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Cardiac CT in Emergency Department Patients with Acute Chest Pain¹

¹ From the Departments of Radiology (U.H., A.J.P., R.C.C., S.A., M.F., F.M., U.S., T.J.B.) and Emergency Medicine (J.T.N.), Massachusetts General Hospital, 165 Charles River Plaza, Suite 400, Boston, MA 02114; and Harvard School of Public Health, Boston, Mass (U.H.). Received April 29, 2005; revision requested June 9 and received August 31; accepted October 13. All authors have no financial relationships to disclose.

View larger version (122K): [in a new window]   Figure 1a.  (a) Axial CT image (0.75-mm section thickness) shows the left main (LM) coronary artery at the level of the ostium. The left main artery arises from the left Valsalva sinus, courses posterior to the right ventricular outflow tract (RVOT), and bifurcates into the left anterior descending (LAD) and the left circumflex (LCX) branches. In about 15% of patients, a separate intermediate branch, or ramus intermedius (RI), also arises from the left main coronary artery. (b) Axial CT image (0.75-mm section thickness) at the midventricular level shows a middle segment of the right coronary artery (RCA) and distal segments of the left anterior descending and left circumflex branches. The latter is seen in the left atrioventricular groove, in close proximity to the great cardiac vein (GCV). (c) Axial MIP image (5-mm section thickness) at the level of the bottom of the heart shows a distal segment of the right coronary artery at the origins of the posterior descending artery (PDA) and the posterior left ventricular (PLV) artery. The posterior descending artery is seen in the posterior longitudinal sulcus, in close proximity to the middle cardiac vein (MCV). A distal segment of the left anterior descending artery also is visible. This case demonstrates right coronary artery dominance in blood supply to the ventricles, a common finding (85%–90% of patients).

 

View larger version (130K): [in a new window]   Figure 1b.  (a) Axial CT image (0.75-mm section thickness) shows the left main (LM) coronary artery at the level of the ostium. The left main artery arises from the left Valsalva sinus, courses posterior to the right ventricular outflow tract (RVOT), and bifurcates into the left anterior descending (LAD) and the left circumflex (LCX) branches. In about 15% of patients, a separate intermediate branch, or ramus intermedius (RI), also arises from the left main coronary artery. (b) Axial CT image (0.75-mm section thickness) at the midventricular level shows a middle segment of the right coronary artery (RCA) and distal segments of the left anterior descending and left circumflex branches. The latter is seen in the left atrioventricular groove, in close proximity to the great cardiac vein (GCV). (c) Axial MIP image (5-mm section thickness) at the level of the bottom of the heart shows a distal segment of the right coronary artery at the origins of the posterior descending artery (PDA) and the posterior left ventricular (PLV) artery. The posterior descending artery is seen in the posterior longitudinal sulcus, in close proximity to the middle cardiac vein (MCV). A distal segment of the left anterior descending artery also is visible. This case demonstrates right coronary artery dominance in blood supply to the ventricles, a common finding (85%–90% of patients).

 

View larger version (121K): [in a new window]   Figure 1c.  (a) Axial CT image (0.75-mm section thickness) shows the left main (LM) coronary artery at the level of the ostium. The left main artery arises from the left Valsalva sinus, courses posterior to the right ventricular outflow tract (RVOT), and bifurcates into the left anterior descending (LAD) and the left circumflex (LCX) branches. In about 15% of patients, a separate intermediate branch, or ramus intermedius (RI), also arises from the left main coronary artery. (b) Axial CT image (0.75-mm section thickness) at the midventricular level shows a middle segment of the right coronary artery (RCA) and distal segments of the left anterior descending and left circumflex branches. The latter is seen in the left atrioventricular groove, in close proximity to the great cardiac vein (GCV). (c) Axial MIP image (5-mm section thickness) at the level of the bottom of the heart shows a distal segment of the right coronary artery at the origins of the posterior descending artery (PDA) and the posterior left ventricular (PLV) artery. The posterior descending artery is seen in the posterior longitudinal sulcus, in close proximity to the middle cardiac vein (MCV). A distal segment of the left anterior descending artery also is visible. This case demonstrates right coronary artery dominance in blood supply to the ventricles, a common finding (85%–90% of patients).

 

View larger version (79K): [in a new window]   Figure 2a.  Right coronary artery anatomy. (a) Schema shows the right coronary artery segments according to the modified 17-segment coronary artery classification system (26). 1 = proximal segment of the main artery, 2 = middle segment of the main artery, 3 = distal segment of the main artery, 4 = posterior descending branch, 16 = posterior left ventricular branch, CB = conal branch, SN = sinonodal branch. (b–d) Multidetector CT images show the right coronary artery (RCA) anatomy with MIP (5-mm section thickness) along the vessel centerline (b), 3D volume rendering from a posterior oblique perspective with partial deletion of the right atrium (RA) and left atrium (LA) (c), and curved multiplanar reformation (d). AM = acute marginal branch, LV = left ventricle, PLV = posterior left ventricular branch, RV = right ventricle. (e) Conventional selective angiogram shows the artery in a right anterior oblique cranial projection.

 

View larger version (144K): [in a new window]   Figure 2b.  Right coronary artery anatomy. (a) Schema shows the right coronary artery segments according to the modified 17-segment coronary artery classification system (26). 1 = proximal segment of the main artery, 2 = middle segment of the main artery, 3 = distal segment of the main artery, 4 = posterior descending branch, 16 = posterior left ventricular branch, CB = conal branch, SN = sinonodal branch. (b–d) Multidetector CT images show the right coronary artery (RCA) anatomy with MIP (5-mm section thickness) along the vessel centerline (b), 3D volume rendering from a posterior oblique perspective with partial deletion of the right atrium (RA) and left atrium (LA) (c), and curved multiplanar reformation (d). AM = acute marginal branch, LV = left ventricle, PLV = posterior left ventricular branch, RV = right ventricle. (e) Conventional selective angiogram shows the artery in a right anterior oblique cranial projection.

 

View larger version (127K): [in a new window]   Figure 2c.  Right coronary artery anatomy. (a) Schema shows the right coronary artery segments according to the modified 17-segment coronary artery classification system (26). 1 = proximal segment of the main artery, 2 = middle segment of the main artery, 3 = distal segment of the main artery, 4 = posterior descending branch, 16 = posterior left ventricular branch, CB = conal branch, SN = sinonodal branch. (b–d) Multidetector CT images show the right coronary artery (RCA) anatomy with MIP (5-mm section thickness) along the vessel centerline (b), 3D volume rendering from a posterior oblique perspective with partial deletion of the right atrium (RA) and left atrium (LA) (c), and curved multiplanar reformation (d). AM = acute marginal branch, LV = left ventricle, PLV = posterior left ventricular branch, RV = right ventricle. (e) Conventional selective angiogram shows the artery in a right anterior oblique cranial projection.

 

View larger version (138K): [in a new window]   Figure 2d.  Right coronary artery anatomy. (a) Schema shows the right coronary artery segments according to the modified 17-segment coronary artery classification system (26). 1 = proximal segment of the main artery, 2 = middle segment of the main artery, 3 = distal segment of the main artery, 4 = posterior descending branch, 16 = posterior left ventricular branch, CB = conal branch, SN = sinonodal branch. (b–d) Multidetector CT images show the right coronary artery (RCA) anatomy with MIP (5-mm section thickness) along the vessel centerline (b), 3D volume rendering from a posterior oblique perspective with partial deletion of the right atrium (RA) and left atrium (LA) (c), and curved multiplanar reformation (d). AM = acute marginal branch, LV = left ventricle, PLV = posterior left ventricular branch, RV = right ventricle. (e) Conventional selective angiogram shows the artery in a right anterior oblique cranial projection.

 

View larger version (121K): [in a new window]   Figure 2e.  Right coronary artery anatomy. (a) Schema shows the right coronary artery segments according to the modified 17-segment coronary artery classification system (26). 1 = proximal segment of the main artery, 2 = middle segment of the main artery, 3 = distal segment of the main artery, 4 = posterior descending branch, 16 = posterior left ventricular branch, CB = conal branch, SN = sinonodal branch. (b–d) Multidetector CT images show the right coronary artery (RCA) anatomy with MIP (5-mm section thickness) along the vessel centerline (b), 3D volume rendering from a posterior oblique perspective with partial deletion of the right atrium (RA) and left atrium (LA) (c), and curved multiplanar reformation (d). AM = acute marginal branch, LV = left ventricle, PLV = posterior left ventricular branch, RV = right ventricle. (e) Conventional selective angiogram shows the artery in a right anterior oblique cranial projection.

 

View larger version (93K): [in a new window]   Figure 3a.  Left coronary artery anatomy. (a) Schema shows the left coronary artery segments according to the modified 17-segment coronary artery classification system (26). 5 = main artery, 6 = proximal segment of the left anterior descending (LAD) branch, 7 = middle segment of the LAD branch, 8 = distal segment of the LAD branch, 9 = first diagonal branch, 10 = second diagonal branch, 11 = proximal segment of the left circumflex (LCX) artery, 12 = first obtuse marginal branch of the LCX artery, 13 = middle segment of the LCX artery, 14 = second obtuse marginal branch of the LCX artery, 15 = distal segment of the LCX artery, 17 = intermediate branch. (b–d) Multidetector CT images show the left main (LM) artery and LAD branch with MIP (5-mm section thickness) along the centerline (b), 3D volume rendering (anterior view) (c), and curved multiplanar reformation (d). The arrowhead in c indicates the intermediate branch (segment 17). LA = left atrium, LV = left ventricle, SP = septal perforator branch. (e) Conventional selective angiogram shows the left main artery and LAD branch in a left anteroposterior cranial projection.

 

View larger version (147K): [in a new window]   Figure 3b.  Left coronary artery anatomy. (a) Schema shows the left coronary artery segments according to the modified 17-segment coronary artery classification system (26). 5 = main artery, 6 = proximal segment of the left anterior descending (LAD) branch, 7 = middle segment of the LAD branch, 8 = distal segment of the LAD branch, 9 = first diagonal branch, 10 = second diagonal branch, 11 = proximal segment of the left circumflex (LCX) artery, 12 = first obtuse marginal branch of the LCX artery, 13 = middle segment of the LCX artery, 14 = second obtuse marginal branch of the LCX artery, 15 = distal segment of the LCX artery, 17 = intermediate branch. (b–d) Multidetector CT images show the left main (LM) artery and LAD branch with MIP (5-mm section thickness) along the centerline (b), 3D volume rendering (anterior view) (c), and curved multiplanar reformation (d). The arrowhead in c indicates the intermediate branch (segment 17). LA = left atrium, LV = left ventricle, SP = septal perforator branch. (e) Conventional selective angiogram shows the left main artery and LAD branch in a left anteroposterior cranial projection.

 

View larger version (130K): [in a new window]   Figure 3c.  Left coronary artery anatomy. (a) Schema shows the left coronary artery segments according to the modified 17-segment coronary artery classification system (26). 5 = main artery, 6 = proximal segment of the left anterior descending (LAD) branch, 7 = middle segment of the LAD branch, 8 = distal segment of the LAD branch, 9 = first diagonal branch, 10 = second diagonal branch, 11 = proximal segment of the left circumflex (LCX) artery, 12 = first obtuse marginal branch of the LCX artery, 13 = middle segment of the LCX artery, 14 = second obtuse marginal branch of the LCX artery, 15 = distal segment of the LCX artery, 17 = intermediate branch. (b–d) Multidetector CT images show the left main (LM) artery and LAD branch with MIP (5-mm section thickness) along the centerline (b), 3D volume rendering (anterior view) (c), and curved multiplanar reformation (d). The arrowhead in c indicates the intermediate branch (segment 17). LA = left atrium, LV = left ventricle, SP = septal perforator branch. (e) Conventional selective angiogram shows the left main artery and LAD branch in a left anteroposterior cranial projection.

 

View larger version (115K): [in a new window]   Figure 3d.  Left coronary artery anatomy. (a) Schema shows the left coronary artery segments according to the modified 17-segment coronary artery classification system (26). 5 = main artery, 6 = proximal segment of the left anterior descending (LAD) branch, 7 = middle segment of the LAD branch, 8 = distal segment of the LAD branch, 9 = first diagonal branch, 10 = second diagonal branch, 11 = proximal segment of the left circumflex (LCX) artery, 12 = first obtuse marginal branch of the LCX artery, 13 = middle segment of the LCX artery, 14 = second obtuse marginal branch of the LCX artery, 15 = distal segment of the LCX artery, 17 = intermediate branch. (b–d) Multidetector CT images show the left main (LM) artery and LAD branch with MIP (5-mm section thickness) along the centerline (b), 3D volume rendering (anterior view) (c), and curved multiplanar reformation (d). The arrowhead in c indicates the intermediate branch (segment 17). LA = left atrium, LV = left ventricle, SP = septal perforator branch. (e) Conventional selective angiogram shows the left main artery and LAD branch in a left anteroposterior cranial projection.

 

View larger version (107K): [in a new window]   Figure 3e.  Left coronary artery anatomy. (a) Schema shows the left coronary artery segments according to the modified 17-segment coronary artery classification system (26). 5 = main artery, 6 = proximal segment of the left anterior descending (LAD) branch, 7 = middle segment of the LAD branch, 8 = distal segment of the LAD branch, 9 = first diagonal branch, 10 = second diagonal branch, 11 = proximal segment of the left circumflex (LCX) artery, 12 = first obtuse marginal branch of the LCX artery, 13 = middle segment of the LCX artery, 14 = second obtuse marginal branch of the LCX artery, 15 = distal segment of the LCX artery, 17 = intermediate branch. (b–d) Multidetector CT images show the left main (LM) artery and LAD branch with MIP (5-mm section thickness) along the centerline (b), 3D volume rendering (anterior view) (c), and curved multiplanar reformation (d). The arrowhead in c indicates the intermediate branch (segment 17). LA = left atrium, LV = left ventricle, SP = septal perforator branch. (e) Conventional selective angiogram shows the left main artery and LAD branch in a left anteroposterior cranial projection.

 

View larger version (121K): [in a new window]   Figure 4a.  Left circumflex coronary artery segments according to the modified 17-segment classification system (26). (a–c) Multidetector CT images show the left circumflex (LCX) artery with MIP (5-mm section thickness) along the centerline (a), 3D volume rendering with an anterior view (b), and curved multiplanar reformation (c). A = ascending aorta, LA = left atrium, RI = ramus intermedius. 5 = left main artery, 11 = proximal segment of the left circumflex artery, 12 = first obtuse marginal branch of the left circumflex artery, 13 = middle segment of the left circumflex artery. (d) Conventional selective angiogram shows the vessel in a right anterior oblique caudal projection. 14 = second obtuse marginal branch of the left circumflex artery, 15 = distal segment of the left circumflex artery.

 

View larger version (132K): [in a new window]   Figure 4b.  Left circumflex coronary artery segments according to the modified 17-segment classification system (26). (a–c) Multidetector CT images show the left circumflex (LCX) artery with MIP (5-mm section thickness) along the centerline (a), 3D volume rendering with an anterior view (b), and curved multiplanar reformation (c). A = ascending aorta, LA = left atrium, RI = ramus intermedius. 5 = left main artery, 11 = proximal segment of the left circumflex artery, 12 = first obtuse marginal branch of the left circumflex artery, 13 = middle segment of the left circumflex artery. (d) Conventional selective angiogram shows the vessel in a right anterior oblique caudal projection. 14 = second obtuse marginal branch of the left circumflex artery, 15 = distal segment of the left circumflex artery.

 

View larger version (117K): [in a new window]   Figure 4c.  Left circumflex coronary artery segments according to the modified 17-segment classification system (26). (a–c) Multidetector CT images show the left circumflex (LCX) artery with MIP (5-mm section thickness) along the centerline (a), 3D volume rendering with an anterior view (b), and curved multiplanar reformation (c). A = ascending aorta, LA = left atrium, RI = ramus intermedius. 5 = left main artery, 11 = proximal segment of the left circumflex artery, 12 = first obtuse marginal branch of the left circumflex artery, 13 = middle segment of the left circumflex artery. (d) Conventional selective angiogram shows the vessel in a right anterior oblique caudal projection. 14 = second obtuse marginal branch of the left circumflex artery, 15 = distal segment of the left circumflex artery.

 

View larger version (116K): [in a new window]   Figure 4d.  Left circumflex coronary artery segments according to the modified 17-segment classification system (26). (a–c) Multidetector CT images show the left circumflex (LCX) artery with MIP (5-mm section thickness) along the centerline (a), 3D volume rendering with an anterior view (b), and curved multiplanar reformation (c). A = ascending aorta, LA = left atrium, RI = ramus intermedius. 5 = left main artery, 11 = proximal segment of the left circumflex artery, 12 = first obtuse marginal branch of the left circumflex artery, 13 = middle segment of the left circumflex artery. (d) Conventional selective angiogram shows the vessel in a right anterior oblique caudal projection. 14 = second obtuse marginal branch of the left circumflex artery, 15 = distal segment of the left circumflex artery.

 

View larger version (131K): [in a new window]   Figure 5a.  Significant stenosis of the left anterior descending artery in a 67-year-old patient with unstable angina and multiple risk factors (history of premature coronary artery disease, hypercholesterolemia, hypertension) but negative results at testing for biochemical markers and no acute ECG changes. (a) Axial thin-section (5-mm) MIP image from multidetector CT shows a significant luminal narrowing (arrowhead) in the middle segment of the artery. (b) Selective coronary angiogram demonstrates an eccentric high-grade (94%) stenosis (arrowhead). (c, d) A comparison of cross-sectional images obtained with multidetector CT in a proximal reference segment (c) and at the location of significant luminal narrowing (d) shows residual contrast material filling in d, with enhancement of a large eccentric lesion consisting of noncalcified plaque.

 

View larger version (102K): [in a new window]   Figure 5b.  Significant stenosis of the left anterior descending artery in a 67-year-old patient with unstable angina and multiple risk factors (history of premature coronary artery disease, hypercholesterolemia, hypertension) but negative results at testing for biochemical markers and no acute ECG changes. (a) Axial thin-section (5-mm) MIP image from multidetector CT shows a significant luminal narrowing (arrowhead) in the middle segment of the artery. (b) Selective coronary angiogram demonstrates an eccentric high-grade (94%) stenosis (arrowhead). (c, d) A comparison of cross-sectional images obtained with multidetector CT in a proximal reference segment (c) and at the location of significant luminal narrowing (d) shows residual contrast material filling in d, with enhancement of a large eccentric lesion consisting of noncalcified plaque.

 

View larger version (107K): [in a new window]   Figure 5c.  Significant stenosis of the left anterior descending artery in a 67-year-old patient with unstable angina and multiple risk factors (history of premature coronary artery disease, hypercholesterolemia, hypertension) but negative results at testing for biochemical markers and no acute ECG changes. (a) Axial thin-section (5-mm) MIP image from multidetector CT shows a significant luminal narrowing (arrowhead) in the middle segment of the artery. (b) Selective coronary angiogram demonstrates an eccentric high-grade (94%) stenosis (arrowhead). (c, d) A comparison of cross-sectional images obtained with multidetector CT in a proximal reference segment (c) and at the location of significant luminal narrowing (d) shows residual contrast material filling in d, with enhancement of a large eccentric lesion consisting of noncalcified plaque.

 

View larger version (98K): [in a new window]   Figure 5d.  Significant stenosis of the left anterior descending artery in a 67-year-old patient with unstable angina and multiple risk factors (history of premature coronary artery disease, hypercholesterolemia, hypertension) but negative results at testing for biochemical markers and no acute ECG changes. (a) Axial thin-section (5-mm) MIP image from multidetector CT shows a significant luminal narrowing (arrowhead) in the middle segment of the artery. (b) Selective coronary angiogram demonstrates an eccentric high-grade (94%) stenosis (arrowhead). (c, d) A comparison of cross-sectional images obtained with multidetector CT in a proximal reference segment (c) and at the location of significant luminal narrowing (d) shows residual contrast material filling in d, with enhancement of a large eccentric lesion consisting of noncalcified plaque.

 

View larger version (163K): [in a new window]   Figure 6a.  Multidetector CT images show acute thrombotic occlusion of the left circumflex artery in a patient with a recent myocardial infarction. Although cardiac CT is unlikely to be performed in patients with a confirmed acute myocardial infarction, it can help improve the planning of interventional strategy for some of these patients. (a) Curved multiplanar reformatted image of the left circumflex artery demonstrates a proximal high-grade stenosis (arrowhead) and a thrombotic occlusion of the middle segment (arrow). (b) Cross-sectional multiplanar reformatted image of the left circumflex artery shows the typical CT appearance of a thrombotic occlusion (arrow), with low-attenuation material obstructing the coronary lumen, and positive remodeling of the vessel segment.

 

View larger version (135K): [in a new window]   Figure 6b.  Multidetector CT images show acute thrombotic occlusion of the left circumflex artery in a patient with a recent myocardial infarction. Although cardiac CT is unlikely to be performed in patients with a confirmed acute myocardial infarction, it can help improve the planning of interventional strategy for some of these patients. (a) Curved multiplanar reformatted image of the left circumflex artery demonstrates a proximal high-grade stenosis (arrowhead) and a thrombotic occlusion of the middle segment (arrow). (b) Cross-sectional multiplanar reformatted image of the left circumflex artery shows the typical CT appearance of a thrombotic occlusion (arrow), with low-attenuation material obstructing the coronary lumen, and positive remodeling of the vessel segment.

 

View larger version (139K): [in a new window]   Figure 7a.  Success of thrombolysis in a patient with acute myocardial infarction. (a) Coronary angiogram obtained before thrombolysis shows occlusion of the left anterior descending (LAD) artery (arrow) distal to the ostium of the second diagonal branch (2nd diag). 1st diag = first diagonal branch. (b) Volume-rendered image from 16-section multi-detector CT, obtained 24 hours after thrombolysis, shows patency of the distal segment of the left anterior descending artery (arrow). (c) Cross-sectional image of the left ventricle obtained at the same time as b shows a region of low attenuation (white arrows) in the anteroseptal segment of the middle and apical portions of the left ventricular myocardium, a finding indicative of a perfusion deficit due to occlusion of a distal segment of the left anterior descending artery. A large thrombus (arrowhead) is visible in the left ventricular cavity. LA = left atrium, LV = left ventricle, RV = right ventricle.

 

View larger version (148K): [in a new window]   Figure 7b.  Success of thrombolysis in a patient with acute myocardial infarction. (a) Coronary angiogram obtained before thrombolysis shows occlusion of the left anterior descending (LAD) artery (arrow) distal to the ostium of the second diagonal branch (2nd diag). 1st diag = first diagonal branch. (b) Volume-rendered image from 16-section multi-detector CT, obtained 24 hours after thrombolysis, shows patency of the distal segment of the left anterior descending artery (arrow). (c) Cross-sectional image of the left ventricle obtained at the same time as b shows a region of low attenuation (white arrows) in the anteroseptal segment of the middle and apical portions of the left ventricular myocardium, a finding indicative of a perfusion deficit due to occlusion of a distal segment of the left anterior descending artery. A large thrombus (arrowhead) is visible in the left ventricular cavity. LA = left atrium, LV = left ventricle, RV = right ventricle.

 

View larger version (128K): [in a new window]   Figure 7c.  Success of thrombolysis in a patient with acute myocardial infarction. (a) Coronary angiogram obtained before thrombolysis shows occlusion of the left anterior descending (LAD) artery (arrow) distal to the ostium of the second diagonal branch (2nd diag). 1st diag = first diagonal branch. (b) Volume-rendered image from 16-section multi-detector CT, obtained 24 hours after thrombolysis, shows patency of the distal segment of the left anterior descending artery (arrow). (c) Cross-sectional image of the left ventricle obtained at the same time as b shows a region of low attenuation (white arrows) in the anteroseptal segment of the middle and apical portions of the left ventricular myocardium, a finding indicative of a perfusion deficit due to occlusion of a distal segment of the left anterior descending artery. A large thrombus (arrowhead) is visible in the left ventricular cavity. LA = left atrium, LV = left ventricle, RV = right ventricle.

 

View larger version (111K): [in a new window]   Figure 8a.  Multidetector CT evaluation of coronary artery bypass grafts. (a) Three-dimensional volume-rendered image demonstrates the patency of a left internal mammary artery graft (arrows) to the left anterior descending artery and a saphenous vein graft (arrowheads) to the first obtuse marginal branch. (b) Three-dimensional volume-rendered image shows a patent saphenous vein graft (arrows) to the posterior descending coronary artery.

 

View larger version (115K): [in a new window]   Figure 8b.  Multidetector CT evaluation of coronary artery bypass grafts. (a) Three-dimensional volume-rendered image demonstrates the patency of a left internal mammary artery graft (arrows) to the left anterior descending artery and a saphenous vein graft (arrowheads) to the first obtuse marginal branch. (b) Three-dimensional volume-rendered image shows a patent saphenous vein graft (arrows) to the posterior descending coronary artery.

 

View larger version (143K): [in a new window]   Figure 9a.  Multidetector CT evaluation for syncope and exertional chest pain. (a) Thin-slab MIP image depicts an anomalous origin of the right coronary artery (arrow) from the left Valsalva sinus as well as narrowing of the proximal segment of the right coronary artery between the main pulmonary artery (MPA) and the ascending aorta (AO). Note the normal origin of the left main coronary artery (arrowhead). (b) Three-dimensional volume-rendered image provides an overview of the coronary anatomy and helps confirm the anomalous origin of the right coronary artery from the left Valsalva sinus (arrow), adjacent to the origin of the left main coronary artery (arrowhead).

 

View larger version (131K): [in a new window]   Figure 9b.  Multidetector CT evaluation for syncope and exertional chest pain. (a) Thin-slab MIP image depicts an anomalous origin of the right coronary artery (arrow) from the left Valsalva sinus as well as narrowing of the proximal segment of the right coronary artery between the main pulmonary artery (MPA) and the ascending aorta (AO). Note the normal origin of the left main coronary artery (arrowhead). (b) Three-dimensional volume-rendered image provides an overview of the coronary anatomy and helps confirm the anomalous origin of the right coronary artery from the left Valsalva sinus (arrow), adjacent to the origin of the left main coronary artery (arrowhead).

 

View larger version (147K): [in a new window]   Figure 10.  Multidetector CT evaluation for atypical chest pain. Thin-slab MIP image depicts two nonstenotic lesions (arrows), both consisting of noncalcified plaque, in the middle segment of the right coronary artery.

 

View larger version (133K): [in a new window]   Figure 11a.  Multidetector CT evaluation for atypical chest pain. (a) Curved multiplanar reformatted image shows positive remodeling of the left main coronary artery lumen by small lesions consisting of mixed calcified and noncalcified plaque (arrow). (b) Cross-sectional image at the level of the left main coronary artery shows mixed plaque with calcified and noncalcified components (arrow). The lesions do not compromise flow through the coronary artery lumen but are evidence of positive remodeling, which cannot be detected with conventional coronary angiography.

 

View larger version (135K): [in a new window]   Figure 11b.  Multidetector CT evaluation for atypical chest pain. (a) Curved multiplanar reformatted image shows positive remodeling of the left main coronary artery lumen by small lesions consisting of mixed calcified and noncalcified plaque (arrow). (b) Cross-sectional image at the level of the left main coronary artery shows mixed plaque with calcified and noncalcified components (arrow). The lesions do not compromise flow through the coronary artery lumen but are evidence of positive remodeling, which cannot be detected with conventional coronary angiography.

 

View larger version (148K): [in a new window]   Figure 12a.  Protocol for combined evaluation of the coronary arteries, thoracic aorta, and pulmonary arteries with a 64-section multidetector CT scanner. (a) Topographic scan of the chest shows extension of the volume coverage and field of view to depict the level just above the aortic arch (red frame) and to include the pulmonary arteries and thoracic aorta in addition to the coronary arteries (green frame). The enlarged field of view is similar to that used for a coronary bypass CT study and may require prolongation of the image acquisition time by 2–4 seconds. (b) Short-and long-axis images show adequate contrast enhancement of the right and left ventricular circulation. The time difference between maximal enhancement in the aorta and that in the main pulmonary artery indicates that a prolongation of contrast material administration to 20–25 seconds is necessary to ensure adequate enhancement of the pulmonary artery tree.

 

View larger version (167K): [in a new window]   Figure 12b.  Protocol for combined evaluation of the coronary arteries, thoracic aorta, and pulmonary arteries with a 64-section multidetector CT scanner. (a) Topographic scan of the chest shows extension of the volume coverage and field of view to depict the level just above the aortic arch (red frame) and to include the pulmonary arteries and thoracic aorta in addition to the coronary arteries (green frame). The enlarged field of view is similar to that used for a coronary bypass CT study and may require prolongation of the image acquisition time by 2–4 seconds. (b) Short-and long-axis images show adequate contrast enhancement of the right and left ventricular circulation. The time difference between maximal enhancement in the aorta and that in the main pulmonary artery indicates that a prolongation of contrast material administration to 20–25 seconds is necessary to ensure adequate enhancement of the pulmonary artery tree.

 

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