially life-threatening congenital coronary artery defects.

List at least three other potentially life-threatening congenital coronary artery defects.

-Anomalous aortic origin of coronary artery (AAOCA)
-Anomalous origin of the left coronary artery originating from the pulmonary artery (ALCAPA)
-Anomalous origin of the right coronary artery originating from the pulmonary artery (ARCAPA)
-Single coronary artery
-Hypoplastic right coronary artery
-Congenital coronary artery ostial stenosis or atresia
-Anomalous circumflex coronary artery arising from the right pulmonary artery (ACARPA)

Discussion:

Congenital coronary artery anomalies (CAAs) are often incidental findings. They can be classified as CAAs of origin, course, and of termination. Although they are rare and most of them are benign variants, some are associated with an increased risk of myocardial ischemia, so recognizing and reporting them is substantial.

References and further reading:

1. Gentile F, Castiglione V, De Caterina R. Coronary Artery Anomalies. Circulation. 2021 Sep 21;144(12):983-996. doi: 10.1161/CIRCULATIONAHA.121.055347. Epub 2021 Sep 20. PMID: 34543069.
2. Waterbury TM, Tarantini G, Vogel B, Mehran R, Gersh BJ, Gulati R. Non-atherosclerotic causes of acute coronary syndromes. Nat Rev Cardiol. 2020 Apr;17(4):229-241. doi: 10.1038/s41569-019-0273-3. Epub 2019 Oct 3. PMID: 31582839.

Cardiac #1

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Clinical Data: Chest pain

Coronary CT angiography was performed.

Describe salient abnormalities.

Salient abnormalities:

9 mm aneurysm arising from left anterior descending (LAD) artery. Contrast blush within pulmonary trunk near abnormal, torturous LAD branch

What is the final diagnosis?

What is the final diagnosis?

Coronary artery-to-pulmonary artery fistula with left-to-right shunt. Left coronary artery aneurysm.

Discussion:

Coronary artery-to-pulmonary artery fistula (CPAF) is a type of coronary arteriovenous fistula (CAVF), where there is an abnormal connection (fistula) between a coronary artery and either pulmonary trunk or main pulmonary artery. This condition is associated with coronary artery aneurysms (CAA), pulmonary atresia, and ventricular septal defect (VSD). Patients are usually asymptomatic; the most common clinical manifestation is chest pain and dyspnea, especially on exertion.

References and further reading:

1. Hang K, Zhao G, Su W, Bao G, Zhao Q, Jiao Z, Tian Z, Zhang H, Nie L, Luo R, Li L, Huang M, Shi L, Li S. Coronary artery-to-pulmonary artery fistula in adults: evaluation with 320-row detector computed tomography coronary angiography. Ann Transl Med. 2021 Sep;9(18):1434. doi: 10.21037/atm-21-4404. PMID: 34733986; PMCID: PMC8506747.
2. Kim H, Beck KS, Choe YH, Jung JI. Coronary-to-Pulmonary Artery Fistula in Adults: Natural History and Management Strategies. Korean J Radiol. 2019 Nov;20(11):1491-1497. doi: 10.3348/kjr.2019.0331. PMID: 31606954; PMCID: PMC6791815.