On behalf of: Sociedad Mexicana de imagen cardiovascular
A 46-year-old man, marathon runner, dyslipidemic in control.
He presented at emergency hospital room with severe angina in January 2014.
An emergency catheterization showed subocclusive lesions in the proximal portion of the left anterior descending artery (LAD) and in right coronary artery; both vessels were repermeabilized with two stents (fig. 1).
Strict medical treatment was followed.
He had typical angina in June 2016, an angiotac was performed and was seen a new proximal subocclusive, calcified lesion in LAD.
In a nuclear cardiology test was demonstrated severe degree of ischemia in all antero-apical and septum regions.
Severe and extense ischemia is an appropriateness use criteria (level of evidence A, recommendation type I) to perform another catheterization, it showed a critical de novo stenosis in LAD territory, where another stent was successfully placed with TIMI I flow.
The patient remains asymptomatic and in functional NYHA class I.
Abstract P259 Figure.
Introduction: Coronary anomalies affect a small percentage of the general population. A solitary coronary ostium (SCA) in the absence of other major congenital anomalies is very rare. The use of cardiac computed tomography (CCT) allows visualization of the coronary anatomy in a 3-dimensional image and demonstrated an added value to coronary angiography. We report cases of single coronary arteries classified as per Shirani Roberts classification criteria1. The theoretical variants of these type of malformations have been described but have not been reported in clinical case before.
Conclusion: According to the literature, coronary anomalies affect 0.3–5.6 percent of the general population. The incidence of coronary anomalies is clinically relevant in view of the fact that they are the cause of 19% of sudden death in athletes. Clinical symptoms are explained by complex path of coronary arteries especially when they course in between great vessels. Our case report depicts localization of lesion is one of the challenging task in analysis. However, localization of lesion is possible in CTA and thus accurately diagnose the ischemia territory. Large pool of data is needed on single coronary artery anomalies, complex lesion structures and intervention strategies to enhance the success rate of complex coronary interventional procedures.
Abstract P260 Figure.
66 years old female with recent CVA and with the following risk factors hypertension, diabetes, was referred for perfusion PET study to evaluate for ischemia.
Procedure: Patient underwent Stress - Rest Rubidium - 82 study following the IV administration of Regadenoson 0.4 mg .
1. Abnormal study. High risk study.
2. Regadenoson-ECG: Positive for ischemia by ST criteria. No chest pain. No arrhythmia.
3. Perfusion: There is a large area of moderate totally reversible perfusion defect in the mid to apical segments of the anterior wall, apex, and apical segments of the septum, inferior and lateral walls. This is consistent with moderate-severe ischemia in the LAD territory.
Total Ischemic Myocardium: 23.53%
4. LV Function: Normal LV size and systolic function (stress EF= 54%, Rest EF= 70%). Stress-induced anterior wall and apical hypokinesia. There was significant drop in stress EF as compared to rest (16 points).
5. Reduced global myocardial flow reserve with steal phenomenon in the LAD territory.
6. Coronary calcium score is 106 which is 50-75th percentile for age/gender matched cohort.
7. TID is high at 1.39.
Abstract P261 Figure.
We present a case of 67 years old patient with a history of aortic valve replacement three months prior to hospital admission with presenting complain of a fever and multiple strokes. Trans-thoracic and Trans-esophageal Echocardiography confirmed the diagnosis of infective endocarditis (IE) by the presence of multiple vegetations attached to the bio-prosthetic aortic valve , in addition there was a suspicion of para-aortic abscess formation . Cardiac computed tomography angiography (CCTA) was done and showed a large aortic pseudoaneurysm (figure) that was missed by Echocardiography. The patient underwent successful aortic valve surgery, aortic root replacement and coronary arteries re-implantation. We presented this case to draw attention to the importance of the CCTA in the diagnosis, the extension, and the surgical management plan of such rare complications of IE.
Abstract P262 Figure.
A 5 years old boy complaining of recurrent difficulty in breathing. the mother sought medical advice and his local chest examination was free, so he was referred for echocardiography which diagnosed the patient to have a coarctation of aorta, and advised a CT for detection of associated congenital cardiac anomalies or presence of aortic collaterals.
The CT was performed using a 64 multi slice detector scanner, and the boy received 12cc of contrast .
the cardiac CT revealed the presence of abnormal left origin of the right brachiocephalic trunk, originating from the inferior aspect of the left end of the transverse aorta, forming a vascular ring with the aortic arch, with compression of the trachea. No coarctation was detected, there was only coiling of the aorta as the defending thoracic aorta begins.
This case shows how the cardiac CT can detect the exact anatomy helping to reach the right diagnosis and planning the management.
Abstract P263 Figure.
There are more and more clinical evidences that endurance sport may induce significant adaptive changes in the ultrastructure and dimensions of heart leading to paroxysmal or persistent atrial fibrillation. However, in some cases it is difficult to differentiate between athlete’s heart and pathologic remodeling with use of conventional ultrasound techniques .
Cardiac magnetic resonance imaging (CMR) can be a useful tool to diagnose congenital heart defect – related dilatation of cardiac chambers in athletes. A case of athlete with adaptive changes in heart overlapped with a big atrial septal defect (ASD II) is presented.
62 year old male asymptomatic marathon runner was referred to cardiologist by family doctor because of heartbeat irregularity on auscultation. A history of cigarette smoking, diabetes, coronary artery disease or arterial hypertension was negative. The athlete reported an incident of acute deep vein thrombosis one year ago. A resting electrocardiogram revealed atrial fibrillation with heart rate 90-110 beats per minute. A transthoracic echocardiography (TTE) showed relevant enlargement of right heart and left atrium, dilatation of ascending aorta with normal aortic valve morphology , normal width of interventricular septum (11mm),slightly impaired left ventricle ejection fraction , mild mitral and tricuspid regurgitation, normal right ventricular systolic function on tissue doppler (TDI).Mean and systolic pulmonary artery pressure were also normal. The left-to-right shunt was not found.
CMR showed impaired left ventricle contractile function (EF 41%) , dilated non-dissected ascending aorta.
Qp:Qs ratio was abnormal, albeit the site of left-to-right shunt was not established . Normal first pass perfusion CMR and absence of late gadolinium enhancement excluded inflammatory process or ischaemia as a cause of depressed left ventricular contractile function. Transesophageal echocardiography (TEE) revealed ASD II (width 15mm). The patient was qualified for occluder implantation.
The presented case demonstrates that TTE including tissue dopper imaging is not always a reliable diagnostic modality to discriminate between exercise-induced and shunt-related dilatation of cardiac chambers in athletes.
Athletes with significant right heart volume overload should undergo CMR, in spite of nonvisualized left-to-right shunt and preserved systolic right ventricular function on 2-D echocardiography or TDI. As abnormal Qp:Qs ratio without evident left-to-right shunts is found on CMR, more invasive diagnostic methods (TEE) should be proposed. Moreover, CMR can also aid in diagnosis of the origin of left ventricular contractile dysfunction in this specific group of patients. In this case, the left ventricle contractile dysfunction probably resulted from long lasting, previously unrecognized atrial arrhythmia secondary to cardiac chamber remodeling due to ASD and intensive endurance training.
A seven days old new born boy presented with cyanosis since birth. Echocardiography was done and showed transposition of great vessels, large ventricular septal defect, and pulmonary atresia.
patient was referred for cardiac CT for more details about the pulmonary branches, peripheral pulmonary circulation, and McGoon ratio measurement before surgical correction. CT was done using a 64 slice multi detector scanner, the baby received 5cc contrast.
the CT confirmed the presence of large ventricular septal defect, transposition of the great vessels, and the pulmonary atresia, but the pulmonary artery was found to originate from the right brachiocephalic trunk running down and branches in left and right confluent pulmonary branches.
this rare complex congenital cardiac anomaly is a perfect example for the importance of cardiac CT in confirming the echocardiographic diagnosis.
