Anatomy and imaging of coronary artery disease with


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  • The venous drainage of the heart is carried out by 3 types of vessels— Coronary sinus– Larger vein draining 75% of total coronary flow. It drains from left side of heart. Anterior coronary veins – drains from right side of heart Thebesian veins- drians blood from myocardium into concerned chambers of heart.
  • 37% OF PATIENTS HAVE TRIFURCATION OF LEFT coronary artery, with an intermediate or ramus medianus artery arising between the LAD and circumflex coronary artery.
  • Whichever artery crosses the crux of the heart and gives off the posterior descending branches is considered to be the dominant coronary artery.
  • Atherosclerosis is an ongoing process, which starts from 1 st decade and continues thereafter.
  • A plaque is a raised focal lesion within the intima. It comprises a soft necrotic core (predominantly lipids, foam cells and debris) surrounded by chronic inflammatory cells, smooth muscle cells and neovascularisation, and covered by a fibrous cap. Plaques often undergo calcification.
  • Cath lab includes a special table, x-ray tube &monitor, supplies (catheter, guidewire) automatic injector pressure Cardiac monitors Vitals monitors
  • Instead of x ray photon beam, rapidly rotating electron beams are used and reflected onto a stationary beam.
  • It is well established that heart rate is the predictor of image quality. And a low heart rate (<60 bpm) substantially improves image quality and accuracy for stenosis detection.
  • Scan is initiated by the patient’s ECG signal at a phase when cardiac motion is minimal while the patient table is stationary
  • The bolus tracking technique uses a series of dynamic low-dose axial scans (every 2 s) at the level of the carina to track the bolus of contrast material and to monitor the contrast enhancement at the level of the ascending aorta. The coronary CTA imaging sequence is initiated when the contrast enhancement reaches a predefined value, usually 100 Hounsfield units.
  • IVUS of a coronary artery is performed in a catheterization laboratory. The IVUS catheter is inserted into an artery in the groin area, and navigated to a coronary artery. The catheter is usually positioned distal to the lesion or stent, and withdrawn through the lesion/stent at a constant speed manually or with an automatic mechanical pullback device.
  • MRI of the coronary arteries (MRCA) was first performed in 1993 with a single slice breathhold technique (2D-MRCA).  The use of a respiratory gated technique (navigator) for MRCA  was introduced later as another possibility to reduce respiratory blur. Without restrictions in imaging time imposed by the patient’s breathhold limits, longer imaging sequences can be used. This allows the complex coronary artery anatomy to be studied with a three dimensional technique (3D-MRCA).
  • both coronary ostia were situated above the sinotubular junction in 6% of randomly selected adult hearts. High take-off of the coronary arteries usually presents no major clinical problems Multiple ostia- In multiple ostia, typically either the RCA and the conus branch arise separately, or the LAD and LCx arteries arise separately with no LCA
  • ALCAPA results in the left ventricular myocardium being perfused by relatively desaturated blood under low pressure, leading to myocardial ischemia. Approximately 85% of patients present with clinical symptoms of CHF within the first 1-2 months of life.
  • Angina could also be due too aortic valve disease and hypertrophic cardiomyopahty.
  • Anatomy and imaging of coronary artery disease with

    2. 2. Coronary arteryCoronary artery is a vasa vasorum that supplies the heart.Coronary comes from the latin ”Coronarius”Meaning “Crown”. 2
    3. 3. Coronary artery• The coronary artery arises just superior to the aortic valve and supply the heart• The aortic valve has three cusps – #left coronary (LC), #right coronary (RC) #posterior non-coronary (NC) cusps. 3
    4. 4. Right coronary artery• Originates from right coronary sinus of Valsalva• Courses through the right AV groove between the right atrium and right ventricle to the inferior part of the septum 4
    5. 5. Branches of RCA Right coronary artery Conus branch Conus artery Sinu nodal artery SINU NODAL BRANCH Marginal artery Post. Descending IV artery AV nodalBranch AV Nodal artery- 5
    6. 6. • Conus branch – 1st branch supplies the RVOT• Sinus node artery – 2nd branch - SA node.(in 40% they originate from LCA)• Acute marginal arteries-Arise at acute angle and runs along the margin of the right ventricle above the diaphragm. • Branch to AV node• Posterior descending artery : Supply lower part of the ventricular septum & adjacent ventricular walls. Arises from RCA in 85% of case. 6
    7. 7. Right coronary anatomy 1 CONUS BR 2 RCA AO LA RCA 3 AM 4SAN RCA 7
    8. 8. RCA AMAM 8
    9. 9. Area of distributionRT CORONARY ARTERY----1)Right atrium2)Ventriclesi) greater part of rt. Ventricle except the area adjoining the anterior IV groove.ii) a small part of the lt ventricle adjoining posterior IV groove.3)Posterior part of the IV septum4)Whole of the conducting system of the heart, except part of the left br of AV bundle 9
    10. 10. Left coronary artery• Arises from left coronary cusps• Travels between RVOT anteriorly and left atrium posteriorly.• Almost immediately bifurcate into left anterior descending and left circumflex artery.• Length – 10-15mm 10
    11. 11. 11
    13. 13. LT CORONARY ARTERY1) Left atrium.2) Ventriclesi) Greater part of the left ventricle, except the area adjoining the posterior IV groove.ii) A small part of the right ventricle adjoining the anterior IV groove.3) Anterior part of the IV septum.4) A part of the left br. Of the AV bundle. 13
    14. 14. DOMINANCE• Determined by the arrangement that which artery reaches the crux & supply posterior descending artery• The right coronary artery is dominant in 85% cases.• 8% cases - - circumflex br of the left coronary artery• 7% both rt & lt coronary artery supply posterior IVseptum & inferior surface of the left ventricle-here it is balanced dominance. 14
    15. 15. ATHEROSCLEROSIS 15
    16. 16. Fatty streaks composed of lipid-laden macrophages (foam cells) Fatty streaky progress to plaque Plaque :- Soft necrotic core of lipid with surrounding chronic inflammatory cells covered by fibrous cap. Progressivelyenlarge causing Pressure atrophy ofcritical stenosis the media causing aneurysmal dilatation Ulcerates or ruptures leading to thrombosis and critical ischemia 16
    17. 17. Coronary pathology in acute coronary syndrome. The evolution of coronarylesions follows a progression from (1) initial plaque formation, (2) plaquegrowth, (3) plaque vulnerability and rupture, and (4) thrombosis. 17
    20. 20. CATHETER ANGIOGRAPHY• A minimally invasive procedure to access coronary circulation and blood filled chambers of the heart using a catheter.• The technique was first performed by Dr. Mason Sones at the Cleveland Clinic in 1958• The major epicardial vessels and their 2nd & 3rd order branches can be visualized using coronary angiography.• It is performed for both diagnostic and interventional (treatment) purposes. 20
    21. 21. INDICATION1. Diagnosis of CAD in clinically suspected pts.2. Providing peri-interventional information for percutaneous coronary intervention3. Coronary anomalies4. To exclude stenoses before non-coronary cardiac surgery (valve surgery after 40 yrs of age)5. Determine patency of coronary artery bypass grafts 21
    22. 22. CONTRAINDICATION Coagulopathy Decompensate congestive heart failure Uncontrolled Hypertension CVA GI Hemorrhage Pregnancy Inability for patient cooperation Active infection Renal Failure Contrast medium allergy 22
    23. 23. 23
    24. 24. PROCEDURE PROPER• PATIENT PREPARATION: 1. Arrives at Cath. Lab at morning with at least 6 hrs. fast 2. Allowed to take all medications as advised by physician including aspirin except oral hypoglycemic agents 3.Intravenous access is secured. 4. Sedation with benzodiazipine is recommended. 24
    25. 25. • Vascular Access: Seldinger Technique is used. Transfemoral route is MC (transradial & transbranchial routes can also be used).• Catheter used- MC is Judkins catheter.• 3 different types are for Rt & Lt coronary artery& Lt ventricle.(Lt ventriculography is followedusually after cor. angio) 25
    26. 26. Catherization: Seldinger Technique 26
    27. 27. • Contrast media-Low osmolarity, Non-ionic• Dose-3-10 ml;320-370 mg of iodine/mg, using a hand-held syringe filled from a reservoir.• Left coronary artery is filled with 6-8 ml, right coronary artery is filled with 3-5 ml usually 27
    28. 28. Angiographic projection-• The heart is oriented obliquely in the thoracic cavity, the coronary circulation is generally visualized in the RAO & LAO projection to furnish true PA & LAT views of the heart. using both cranial & caudal angulations.• For LCA branches, views - -AP ,RAO, LAO with cranial tilt• For RCA branches, views reqd. are -AP,RAO ,LAO ĉ or ĉout cranial 28
    29. 29. Angiographic view of LCA 29
    30. 30. Angiographic view of RCA 30
    31. 31. Pitfalls of coronary angiography 1. Inadequate vessel opacification- May give impression of ostial stenoses, missing side branches or thrombus. 2. Eccentric stenosis- Coronary atherosclerosis often leads to eccentric or slit–like narrowing than central narrowing; so if the long axis of the vessel is projected, the vessel may appear to have a normal or near normal caliber. 3. Superimposition of branches 4. Foreshortening of the stenotic segment due to projectional defect 31
    32. 32. Rotational CA• X-ray system rotates around the patient during the acquisition of a single run• Significant reduction in both contrast agent usage and radiation dose of up to 30%, without compromising image quality• Contrast medium is injected automatically (3 mL /s for the LCA and 2 mL/s for the RCA) range 12-18 cc• After this preload, rotation of the C-arm was started automatically and X-rays taken 32
    33. 33. Complication-Overall mortality is about 0.2%. # Vascular-hematoma, false aneurysm, AVF# Cardiacarrythmia MI cardiac-arrythmia, MI#contrastmedia induced- heart failure, ECG changes,,allergic reaction  33
    34. 34. Tight stenosis noted involving A partially obstructive the mid segment of right narrowing noted in the coronary artery. Distal proximal segment of branches are normal. the LAD 34
    36. 36. AVAILABLE TECHNOLOGY• Currently, two competing CT technologies are used- 1. Electron-beam CT and 2. Mechanical multi–detector row CTElectron beam CT : # Used specifically for cardiac imaging d/t high temporal resolution # Uses a rapidly rotating electron beam, which is reflected onto a stationary tungsten target # Imaging done in sequential mode, where single transverse sections are sequentially acquired. # However, due to higher cost and limited availability, MDCT is most commonly used. 36
    37. 37. CT CORONARY ANGIOGRAPHY• Coronary computed tomography angiography (CCTA) is an effective noninvasive method to image the coronary arteries• MDCT has multiple detector rows are placed opposite the x-ray tube which shortens the examination time and improves the temporal resolution• The new generation 64 detector MDCT system has allowed higher isotropic resolution, with visual clarity of up to fifth- order coronary arterial branches. 37
    38. 38. Which ? MDCT is optimum• 4/8-slice –For detection CAD sensitivity: 86% and ruled out in 64 of 80 patients (specificity: 81%).• 16 slice MDCT -sensitivity: 96% ,specificity: 83• 64 slice CT -sensitivity: 97% ,specificity: 92% 38
    39. 39. • High-quality source images are the most important prerequisite for the diagnostic assessment of coronary CTA.• Image quality depends on: 1. Heart rate – Image quality improves with heart rate less than 65. 2. Proper coronary CTA scan and post processing protocol. 3. The synchronization of raw image data with electrocardiography (ECG) information 4. Breath Holding : 45 sec (4 detector) to 9 sec (64 detector) 39
    40. 40. INDICATION• Screening high risk patients• Evaluation of chest pain• Post procedural study Post CABG Post stent• Dilated Cardiomyopathy• Non-cardiac surgery evaluation 40
    41. 41. CONTRAINDICATIONS• Absolute contraindication : 1. Hypersensitivity to iodinated contrast agent 2. Pregnancy Relative contraindication Irregular rhythm Renal insufficiency (sr. creatinine > 1.5 mg/ml) Hyperthyroidism Inability to hold breath for 10 sec History of allergy to other medication Metallic interference (e,g: pacemaker, defibrillator wires) 41
    42. 42. PATIENT PREPARATION• Avoid caffeine and smoking 12 hours prior to the procedure to avoid cardiac stimulation.• B- blocker : Oral or I.V B-blocker is used in patient with heart rate greater than 60 bpm oral 50- 100 mg metaprolol administered 45 min to 1 hr before procedure. or I.V Metaprolol 5 to 20 mg at the time of procedure Sublingual Nitrates or Nitroglycerine: given immediately before the procedure to dilated the coronary arteries. 42
    43. 43. Patient Positioning and Preparation for Scanning• Patients are positioned on the CT examination table in the supine position• ECG leads are attached to obtain an adequate ECG tracing.• Intravenous access via a large intravenous line (18 gauge cannula) is necessary to ensure easy injection of the viscous contrast agent at a flow rate of 5 mL/s• Training of patients with repeated breath holds 43
    44. 44. ECG gating protocols• For ECG synchronized scanning of the cardiac region, two different approaches are taken 1. Prospective ECG gating 2. Retrospective ECG gating 44
    45. 45. PROSPECTIVE ECG GATING• Scan acquisition is triggered by the ECG signal at the prospected mid- diastolic phase of the cardiac cycle.• Between 40% and 80% of the R-R interval• Benefits: Smaller patient radiation dose• Limitation: Reconstruction of image in different cardiac phase for functional analysis of ventricle is not feasible 45
    46. 46. RETROSPECTIVE ECG GATED SCANNING  Heart region is scanned continuously  Contiguous data of cardiac region are acquired  Patient’s ECG is recorded at the same time  Scan data with least cardiac motions , usually the diastolic phase , are selected later for image reconstructionAdvantage:•Entire volume is acquired continuously and gapless•Image may be reconstructed with overlapDisadvantage:• Higher patient radiation exposure 46
    47. 47. ECG controlled dose modulation Diagram showing effect of ECG dose modulation. In Fig 1- continuous scanning throughout the cardiac cycle with full tube current , resulting in high radiation dose. In Fig 2- ECG dose modulation is turned on and full tube current is applied only during 40-80% of cardiac cycle, where cardiac motion is least. In Fig 3- To further decrease radiation, a single phase of cardiac cycle is selected for scanning during which full tube current is applied. 47
    48. 48. Image acquisition and reconstruction• The acquisition of the dataset for coronary CTA consists of 3 steps : 1. Topogram 2. Contrast medium protocol : to ensure homogeneous contrast enhancement of the entire coronary artery tree 3. Coronary CTA scan 48
    49. 49. TOPOGRAM SCAN START POSITION• Native coronary arteries # Begin above carina # Tortuous aorta or prominent upper left heart border – begin scan 1-2cm higher• Bypass Grafts Veins: top of arch LIMA: above clavicles SCAN ENDING POSITIONImage acquisition end 2 cm below the diaphragm 49
    50. 50. Contrast Medium Protocol• Optimal coronary artery opacification depends on : 1. The iodine medium concentration – (300-400 mg iodine/ ml is used) 2. The volume and rate of contrast administration 3. Timing of the contrast medium delivery. 50
    51. 51. Volume and rate of contrast administrationUsing 64 detector MDCT technology:• 80ml of contrast agent is injected at 6 ml/sec f/b 40ml saline solution at 4ml/secUsing 16 detector MDCT technology:• 100- 120 ml of contrast agent @ 4 to 5 ml per sec. 51
    52. 52. • Delivery of contrast medium s/b timed to ensure that the scan of cardiac region will occur at the peak of opacification of the coronary tree.• It can be assessed by two techniques- 1. Automated contrast bolus tracker technique- the ROI is placed on ascending aorta. When ct value of ROI is greater than predetermined threshold of 100- 150 HU, the scan begins. 2. Test bolus scan – here a small bolus of contrast is injected to determine contrast transit time. The time from the start of the injection to the peak contrast enhancement in the ascending aorta determines the scan delay after the initiation of contrast material administration. 52
    53. 53. • After contrast administration, CT is obtained in single breath-hold• Scan volume covers the entire heart from the proximal ascending aorta (approximately 1–2 cm below the carina) to the diaphragmatic surface of the heart 53
    54. 54. Scanning protocol 54
    55. 55. Post processing protocol• The axial source images obtained are utilized for multiplanar reconstructions in at least 2 planes• Commonly used techniques are : Maximum intensity projection (MIP), Volume rendering (VR), Multiplanar reconstruction (MPR) or Curved planar reconstruction (CPR 55
    56. 56. Curved multiplanar "Ribbon" multiplanar reconstructionreconstruction (MPR) image (MPR) 3D Volume-rendering Maximum intensity projection56 (MIP)
    57. 57. RADIATION DOSE• Ranges between 12-16 mSv depending on CT scanner and type of ECG gating used.• ECG-controlled dose modulation systems allows reduction of radiation exposure by upto 50%• Lower the KVP to 100 causes significant dose reduction.• A prospective gate window of 20% over diastole in patients with HR of 60, can reduce total dose by 80%. 57
    58. 58. Coronary artery assessment The best evaluated coronary artery is the LAD as it runs along the axis of the scan and is not significantly affected by cardiac movements The LAD is well visualized in 76-96% of cases The left CX artery may be affected by cardiac motion artifacts and can be assessed in 52-95% of cases RCA is most affected by cardiac movement Proximal coronary segments are better visualized than distal ones. 58
    59. 59. ADVANTAGES OF MDTC• Non invasive procedure without any hospital stay.• MDCT CA can precisely identify total occlusion, indicate cause and extent.• Morphology of the occluded segment and the time the artery was occluded # In acute obstruction, low density intraluminal defect caused by thrombosis with an increase in luminal area and diameter are seen. # In chronic cases , the obstruction shows calcified or mixed plaques with the artery lumen with normal or slightly narrowed lumen 59
    60. 60. • Predictors of failure to open an occluded artery include 1.occlusion length greater than 15mm 2.Presence of severe calcification in the compromised segment.• Vessel distal to the completely obstructed segment is visualized , not possible with catheter angio. 60
    61. 61. 61
    62. 62. Calcium scoring• Coronary calcium screening is intended to detect calcified atherosclerotic plaque burden as a surrogate marker for coronary atherosclerosis.• Based on the principle that– # Obstructive atherosclerotic plaques are calcified – so called “Hard Plaque” # Calcium is not present within the wall of a normal coronary artery 62
    63. 63. INDICATION• Women over the age of 55 and men over the age of 45 should consider the coronary calcium scan, if they have coronary artery disease risk factors:  ---- Family history of heart disease ---- High cholesterol level (hypercholesteremia) ---- High blood pressure ---- Smoking, Obesity ---- Diabetes ---- High-stress lifestyle 63
    64. 64. Minimum requirement for calcium scoring 64
    65. 65. HOW THE PROCEDURE IS DONEPreparation: # No special preparation is necessary # Avoid caffeine and smoking four hours before the exam. # Heart rate > 90/min → β- blockerProtocol : # No contrast used # 2.5 mm to 3 mm slice thickness # Prospective ECG –gated acquisition for calcium scoring. 65
    66. 66. • The threshold for calcification is set at an attenuation value of ≥ 130 HU, for an area of > 1mm2 along the course of the coronary arteries.• For MDCT the threshold value for calcification is 90 HU ( because of high signal to noise ratio )• Automated measurement of the lesion area in mm 2 and maximum CT No. (HU) of each lesions are recorded. 66
    67. 67. • Density score of the lesions are determined as• The total as well as individual coronary artery calcium score is calculated using special software at the workstation 67
    68. 68. Methods• Quantitative calcium scores are calculated according to the method described by Agatston et al . Calcium score= density score x volume• CAC scores are typically reported for each major coronary artery (left main, left anterior descending, circumflex, right coronary artery) separately• The total score is achieved by adding up each of the scores for all the slices 68
    69. 69. WHAT DOES THE CALCIUM SCORE REPRESENT• Detection of any degree of coronary calcium on CT indicates that CAD is present• It provides a quantitative estimation of plaque burden. Higher the score the larger the plaque burden & higher the subsequent cardiac events.• Score of zero indicates unlikely chance of CAD, does not eliminate the possibility. 69
    70. 70. CALCIUM SCORING GUIDELINESCALCIUM IMPLICATION RISK OF CORONARYSCORES ARTERY DISEASE0 No identifiable plaque Very low, less than 5%1 – 10 Minimal identifiable plaque Very unlikely, less than 10%11 – 100 Definite, at least mild Mild or minimal coronary atherosclerotic plaque narrowing likely101 - 400 Definite, at least moderate Mild coronary artery disease plaque highly likely, significant narrowing possible401 or Extensive atherosclerotic High likelihood of at least onehigher plaque significant coronary narrowing 70
    71. 71. GUIDELINES FOR THE PHYSICIANS IN INTERPRETING A PATIENTS SCORE Presence of any detectable calcium Implies presence of CADMore aggressive BP control, lipid lowering 71
    72. 72. GUIDELINES cont…. Patients with high scores (>400)likelihood of harboring a significant stenosisShould undergo stress testing to evaluate for inducible ischemia 72
    73. 73. GUIDELINES cont…. Patients with intermediate scores Require further testing based on other factors like age etc. Score of zero No need for further imaging tests forCoronary disease 73
    74. 74. Advantages of Coronary calcium scoring• Gives an idea of whether CAD is present, despite a lack of symptoms or is likely to develop in next few years develop in next few years.• Non invasive and less time consuming.• No contrast required needed.• The examination can suggests the presence of CAD even when the coronary arteries are <50% narrowed. 74
    75. 75. LIMITATIONS• Not all calcium deposits mean there is a blockade and not all blocked arteries contain calcium.• The earliest form of CAD soft plaque, cannot be detected by cardiac CT.• A high heart rate interferes with the test.• Men <35 yrs and women <40 yrs are not likely to benefit from cardiac CT for calcium scoring unless there is risk factors such as diabetes or a strong family history of heart disease. 75
    76. 76. Transthoracic echocardiography imaging of coronary arteries• With available technique, it is possible completely evaluated left anterior descending and a part of posterior descending artery.• It is nowadays possible to investigate LAD in 98% of patients and PDCA in 60–70% of patients 76
    77. 77. Transthoracic positioning of probe in order tohighlight the two major coronary arteries 77
    78. 78. Transducer beam orientations to the LAD and to posteriordescending CA with the corresponding echocardiographyimages of the mid-distal tract of LAD.Pulse-wave flow andposterior descending coronary artery (PDCA). 78
    79. 79. Stress Echocardiography• Echo combined with exercise or pressor agents like Dobutamine.• There are two techniques for performing stress echo:- a) Detection of wall motion abnormalities induced with exercise/ dobutamine. b) Measurement of altered myocardial perfusion on contrast ECHO. 79
    80. 80. • The hallmark of myocardial ischemia during stress echo is the occurrence of reduced systolic wall thickening• Precedes chest pain and ST-T wave changes, which makes stress echo more sensitive than exercise treadmill ECG testing.• Limitation- a) Poor inter-observer agreement b) Optimal acoustic window may not be present in every patient. 80
    81. 81. INTRAVASCULAR ULTRASOUND.• Intravascular ultrasound (IVUS) is catheter based imaging technique, using a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter• Allows the application of ultrasound technology to see inside of coronary artery.• Used in the coronary arteries to determine the amount of atheromatous plaque 81
    82. 82. ProcedureCarried out during coronarycatheterization procedureA miniature transducerwithin a catheter isintroduced in vessel lumenas distal as possibleAutomatically pulled back @0.5 mm/sec 82
    83. 83. 83
    84. 84. IVUS contd ….Advantage : 1. visualization of complete circumference of vessel wall as well as the plaque 2. allows stenosis measurement with direct planimetry 3. evaluation of diffusely calcified ostial or bifurcation stenosis.Disadvantage : 1. Invasiveness 2. Cost. 84
    85. 85. MAGNETIC RESONANCE IMAGING IN CAD• Coronary MRA has not gained acceptance for screening of CAD.• Difficulties for MRA- # Small caliber of coronary artery- LMCA- 4-6 mm LAD, LCA & RCA- 3-4mm # Tortuous course # Respiratory motion Artifacts # Coronary artery motion artifacts during cardiac cycle 85
    86. 86. • When properly executed, the breath-hold technique with cardiac gating yields extremely good quality images of the coronary arteries• Navigator-echo Sequence makes up for the respiratory movements with some degradation of image quality• Accuracy of MRA in these proximal segments was approximately 90% 86
    87. 87. MAGNETIC RESONANCE IMAGING• First choice in evaluation of proximal coronary pathology in young and in particular if associated congenital anomalies are present• The limitations for imaging the distal coronary arterial segments remain• The use of contrast agents improve the signal-to- noise ratio in these distal coronary branches• In future with the advent of shorter scan times better post processing software -the diagnostic accuracy of 3D, navigator-echo MR angiography will increase 87
    88. 88. Advantages of Coronary MRI  No radiation and minimal invasiveness (IV injection)  3-dimensional anatomic images (3D coronary artery and myocardial imaging)  Comprehensive functional imaging - Myocardial mechanical work  - Myocardial perfusion  - Myocardial oxygenation  - Myocardial Viability 88
    89. 89. Detailed view on the right coronary artery in the atrioventricular groovebetween the right ventricle (RV) and atrium (RA). The arrows indicatestenoses in the proximal and mid segment. (B) Correspondingconventional coronary angiogram. 89
    90. 90. Example of a significant stenosis (arrow head) in the left anterior descending coronary artery (LAD). (A) Conventional coronary angiogram. (B) Magnetic resonance imaging. Ao, aorta; LM, left main; LV, left ventricle; RVOT, right ventricular outflow tract. 90
    91. 91. MYOCARDIAL PERFUSION IMAGING• Thallium-201/Technetium 99m labelled agents like Tc99m-sestamibi are used in MPI.• Principle- During stress, blood flow increases in normal coronary arteries but not in stenosed artery. As a result, myocardium distal to the stenosis remains hypoperfused.• Represented as regions of decreased perfusion on stress images. 91
    92. 92. Coronary artery anomalies• Occurs in 0.3 to 1% of general population• Important cause of sudden cardiac death.• Can be hemodynamically significant (Malignant) or insignificant (Benign). 92
    93. 93. Congenital variation of coronary anatomy• Angelini has suggested classifying coronary anomalies into three categories: 1. Abnormalities of the coronary ostia: a) High Take off b) Multiple ostia c) Single coronary artery d) Anomalous origin of coronary artery from pulmonary trunk e) Origin of coronary artery or branch from opposite or noncoronary cusp with abnormal course 93
    94. 94. 2. Anomalous course: a) Myocardial bridging b) Duplication of arteries3. Anomalies of termination: a) Coronary artery fistula b) Coronary arcade c) Extra cardiac termination. 94
    95. 95. Single coronary artery .(a)Oblique VR image of the top of the heart shows only onecoronary artery arising from the left coronary sinus. The RCA (arrow) courses betweenthe aorta(A)and the pulmonary artery(PA).(b)On a sagittal oblique VR image, the singlecoronary artery demonstrates a high takeoff (arrowhead) above the sinotubular junction. 95
    96. 96. Coronary anomaliesA. Benign or Minor Coronary Anomalies 1. Left Cx artery arising from right aortic sinus – Most common 2. Independent origin of LAD artery and Cx from the left aortic sinus – The absence of LMCA is the common anomaly of the left coronary vessel system. 96
    97. 97. Malignant or major coronary Anomalies 1. RCA arising from left coronary sinus: Most common malignant coronary anomaly.Present in 20—25% of cases. RCA has inter-arterialcourse and prone for compression 97
    98. 98. Contd….. 2. LMCA arising from right aortic sinus :LMCA courses between aorta and pulmonaryartery. 60 % die before are 20 during sternousexercise. 98
    99. 99. 3. Anomalous origin of LMCA, LAD or RCA from thepulmonary trunk: Anomalous origin of LMCA is called Blant-White-Garland syndrome, whereas if anomalous origin of RCAis called reverse Blant-White-Garland syndrome. 99
    100. 100. 4. Coronary Artery fistula: communication between one ortwo coronary arteries and acardiac chamber or systemic vein.Large AV communication producemyocardial perfusion deficit.5. Myocardial bridging:Epicardial segment of a coronaryartery  tunnels through a portion of myocardium.Involves middle segment of LAD. 100
    102. 102. What is coronary artery disease ?• Coronary artery disease (CAD) is a complex disease due to reduced or absent blood flow in one or more of the arteries that supply the heart. • Excluding congenital anomalies , it is usually caused by atherosclerosis. 102
    103. 103. 1. Atheromatous coronary artery disease• Typical major coronary artery branches have internal diameter of 2.5-3.5 mm; LCA having internal diameter of about 4mm.• Atheromas due to chronic endothelial injury• Flecks of calcification - indicate obstructive atheromatous disease.• Calcification is the rationale for using CT to detect asympt. CAD. 103
    104. 104. • A reduction in lumen diameter >60% is enough to represent a hemodynamically significant stenosis.• Chronic increase of size of plaque leads to stable angina or ischemic cardiomyopathy.• Acute changes, especially plaque rupture lead to a variety of “acute coronary syndrome” most imp. are unstable angina & MI. 104
    105. 105. Conditions result from CAD is :-1. Angina Pectoris2. Myocardial InfarctionANGINA PECTORIS: Symptom complex caused by transient myocardial ischemia d/t fixed atheromatous stenosis of one or more arteries.Types : It has 3 types :-- 1.Stable Angina 2. Un stable angina & 3.Variant Angina (Prinzmetal’s or resting angina) 105
    106. 106. Myocardial Infarction• Irreversible necrosis of heart muscle secondary to prolonged ischemia• Presents with prolonged chest pain, anxiety, breathlessness and collapse• Sudden cardiac death can occur d/t ventricular fibrillation.• Diagnosed by raised cardiac biomarker• Role of imaging comes after initial stabilization of the pt. 106
    107. 107. Coronary Artery Disease2) Aneurysm of coronary artery # Atheromatous-may lead to localized or part of generalized ectasia. Symptom or death by rupture or pressure on the parent artery or by distal embolisation. # Inflammatory -‘Kawasaki Syndrome’(mucocut. L.N.syndrome)-Aneurysm & stricture of cor. artery in children 107
    108. 108. Imaging of coronary arterial and heart diseaseX-Ray findingsi) Coronary artery calcification :Best seen in proximal LCA & may be identified near the aortic root on both PA & Lat. commonly in pts. >70 yrs. In pts <50yrs calcification -calcified atheromatous plaque.ii) Acute MI ----- CXR is normal in acute phase(within 24 hrs) ----- Later changes – # Upper lobe diversion PVH, Septal thickening # Alveolar pulmonary edema MC feature identified. # Pleural effusion if there is prolonged left heart failure. Progressive cardiomegaly occur more often in anterior MI it is a bad prognostic sign. 108
    109. 109. iii) Acute MR: # It is usually due to dilatation of mitral valve annulus or papillary muscle rupture. # Cardiomegaly with or without PVH. # CXR feature is same as in other cause of MRiv) Rupture of IV septum: rare complication. # It is between 4-21 days infarction. # Pulmonary plethora & pulmonary edema.v) Lt ventricular rupture: it is a common complication. # Pericardial tamponade occurs-leads to death 109
    110. 110. vi) Lt ventricular aneurysm: MC complication in clinical practice. # Occurs if the infarcted segment is large. # Most Commonly in the cardiac apex in assoc. with anterior infarct. # Localized bulge on the left heart border on CXR, but may not be seen if aneurysm is not well demarcated. # Curvilinear calcification in the walls of aneurysm after several yrs.vii) Pericardial effusion: Most commonly associated with partial ventricular rupture. Mild cardiomegaly on CXR. 110
    111. 111. 111
    112. 112. ECHOCARDIOGRAPHY Ostia of main coronary arteries may be imaged. Helps in distinguishing anomalous origin of coronary arteries presenting with lt ventricular disease, dilated cardiomyopathy, or myocarditis. Useful in detecting coronary artery aneurysm e.g. Kawasaki disease. Transthoracic & transesophageal USG can be helpful in imaging proximal rt & lt coronary artery. Echo is the tech. of choice for detection & quantification of ventricular aneurysm & detection of concomitant thrombus. 112
    113. 113. STRESS ECHO:A stressor stimulus e.g. exercise or a pharmaceutical agent like Dobutamine is applied & then followed be echo.Improves sensitivity for detecting CAD.MYOCARDIAL PERFUSION IMAGING:Radioactive tracer (Thallium201, Technitium-99m labeled tracer) is injected and scintigrams are obtained at rest and during stress.A perfusion defect during stress but not at rest provides e/o reversible myocardial ischemia. 113
    114. 114. Coronary CT angiography• Best non invasive modality for depiction of coronary artery anatomy and disease• Evaluates the plaque burden and morphology accurately• Important “ rule –out” modality in patients with atypical chest pain• Technique of choice to evaluate bypass graft.• Dose limiting techniques, coupled with adherance to ALARA principle may shift the risk-benefit ratio in favour of this modality. 114
    115. 115. CARDIAC MRICardiac MRI is a established tool in assessing congenital heart disease & diseases of aorta & pericardium, but role in coronary artery evaluation is not very significant.—These noninvasive techniques are useful in initial screening for coronary artery stenosis , evaluating bypass grafts and determining the patency of infarct related artery after coronary thrombolysis. 115
    116. 116. Imaging in post bypass surgery and stent patients• CCTA is highly recommended for follow up evaluation of CABG.• Unlike invasive coronary angiograms, MDCT does not require accurate localization of Ostia of venous graft for selective contrast injection.• Sensitivity of 97-100 % for graft stenosis/occlusion• However, surgical metallic clips may lead to artifact 116
    117. 117. • Routine application of CT to assess patients with coronary stents is currently not recommended.• Visualization of the stent lumen is often affected by artifacts, and especially the PPV is low. 117
    118. 118. 118
    119. 119. Fig. LAD thrombus demonstrated with MDCTA. A: Patient with a thrombus in theLAD (arrow). B: Multiplanar reformatting of the same data set demonstrating theextent of the thrombus formation in the LAD. C: In the coronary angiogram, onlyslightly diminished enhancement is visible at the corresponding location 119
    120. 120. Fig. Stenosis of LAD demonstrated with MDCTA. A: 55-year-oldmale patient with a single-vessel disease in the LAD (arrow). B:Finding of CTA confirmed by cardiac catheter with a high-gradestenosis in the midsegment of the LAD. 120
    121. 121. Fig. Acute coronary syndrome. anterior wallperfusion deficits on short axis wasnoted(A) and vertical long axis (B)reconstructions are seen, includingsubendocardial components (thin arrows). C:A reconstructed image to detail the coronaryarteries shows a filling defect (yellow arrows)occluding the LAD and smaller nonocclusiveplaques (white arrows) in a large diagonalbranch. Note the cardiac vein (bluearrowhead) immediately posterior to the 121diagonal branch.
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    123. 123. Conclusion• Non- invasive cardiac imaging is now central to diagnosis and management of CAD patients, however cannot replace existing modalities• ECHO c/be performed bedside and is advantageous for acutely ill patients• Cardiac catheterization offers the option of intervention• Myocardial perfusion scanning and MDCT can be offered to patients with intermediate likelihood of CAD 123
    124. 124. • MDCT c/become investigation of choice for evaluation of bypass graft in CABG patients• Currently CMR lags behind CTA for non invasive coronary angiography, it is already emerged as a highly effective method for assessing ventricular function , myocardial mass and myocardial viability. 124
    125. 125. 125