参考周二讲课sunjing

1、Congenital Anomalies of the Coronary Arteries SUN JINGIntroductionPrevalence: 1-2%Coronary angiographyCT angiographyCardiac MR imaging RSNA, 2012 Fig1. Left coronary (LC), right coronary (RC) and posterior non-coronary (NC) cuspCoronary anatomy Coronary anatomy Left Main or left coronary artery (LCA

2、)Left anterior descending (LAD)diagonal branches (D1, D2)septal branchesCircumflex (Cx)Marginal branches (M1,M2)Right coronary arteryAcute marginal branch (AM)AV node branchPosterior descending artery (PDA)Fig2. RCA, LAD and Cx in the anterior projectionLCA divides into LAD and CxCx with obtuse marg

3、inal branch (OM)LAD with diagonal branches (DB)volume rendered images Fig3. LAD and Cx Fig4. In 15% of cases a third branch arises in between the LAD and the Cx, known as the ramus intermedius or intermediate branch. Fig5. septal branches and RCAFig6. branches of RCACoronary anomalies(a) hemodynamic

4、ally significant anomaliesassociated with shunting, ischemia, or sudden cardiac death(b) Non-Hemodynamically significant AnomaliesHemodynamically significant anomaliesAtresiaOrigin from the pulmonary artery Interarterial courseCongenital fistula Hemodynamically significant anomaliesAtresiaOrigin fro

5、m the pulmonary artery Interarterial courseCongenital fistula Figure 7. Congenital atresia of the LMCA in a 21-year-old patient who underwent aortocoronary bypass and presented with recurrent chest pain.(a) Volume-rendered image shows a saphenous vein bypass graft (solid arrow) from the aorta to the

6、 left anterior descending (LAD) coronary artery (open arrowhead). (b) Oblique axial maximum intensity projection CT image shows the same findings. White arrow = saphenous vein bypass graft, arrowhead = LAD branch, black arrow = LCX branch. Figure 8. Atresia of the LMCA in a 47-year-old woman with ex

7、ertional chest pain . Volume-rendered image shows a large conus artery (solid arrow) collateral to the LAD artery (arrowhead). Hemodynamically significant anomaliesAtresiaOrigin from the pulmonary artery Interarterial courseCongenital fistula ALCAPA(anomalous origin of the left coronary artery from

8、the pulmonary artery)Bland-Garland-White syndrome,19560.25-0.5% of the congenital heart diseaseOrigin of the RCA, LAD artery, or LCX artery from the pulmonary artery has also been reported.Fig9. anomalous origin of the LCA from the pulmonary artery, also known as ALCAPA.Figure 10. Origin of the RCA

9、from the pulmonary artery in a 38-year-old man with chest pain and anomalous anatomy at cardiac catheterization. Oblique coronal CT image (a) and volume-rendered image (b) show origin of the RCA (arrows) from the main pulmonary artery (PA). Hemodynamically significant anomaliesAtresiaOrigin from the

10、 pulmonary artery Interarterial courseCongenital fistula Figure 11. coronary artery arises off a contralateral coronary artery or coronary cusp Fig12. a patient with an anomalous origin of the LCA from the right sinus of Valsalva and coursing between the aorta and pulmonary artery.Sudden death is fr

11、equently observed in these patients.Fig13. anomalous LCA arises from the right sinus of Valsalva andpasses between the aortic root and the RVOTRadiology 2003; 227:201208Figure 14. Interarterial coronary artery in a 40-year-old man with atypical chest pain. (a) Oblique axial CT image shows the RCA (a

12、rrow) coursing between the aorta and pulmonary artery (PA). (b) Sagittal CT image shows the interarterial vessel (arrow) located cranial to the expected location of a transseptal coronary arteryFigure 15. Interarterial coronary artery in a 56-year-old man with chest pain. CT image (a) and volume-ren

13、dered image (b) show an interarterial LAD artery (arrow) arising from the RCA and coursing between the aorta (Ao) and pulmonary artery (PA). Figure 16. anomalousRCA from the left sinus of Valsalva that courses intraarterially betweenthe aortic root and the RVOT Radiology 2003; 227:201208Hemodynamica

14、lly significant anomaliesAtresiaOrigin from the pulmonary artery Interarterial courseCongenital fistula （CAF）involves termination of a coronary artery or its branches into a cardiac chamber or low-pressure vascular structure Figure17. Coronary artery fistula in a 59-year-old woman with palpitations.

15、 Volume-rendered image (a) and CT image (b) show a fistulous vessel (arrow) that arises from the LAD artery (arrowhead) and terminates in the main pulmonary artery (PA). Figure 18. CAF in a 54-year-old woman with palpitations. (a, b) CT images show a tortuous LCX artery (arrows) that is dilated in c

16、omparison with the LAD artery (arrowhead in a). The dilated LCX artery inserts into the great cardiac vein near the coronary sinus (arrowheads in b). (c) Volume-rendered image shows the markedly tortuous LCX artery (arrows).Fig19. Left to right shunt: septal branch of LAD teminates in right ventricl

17、eNon-Hemodynamically significant AnomaliesDuplicationHigh originPrepulmonic courseTransseptal courseRetroaortic courseShepherds Crook RCASystemic terminationNon-Hemodynamically significant AnomaliesDuplicationHigh originPrepulmonic courseTransseptal courseRetroaortic courseShepherds Crook RCASystemi

18、c terminationFigure 20. Duplication of the LAD artery in a 52-year-old woman at preoperative evaluation. Volume-rendered image (a) and oblique axial CT image (b) show two equally sized LAD arteries (arrows). The aorta (Ao) is noted to be aneurysmal. Non-Hemodynamically significant AnomaliesDuplicati

19、onHigh origin (RCALMCA)Prepulmonic courseTransseptal courseRetroaortic courseShepherds Crook RCASystemic terminationFigure 21. High coronary artery origin in a 45-year-old man with an abnormal RCA at cardiac catheterization. Volume-rendered image (a) and oblique sagittal maximum intensity projection

20、 CT image (b) show high origin of the RCA (arrows). Dotted line in a = sinotubular junction of the aorta. Non-Hemodynamically significant AnomaliesDuplicationHigh originPrepulmonic courseTransseptal courseRetroaortic courseShepherds Crook RCASystemic terminationFigure 22. Prepulmonic coronary artery

21、 in a 53-year-old man with anomalous coronary artery anatomy at conventional angiography; further characterization with cardiac CT was performed. Volume-rendered image (a) and sagittal CT image (b) show a prepulmonic LMCA (arrow). The LMCA courses anterior to the right ventricular outflow tract, jus

22、t below the pulmonary artery (PA in b), before giving off the LAD artery (white arrowhead in a) and LCX artery (black arrowhead in a). Figure 23. Prepulmonic coronary artery in a 41-year-old man with chest pain. CT image (a) and volume-rendered image (b) show a prepulmonic RCA (arrows) that courses

23、in front of and just caudad to the pulmonary artery (PA) after arising from the LAD artery (arrowhead in a). Ao = aorta. Non-Hemodynamically significant AnomaliesDuplicationHigh originPrepulmonic courseTransseptal course(LAD OR LMCA)Retroaortic courseShepherds Crook RCASystemic terminationFigure 24.

24、 Transseptal coronary artery in a 39-year-old man. (a) Axial CT image shows a transseptal LAD artery (arrow) that arises from the RCA (arrowhead). (b) Coronal CT image shows the transseptal artery (arrow), which has a hammock-like downward slope(c) Sagittal CT image shows the transseptal artery (arr

25、ow) coursing below the superior margin of the muscular portion of the interventricular septum (arrowhead). Comparison of Transseptal and Interarterial Coronary Arteries Transseptal VarianInterarterial Variant Artery is surrounded by septal myocardium Artery is surrounded by epicardial fat Artery cou

26、rses downward (hammock sign), below the crista supraventricularis Artery does not have a downward course Artery does not have an oblong or slitlike orifice Artery may have an oblong or slitlike orifice Non-Hemodynamically significant AnomaliesDuplicationHigh originPrepulmonic courseTransseptal courseRetroaortic courseShepherds Crook RCASys