الفهرس 
Development of Coronary Blood VesselsOnly 14 pages are availabe for public view
 |  | from | 246 |  |  |
| | | from | 246 | | |
Abstract
The prevalence of coronary artery anomalies increases and they are classified into those of its origin, course, intrinsic arterial anatomy, and termination. Anomalous origin from opposite sinus with malignant interarterial course between aorta and pulmonary artery leads to significant compression during strenuous exercise and is an important predisposing factor to sudden cardiac death. This study aimed at determination of the prevalence and description of the coronary congenital anomalies and their variations using multislice coronary CT angiography. This prospective study included 630 patients, 280 males and 350 females. Their ages ranged between 3 days & 81 years. Those patients were referred to Diagnostic Radiology and Medical Imaging department at Tanta University Educational Hospital from Cardiology department and private clinics with either myocardial ischemic symptoms or suspected coronary anomalies by echocardiography or invasive coronary angiography. Patients who were clinically unstable to withstand the duration of CT examination (n=5), patients with history of allergy to IV contrast media (n=25), patients who had impaired renal function (creatinine level ≥ 1.5 mg/dl) (n=19) , patients who could not tolerate the required breath holding time for examination (n=3) , pregnant women (n=4) and patients with bad general condition and needing life support (n=22) were excluded from this study. All patients were subjected to proper history taking, clinical examination and laboratory investigations with certain emphasis on the results of renal function tests prior to the multidetector CT scanning. Pediatric patients with age less than or equal 7 years old (111 patients) were sedated before start of examination either by oral drug (Chloral Hydrate) (in76 patients) or IV drug (Midazolam) (in 35 patients), the later was given by pediatrician or anesthesiologist. Adult patients with higher heart rate than 65 beats/minute (360 patients) were given medications to lower their heart rates (by oral short acting Beta blocker or calcium channel blocker). Test injection with saline was done then injection of non ionic, non diluted IV contrast media (Ultravist 370 mgI/ml) followed by IV saline flush injection. All patients were scanned with 320-row multidetector CT scanner with prospective ECG gated CTA protocol. Automatic and manual bolus tracking techniques were used for adult and pediatric patients respectively. The obtained images were transferred to a workstation to obtain multiplanar reformatted images as well as maximum intensity projection and 3D volume rendered images. The most common complaint was atypical chest pain found in 368 patients. 78.6% of adult patients showed right dominant circulation. Left main coronary artery trifurcated and gave rise to left anterior descending artery, ramus intermedius and left circumflex artery in 79 adult patients. The most common non coronary cardiac finding was aortic valve calcification in 12.7% of adult patients and the most common intracardiac anomaly was perimembranous ventricular septal defect in 16/134 pediatric patients. Prevalence of coronary artery anomalies was 34.4% of all the studied population. 10.9% were anomalies in vessel origin, 22.2% were anomalies in vessel course and intrinsic anomalies and 1.3% were anomalies in its termination. As regards right coronary artery anomalies (RCA). 2.1% of anomalies were origin anomalies; the most common anomaly was abnormal origin from left coronary sinus by separate ostium with malignant interarterial course (in 5 patients). Overall agreement between CT coronary angiography (CTA) and invasive coronary angiography (ICA) results was fair agreement (K value= 0.391). 2.2% of the studied patients had anomalies in course and intrinsic anomalies with the most common type was RCA ectasia (in 8 patients). Only 1 patient showed anomalies in termination with right coronary artery fistulous connection to right ventricle and very good agreement between CT coronary angiography (CTA) and invasive coronary angiography (ICA) results (K value= 1.000). Nineteen patients had left main coronary artery (LMCA) anomalies. Eleven patients had different anomalies in origin & 8 patients had anomalies in its course. The most common anomaly in origin was abnormal origin from right coronary sinus and 1.3% of patients showed anomalies in LMCA course, 75% of them had short LMCA. Thirteen (2.1%) patients with left anterior descending artery (LAD) anomalies showed origin anomalies with good agreement between CTA and ICA results (K value= 0.696), while 16.8% showed anomalous course and intrinsic anomalies with fair agreement between CTA and ICA results (K value= 0.331). 0.16% showed anomalous termination with very good agreement between CTA and ICA results (K value= 1.000). The most common anomalous origin was absent LMCA with separate ostia of LAD and left circumflex artery (LCx) with moderate agreement between CTA and ICA results (K value= 0.597) and the most common anomaly in LAD course was myocardial bridging , this was considered the most common coronary artery anomaly with statistically significant results (P value< 0.001). One case had a left LAD anomaly in termination with fistulous connection to right ventricle and very good agreement between CTA and ICA results (K value = 1.000). Ninteen (3.1%) patients had anomalies in left circumflex (LCx) artery. Eleven patients had anomalies in its origin and the most common type was absent LMCA with direct origin of both LAD and LCx arteries from left anterior sinus of Valsalva by separate ostium and good agreement between CTA and ICA results (K value= 0.725). Four patients showed anomalies in its course and they had ectasia with very good agreement between CTA and ICA (K value= 0.856). Four cases showed LCx fistula with good agreement between CTA and ICA results (K value= 1.000). Three cases showed different acute marginal branch anomalies with good agreement between CTA and ICA results (K value= 0.799). Twenty three cases showed anomalies in posterior descending artery(PDA), 21 of them were anomalies in origin and 2 were anomalies in its course with statistically significant results (P value <0.001). Two cases showed posterolateral branch (PLB) myocardial bridging and 1 case showed PLB fistula to bronchial artery with side fistula to right pulmonary artery. Two cases showed diagonal branch anomalies in course and intrinsic anomalies whereas 1 case showed termination anomaly. Obtuse marginal branches (OM) showed anomalies in their course with statistically significant results and good agreement between CTA and ICA (K value= 0.666, P value 0.001). from this study we can reach to the following conclusions: - The prevalence of coronary anomalies is higher with multidetector coronary CT angiography (CTA) than invasive coronary angiography (ICA) even after exclusion of patients with myocardial bridging which is more frequently found with CTA. So the true prevalence of coronary anomalies in the general population may have been underestimated based on ICA. - Electrocardiography (ECG) gated multidetector coronary computed tomographic angiography (CTA) with 3-D reconstruction provides excellent spatial and temporal resolution, allowing accurate anatomical assessment of coronary artery anomalies. - Multidetector coronary CTA had added value of illustration of the intracardiac non coronary abnormalities, as well as extracardiac anatomical structures.