Imaging of coronary artery anomalies

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Diagnostic methods 203
Imaging of coronary artery anomalies: the role of
multidetector computed tomography
Fehmi Kacmaza, Nilgun Isiksalan Ozbulbulb, Omer Alyana, Orhan Madena,
Ahmet Duran Demira, Yucel Balbaya, Ali Riza Erbaya, Ramazan Ataka,
Kubilay Senena, Tulay Olcerb and Erdogan Ilkayc
Background Coronary artery anomalies are evaluated
by using catheter-based angiography. Multidetector
row-computed tomography (MDCT) is a new noninvasive
imaging technique that has excellent spatial resolution for
detecting the origin and course of a coronary anomalous
vessel.
Objective To determine the sensitivity of multidetector
computed tomography in patients who had coronary artery
anomaly demonstrated by conventional coronary
angiography.
Material and methods A retrospective evaluation to
identify 23 patients, who underwent retrospective
electrocardiographic (ECG)-gated MDCT, was done and in
whom an anomalous coronary vessel was found at a single
center. Metoprolol (50–100 mg) was given orally to all
patients to reduce heart rate so as to get high-quality
MDCT images. After performing MDCT, the CT scans of
each patient were analysed and compared with their
coronary angiograms by two experienced radiologists and
one cardiologist who were unaware about the study, and
the sensitivity of MDCT was determined.
Results Twenty-three patients (age range 28–73) with
seven different coronary arteries of the anomalous type
were evaluated. Nineteen patients had an anomalous left
coronary artery; three patients had an anomalous single
coronary artery; and one patient had an anomalous right
coronary artery. The most common anomaly type was the
Introduction
The origin of the coronary artery anomalous is a rare
congenital condition with an incidence ranging from
0.17% in autopsy cases [1] to 1.2% in angiographically
evaluated cases [2]. Most of these anomalous conditions
are not clinically important. Nonfatal or fatal acute
myocardial infarction can, however, occur in such
patients, [3,4] most notably among young athletes
[5,6]. In some cases the aberrant vessel, which passes
between the aorta and the main pulmonary artery, can
cause a risk for sudden death, particularly if the vessel
supplies the left coronary artery distribution [7].
Coronary artery bypass grafting may be indicated for such
patients [8].
c 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
0954-6928 left circumflex coronary artery (52%). The origin and course
of all anomalous vessels were detected by ECG-gated
MDCT (Lightspeed 16, GE Medical Systems, Milwaukee,
Wisconsin, USA). The sensitivity of 100% of MDCT was
detected in patients who had anomalous coronary vessels.
Conclusion We suggest that MDCT could be a noninvasive alternative imaging technique to conventional
coronary angiography for screening the anomalous vessels
of coronary arteries because of its excellent spatial
resolution, which is very important for detecting the
relationship of anomalous vessels with great arteries and
c 2008
cardiac structures. Coron Artery Dis 19:203–209 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Coronary Artery Disease 2008, 19:203–209
a
Cardiology Clinics, Turkish Society of Cardiology, bDepartment of Radiology,
Turkiye Yuksek Ihtisas Hospital, Turkish Society of Radiology and cDepartment of
Cardiology, Mesa Hospital, Fellow of European Society of Cardiology,
Ankara, Turkey
Correspondence to Dr Fehmi Kacmaz, MD, Bingol Devlet Hastanesi, Kardiyoloji
klinigi, 12100 Duzagac-Bingol, Turkey
Tel: + 90 426 214 14 00; fax: + 90 312 310 03 78;
e-mail: [email protected] or [email protected]
This manuscript has been accepted as a poster presentation at the 7th
International Congress on Coronary Artery Disease in Venice, Italy 2007.
Received 21 August 2007 Revised 15 November 2007
Accepted 5 December 2007
Coronary artery anomalies are evaluated by using
catheter-based angiography, which is known as the gold
standard for imaging methods. In addition to coronary
angiography, transesophageal echocardiography [9–11]
may also clinically detect coronary anomalies, but this
method is not totally non-invasive and is too costly for
screening large populations. Contrast-enhanced electron
beam tomography has also been recommended [12]. It
offers excellent spatial resolution and identifies most
anomalies of the coronary course. Magnetic resonance
imaging (MRI) has often been used to determine the
coronary artery anomalous in equivocal cases. MRI can,
however, be limited by low spatial resolution and artifacts
and can be technically challenging [13]. Multidetector
204
Coronary Artery Disease 2008, Vol 19 No 3
row-computed tomography (MDCT) is a new imaging
technique developed recently, and its importance is
gradually increased in the area of cardiac imaging.
Therefore, we aimed to determine the sensitivity of
MDCT in 23 patients who had an coronary artery
anomalous detected by coronary angiography initially in
a single center.
Materials and methods
Patients
Between June 2005 and February 2007, a total of 9341
consecutive patients underwent coronary angiography,
and 23 patients with anomalous coronary arteries were
identified. All patients were admitted to the hospital with
a complaint of angina and/or dyspnea. Patients who had
atrial fibrillation were excluded. Patient preparation
included instruction to avoid caffeine on the day of the
study. Metoprolol (50–100 mg) was administered orally 3
days before the MDCT scan to decrease the heart rate
and to obtain optimal images. We performed MDCT on
all patients who had coronary artery anomaly detected
initially by coronary angiography. All patients were orally
informed about study in clear terms; the study was
started after patients gave written informed consent; and
the study protocol was approved by the institutional
review board. To detect the realistic sensitivity of MDCT,
the results of MDCT were evaluated by two experienced
radiologists and one cardiologist, all of whom were
unaware of the study. Finally, we determined the
diagnostic sensitivity of MDCT in patients who had
coronary artery anomaly.
Multidetector row-computed tomography image and
data analysis
Patients with angiographically documented coronary
artery anomaly underwent 16-slice CT coronary angiography. Medications were not discontinued throughout
the angiographic and MDCT studies. MDCT (16-light
speed, General Electric, Milwaukee, Wisconsin, USA)
was performed 2 to 3 weeks later to prevent contrast
agent nephropathy secondary excessive contrast agent.
All image acquisitions were obtained in the craniocaudal
direction and in the supine position during inspiratory
breath hold preceded by mild hyperventilation and
inhalation of oxygen (2–3 lt/min) for 5 min. First,
noncontrast localization scan was performed that yielded
an anteroposterior view of the chest; it was used to
position the imaging volume for coronary artery imaging,
which extended from the carina to 10 mm below the
diaphragmal face of the heart. In a second step, a bolus of
30 ml of contrast agent (Iohexol, Ultravist 350, Schering
AG, Berlin, Germany) was injected intravenously at 4 ml/s
via an 18-gauge catheter placed in the antecubital vein.
After a delay of 10 s, a sequence of 10 axial images at the
level of the carina was acquired with an interval of 2 s
between subsequent images. From the time interval
between contrast agent injection and acquisition of the
images with peak attenuation in the aortic root, the
contrast agent transit time was determined. In a third
step, contrast agent (130 ml) was injected into antecubital vein at 4 ml/s, and the CT scan was initiated after
a delay according to the previously determined contrast
agent transit time. The volume data set for coronary
artery visualization was acquired (16 0.625 mm detector
configuration, table feed 3 mm/rotation, pitch 0.3, rotation time 0.5 s, tube voltage of 120 kV). After the
acquisition of the raw spiral data, retrospective ECG
synchronized slices were reconstructed at 75% of the R–R
interval. These images were transferred to a workstation
for processing AW4.2 (Advantage Windows 4.2, GE,
Medical Systems, Wisconsin, USA). Axial, sagittal,
coronary multiplanar reformations, and three-dimensional
images were created using standard software. MDCT
images were analyzed by two experienced radiologists and
one cardiologist, all of whom were unaware of study.
Results
Patient characteristics and scan parameters are shown in
Table 1. Twenty-three patients (15 males, 8 females; age
range 28–73 years), who had coronary artery anomaly
detected by coronary angiography, were evaluated. All
patients had sinus rhythm. The heart rates of the patients
were ranged between 48 and 66 bpm.
Coronary artery anomaly type and course of
anomalous coronary vessels
In this study, we detected seven different types of
coronary artery anomalous when we analyzed all coronary
Table 1
Patients’ characteristics and scan parameters of each
patient
Patient no.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Age/sex
Heart rate
during scan
(bpm)
Contrast
transit time (s)
Z-axis
coverage
44/M
59/M
28/F
67/M
64/M
57/M
61/M
61/F
73/M
56/F
48/M
52/F
65/M
42/M
59/M
54/F
67/F
54/F
57/M
61/M
71/M
60/M
56/F
48/56
64/66
60/65
54/58
62/68
56/62
60/62
58/61
64/68
60/61
63/68
60/66
65/66
48/56
64/66
62/65
53/58
62/65
54/62
60/62
58/61
60/66
60/60
24
20
19
22
19
21
20
22
18
20
19
19
19
24
20
19
23
19
21
20
22
18
20
90
120
90
90
120
120
90
120
90
90
120
90
120
90
120
90
90
120
120
90
120
90
120
bpm, beat per minute; F, female; M, male; s, second.
Imaging of coronary artery anomalies Kacmaz et al. 205
angiography and MDCT images. Nineteen (82%) patients had anomalous left coronary artery; three (13%)
patients had single coronary artery and one (5%) patient
had anomalous origin of right coronary artery (RCA).
Origin and course of all anomalous coronary arteries were
shown by multidetector computed tomography and
diagnostic sensitivity equal to 100% for MDCT was
identified. Left coronary artery anomalies were also
separated as being of anomalous origin in the left main
coronary artery, the left anterior descending coronary
artery (LAD), and left circumflex coronary artery (LCX).
The anomalous origin of LCX [12 of 23 (52%) patients]
was the most anomalous type in this study. The origin of
11 of 12 anomalous vessels of LCX began in the right
sinus of Valsalva and has passed retroaortic vessels and
coursed through sulcus atrioventricularis (Fig. 1); one
anomalous vessel originated from the distal portion of
RCA. The remaining three of 19 (13%) patients with an
anomalous origin of the left coronary artery had an
anomalous origin in the left main coronary artery (all arose
from the right sinus of Valsalva). Three (13%) patients
had anomalous origin of the left anterior descending
coronary artery (which arose from the right sinus of
Valsalva). One patient had an anomaly of the double left
anterior descending coronary artery and that anomalous
vessel originated from the right sinus of Valsalva and had
coursed anteriorly to the main pulmonary artery (Fig. 2a–d).
Origin and courses of all anomalous vessels have been
determined in Table 2.
Fig. 1
Single coronary arteries have arisen from the right sinus of
Valsalva in two patients and the left sinus of Valsalva in
one patient. The single coronary arteries originating from
the right sinus of Valsalva have coursed anteriorly to the
main pulmonary artery (Figs 3a–c and 4). In this study,
one patient had an anomalous origin of the right coronary
artery arising from the left sinus of Valsalva. In this the
patient anomalous vessel has coursed between the main
pulmonary artery and the aorta (Fig. 5).
Ten of 23 (43%) patients also had atherosclerotic coronary
artery disease (in four patients with single vessel disease,
in five patients with two-vessel disease, and in one
patient with three-vessel disease). One patient had a
muscular bridge at the distal portion of the left anterior
descending coronary artery. Coronary bypass grafting
operation was recommended for patients who had
three-vessel disease. In the remaining patients, percutaneous coronary intervention was performed.
Discussion
Here we demonstrated a diagnostic sensitivity of 100% of
MDCT for the detection of the origin and course of the
anomalous vessel in patients who had coronary artery
anomaly. Coronary artery anomalies are found in about 1%
of patients undergoing cardiac catheterization [8]. Three
types of ectopic anomalies have been described in the
current literature: (i) ectopic origin from coronary sinus,
(ii) absent coronary artery, (iii) ectopic origin from a main
pulmonary artery. The first two types of anomaly are most
common in adults. Another type of anomaly is a coronary
arterivenous fistula, which accounts for approximately
13% of coronary anomalies [8,14]. Approximately 20% of
coronary anomalies have been implicated in chest pain,
sudden death, cardiomyopathy, syncope, dsypnea, ventricular fibrillation, and myocardial infarction [15].
Coronary artery anomalies are the second most common
cause of death because of structural heart disease in
young athletes [16]. The left main coronary artery arising
from the right sinus of Valsalva can cause exercise angina,
myocardial infarction, syncope, and sudden death. In
particular, an anomalous vessel that crosses between the
aorta and the main pulmonary artery, either a left coronary
artery originating from the right sinus or a right coronary
artery arising from the left sinus, may be associated with a
poor prognosis [17,18].
Available imaging methods for coronary anomalies
A 44-year-old patient had exercise angina: three-dimensional volume
rendering (VR) view of an anomalous left circumflex artery (LCX)
originating from the right sinus of Valsalva.
Transthoracic echocardiography (TTE) is a practical
diagnostic test for the detection of the origin of coronary
artery abnormalities if specific attention is paid to the
coronary arteries. This may provide a diagnosis by
identifying anomalous arterial origins, delineate whole
fistulous courses, and characterize their hemodynamic
status, size and function of the receiving chambers, which
may reflect potentially adverse effects of a coronary steal.
206
Coronary Artery Disease 2008, Vol 19 No 3
Fig. 2
A 64-year-old man had exercise stable angina: (a) Three-dimensional volume rendering (VR) image and (b) axial thick slab maximum intensity
projection (MIP) show double left anterior descending coronary artery (LAD). Short arrow shows anomalous left anterior descending artery arising
from right sinus of Valsalva. Long arrow shows normal anatomic coursing of left anterior descending artery arising from left sinus of Valsalva. (c) Right
oblique cranial coronary angiography image shows left anterior descending coronary artery arising from right sinus of Valsalva. (d) Right oblique
caudal angiographic image shows normal coursing LAD originated from left sinus of Valsalva.
Table 2
Origin and course of anomalous vessels of each patient detected by multidetector computed tomography
Patient no.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
Anomalous vessel
Origin of anomalous vessel
LCX
LCX
LMCA
LCX
LCX
LCX
LCX
LAD
LAD
LCX
RCA
LCX
LCX
LCX
LCX
LMCA
Single
LAD
LCX
LMCA
Single
Single
Double LAD
RSV
RSV
RSV
RSV
RSV
RSV
RSV
RSV
RSV
RSV
LSV
RSV
RSV
RSV
RCA
RSV
LSV
RSV
RSV
RSV
RSV
RSV
Anomalous vessel from RSV
Course of anomalous vessel
Retroaortic
Retroaortic
Anterior to pulmonary artery
Retroaortic
Retroaortic
Retroaortic
Retroaortic
Antrior to right ventricle
Retroaortic
Retroaortic
Between aort and pulmonary artery
Retroaortic
Retroaortic
Retroaortic
Sulcus atrioventricularis
Retroaortic
RCA: retroaortic, LMCA: anterior to pulmonary artery
Anterior of right ventricle
Retroaortic
Retroaortic
LCX: Retroaortic, LAD: Anterior to pulmonary artery
LCX: Retroaortic, LAD: Anterior to pulmonary artery
Anomalous AD vessel: anterior to pulmonary artery
AD, anterior descending coronary artery; LAD, left anterior descending coronary artery; LCX, left circumflex coronary artery; LMCA, left main coronary artery; RCA, right
coronary artery; RSV, right sinus of Valsalva.
Imaging of coronary artery anomalies Kacmaz et al. 207
Fig. 3
A 67-year-old female patient had complaint of stable exercise angina: (a) Three-dimensional volume rendering (VR) view of an anomalous left
circumflex artery (LCX) originating from the right sinus of Valsalva and single coronary artery [arrow shows left anterior descending coronary artery
(LAD)]. (b) Multiplanar reformation image shows single coronary artery arising from the right coronary sinus and coursing anterior to the pulmonary
artery (arrow). (c) Axial thick slab maximum intensity projection (MIP) shows an anomalous left circumflex artery (LCX) originating from the right sinus
of Valsalva and coursing between the left atrium (LA) and aorta (arrow). RCA is also shown (arrowhead).
Fig. 4
Fig. 5
A 67-year-old male patient had exercise dyspnea and angina: axial thick
slab maximum intensity projection (MIP) shows single coronary artery
arising from right sinus of Valsalva (arrow) and coursing anteriorly to the
pulmonary artery.
A 61-year-old female patient had atypical chest pain: three-dimensional
volume rendering (VR) image shows an anomalous RCA originating
from the left coronary sinus and coursing between the aorta and
pulmonary artery (PA).
Moreover, the exact course of the anomalous vessel or
coronary artery fistula may not be detected by TTE.
Transoesophageal echocardiography also may fail to
delineate completely coronary anomalies, and it is not
totally noninvasive.
Other noninvasive techniques such as nuclear and cineMR cardiac imaging have gained increasing importance in
current literature. MR imaging has been the noninvasive
imaging method for the identification of congenital
coronary artery anomalies and their courses [3,19]. New
208
Coronary Artery Disease 2008, Vol 19 No 3
MR imaging sequences have improved image quality with
better anatomical definition and have become an alternative choice to evaluate flow and function [20]. The
accuracy rate of magnetic resonance angiography in
patients with coronary artery anomalies was differentiated
from 93 to 100% in the current literature [6,17,21]. The
rate specificity and sensitivity of MR angiography in
patients that had coronary anomaly have been shown to
be higher than conventional coronary angiography in
studies where both imaging techniques are compared.
MR coronary angiography is recommended as a new gold
standard for diagnostic imaging methods in coronary
artery anomalies [17]. The spatial resolution of MR
imaging is marginal for coronary artery imaging. Its
greatest limitation is in determining the distal arterial
course [22]. Furthermore, MRI is limited by low spatial
resolution and artifacts; it can be technically challenging [13].
In comparison, MDCT cardiac imaging provides excellent
distal coronary artery and side branch visualization.
Furthermore, if required, an entire three-dimensional
volume of the heart and great vessels may be acquired
within 20 s. As opposed to magnetic resonance imaging,
which also permits the analysis of coronary anomalies in
tomographic images, MDCT requires a radiation and a
contrast agent. The high resolution of the data sets
(permitting analysis even of small details) and the speed
of image acquisition make MDCT reasonable to use as
one of the first-choice imaging modalities in the workup
of known and suspected coronary anomalies.
ECG-controlled dose modulation is now available on most
scanners. This method reduces the tube current during
systole, resulting in a 30–50% reduction in effective
radiation exposure [23]. Dose modulation should be used
in all patients with a regular low heart rate (sinus rhythm,
< 65 beats per min, low heart rate variability, and absence
of arrhythmia).
The presence of anomalous coronary arteries can be a
differential diagnosis in patients with suspected coronary
disease, chest pain, or syncope. Cardiac catheterization
has been indicated in detail in the entire coronary
vasculature before intervention and has remained the
gold standard for imaging modality to visualize coronary
anatomy. Accurate diagnosis of anomalous coronary
arteries by invasive coronary angiography, however, is
limited by the inability to define the anatomic course in
relation to surrounding structures. Owing to the potentially complex three-dimensional nature of these anomalies, conventional coronary angiography, infrequently,
incompletely delineates the anatomical course of the
coronary artery. Therefore, detailed assessment of anomalous coronary arteries, including their origin and course,
is difficult with invasive coronary angiography. The threedimensional nature of MDCT coronary angiography data
sets allows exact analysis of anomalous coronary arteries.
Early reports of using computed tomography (CT) to
evaluate coronary artery have emphasized electron beam
technology. Ropers et al. [12] used ECG-gated electron
beam CT with 3-mm collimation and three-dimensional
reconstructions to assess 60 patients, 30 of whom had
coronary artery anomalies. Two observers successfully
categorized each patient according to the presence or
absence of coronary anomalies. Twenty-nine of the 30
anomalies were characterized accurately. Although this
study demonstrated the feasibility of CT, electron beam
CT is not widely available and is limited by relatively poor
z-axis resolution. MDCT angiography is a new imaging
method to delineate clearly the origin and course of the
coronary artery anomalous. In general, MDCT is substantially faster than MR imaging. The small-section
thickness permitted it to obtain volumetric reconstructions of high quality. Although these images were not
crucial in the diagnosis of the anomaly, they were valuable
for depicting the relationships among the coronary vessel,
great vessels, and cardiac chambers. Such images give the
surgeons a better understanding of the complex anatomy
before repair.
As demonstrated in this study, MDCT can differentiate
between the precise origin and course with excellent
spatial resolution. Some reports had supported our
findings in current literature. Schmitt et al. [24] have
reported that 28 patients showed an anomalous origin and
course of coronary arteries detected by ECG-gated 4-row
and 16-row MDCT including thin maximum intensity
projection (MIP), multiplanar reformation (MPR), and
volume rendering technique (VRT) post-processing
compared with coronary angiography. Shi et al. [25]
reported a study in which 242 consecutive patients
referred for noninvasive coronary CT imaging were
reviewed for the study, and 16 patients (6.6%) with
anomalous coronary arteries were detected. MDCT and
coronary angiography images were analyzed in a blinded
fashion for the accuracy of anomalous artery origin and
path detection. Results were compared in a secondary
consensus evaluation. Coronary anomalies for all 16
patients were correctly displayed on MDCT. Coronary
angiography alone achieved correct identification of the
abnormality in only 53% (P = 0.016).
In another study, Berbarie et al. [26] reported a series of
cases of coronary artery anomalies detected by MDCT
with up to 64 detector arrays, and in that series of cases,
the investigators describe their institution’s experience
with CT coronary angiography as a complement to
invasive coronary angiography in determining the origin
and course of different anomalous coronary arteries in 16
patients. Anomalous coronary arteries were all clearly
defined with regard to their origin and course. Deibler
et al. [27] described a single-center experience of using
retrospectively gated MDCT coronary angiography for the
imaging of nine patients diagnosed as having congenital
Imaging of coronary artery anomalies Kacmaz et al. 209
coronary anomalies on invasive, selective coronary angiography. In one patient, MDCT showed a normal but
extremely anterior origin of the right coronary artery from
the right aortic sinus of Valsalva. In the other eight
patients, the origin and course of coronary arteries were
recognized easily on MDCT.
The sensitivity of 16-MDCT in coronary artery anomalies
has been showed as 100% in recent studies. Similarly, in
our study the origin of all anomalous vessels was shown by
conventional coronary angiography and 16-gated MDCT.
The course of all anomalous vessels was also shown by
MDCT. One hundred percent sensitivity of the 16-row
MDCT was detected in this study, as in other recently
published studies. In this series, multidetector row-CT
angiography provided an accurate depiction of vessel
origin and course in this review of 23 anomalous coronary
arteries. All patients were referred after coronary
angiogram. The results of this study suggest that MDCT
is a viable noninvasive modality in the delineation of
coronary arterial anomalies, particularly if the results of
coronary angiography are equivocal and the course of
anomalous vessel is unknown.
4
5
6
7
8
9
10
11
12
13
Conclusion
ECG-gated 16-row MDCT is an accurate diagnostic tool
to define the origin and course of anomalous coronary
vessels. MDCT should be performed for patients that
have a coronary artery anomaly, especially when they have
symptoms relating to anomalous vessels, because it is able
to determine how the anomalous vessel relates with
arteries and other cardiac structures. It should therefore
be considered as a prime noninvasive imaging tool for
suspected coronary artery anomalies. Noninvasiveness
and precise visualization characteristics of MDCT make
it a standard reference for evaluating anomalous coronary
arteries.
14
15
16
17
18
19
Study limitations
Having evaluated 23 patients with coronary artery
anomalies, the current numbers are low enough to
determine exact sensitivity of MDCT compared with
coronary angiography. Therefore, we need a large series of
tests to obtain a realistic sensitivity of MDCT. One of the
other study limitations is that MDCT was performed on
all patients after coronary angiography. Therefore, all
MDCT images were evaluated by two radiologists and
one cardiologist, who were unaware of the coronary
angiography results.
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