Summary: A 21-year-old woman presented to the emergency department (ED) with
recurrent chest pain, and a normal echocardiogram (ECG), and initial set
of troponins. There was no objective evidence of myocardial injury;
however, there was a recent history of unexplained elevated troponin,
T-wave abnormality, and nonsustained ventricular tachycardia. A cardiac
computed tomography angiogram (CCTA) was ordered.
A 21-year-old woman presented to the emergency
department (ED) with recurrent chest pain, and a normal echocardiogram
(ECG), and initial set of troponins. There was no objective evidence of
myocardial injury; however, there was a recent history of unexplained
elevated troponin, T-wave abnormality, and nonsustained ventricular
tachycardia. A cardiac computed tomography angiogram (CCTA) was ordered.
The CCTA revealed an anomalous origin of
the dominant right coronary artery (RCA) from the left coronary sinus
of Valsalva and with an interarterial course (Figure 1). The proximal 2
cm of the RCA was intramural and with acute angulation. The rest of the
study was normal.
Malignant congenital coronary anomaly
prevalence of coronary anomalies (CA) in the general population is ≤
1%. CA may be classified as either benign or malignant based on origin,
course and termination. Surgical repair of an anomalous RCA from the
left cusp remains controversial;1 however, due to the
patient’s symptoms, prior history of elevated troponins and arrhythmia,
the patient was admitted and underwent cardiac surgery (Figure 2) with
reimplantation of the RCA. A pre-operative ECG was normal. An invasive
coronary angiogram was not performed. Two weeks postoperative, the
patient returned to the ED with new onset of chest discomfort, for which
a repeat CCTA was performed. The subsequent CCTA demonstrated a patent
reimplanted RCA (Figure 3), and the patient was diagnosed with
postsurgical pericardiotomy (Dressler’s) syndrome.
CCTA is well
recognized as the imaging study of choice for the evaluation of
congenital coronary anomalies in adults. Also, CCTA is rapidly becoming
the preferred study, in low- to intermediate-risk patients, for the
evaluation of chest pain in the ED. CCTA has proven to be as accurate as
the current standard of care, but with the added advantage of
decreasing patients’ length of stay by 55% and reduction of costs by
38%.2 Additional potential advantages of CCTA include the
avoidance of discharging patients from the ED with acute coronary
syndrome (2% to 13%) that have negative troponins and ECG.
the Philips iCT, studies in these types of patients are routinely
acquired with a prospectively-gated axial technique (Step & Shoot
Cardiac, Philips Healthcare, Cleveland, OH, USA) at 75%
physiologic-cardiac phase, 100 kVp, in 2 heart beats (8-cm z-axis
coverage), and with 70 cc IV of low-osmolar contrast. In preparation for
the CCTA, patients are routinely administered 100 mg PO of metoprolol
in the ED, with an additional IV dose (up to 30 mg) in the CT suite if
needed. Within 5 min prior to the acquisition, patients are given
sublingual 0.4 mg of nitroglycerin to achieve coronary vasodilation.
The raw data is processed with the iDose4 iterative reconstruction technique. When compared to standard reconstruction, iDose4
reduces noise and significantly improves spatial resolution at low
dose. Images are reviewed on the Philips IntelliSpace Portal.
CCTA is the study of choice for the evaluation of congenital coronary anomalies in adults.
with chest pain, that are at low- to intermediate risk for a major
adverse cardiac event (MACE), presenting to the ED can be accurately and
rapidly evaluated with CCTA. In most cases, the studies are of high
quality and low radiation dose. A negative CCTA results in faster
discharge from the ED and significant cost savings. Also, patients
discharged from the ED with a negative CCTA have shown to be MACE free
at 2 years,3 thus providing additional prognostic value.
- Lee BY. Anomalous right coronary artery from the left coronary sinus with an interarterial course: Is it really dangerous? Korean Circ J. 2009;39:175-179.
Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (Coronary
computed tomographic angiography for systematic triage of acute chest
pain patients to treatment) trial. J Am Coll Cardiol. 2011;58:1414-1422.
CL, Banerji D, Siegel E, et al. Prognostic value of CT angiography for
major adverse cardiac events in patients with acute chest pain from the
emergency department: 2-year outcomes of the ROMICAT trial. JACC Cardiovasc Imaging. 2011;4:481-491.