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Use of Multislice Computed Tomographic Coronary Angiography for the Diagnosis of Anomalous Coronary Arteries
Use of Multislice Computed Tomographic Coronary Angiography for the Diagnosis of Anomalous Coronary Arteries Rafic F. Berbarie, MDa, William D. Dockery, MDb, Kenneth B. Johnson, MDa, Robert L. Rosenthal, MDa, Robert C. Stoler, MDa, and Jeffrey M. Schussler, MDa,* The accurate diagnosis of anomalous coronary arteries by invasive angiography is limited by the inability to define the anatomic course in relation to surrounding structures. Computed tomographic coronary angiography has recently emerged as a noninvasive method to visualize the coronary arteries. Multislice computed tomography with up to 64 detector arrays, along with 3-dimensional rendering, has further improved the temporal and spatial resolution of noninvasive coronary imaging. In this series of cases, the investigators describe their institution’s experience with computed tomographic coronary angiography as a complement to invasive coronary angiography in determining the origin and course of different anomalous coronary arteries in 16 patients. With the aid of 3-dimensional volume rendering, 6 anomalous right coronary arteries, 4 anomalous left circumflex coronary arteries, 4 single coronary arteries, and 2 anomalous left main coronary arteries were all clearly defined with regard to their origin and course. It is proposed that computed tomographic coronary angiography is the diagnostic test of choice in the evaluation of such anomalies. © 2006 Elsevier Inc. All rights reserved. (Am J Cardiol 2006;98:402– 406) Coronary artery anomalies, although rare, are potentially lethal. In children and young athletes, they remain among the main causes of sudden cardiac death.1–3 Although such anomalies are usually detected during invasive coronary angiography, accurate diagnosis may be difficult because invasive angiography provides limited information about the spatial relation of an anomalous coronary artery with regard to other structures.4 Computed tomographic coronary angiography (CTCA), using the latest generation of multislice computed tomographic (MSCT) scanners, is developing rapidly as a noninvasive technique for the visualization of the coronary arteries.5,6 In this series of cases, we describe our institution’s experience with CTCA as a complement to coronary angiography and its use in determining the origin and course of various anomalous coronary arteries. •••
We retrospectively reviewed the clinical data and imaging studies of 16 patients who underwent CTCA from May 2003 to October 2005 specifically for the purpose of evaluating anomalous coronary arteries. In these 16 patients, CTCA was requested by cardiologists after invasive coronary angiograms suggested the presence of coronary artery anomalies. The patients’ clinical data with regard to presenting symptoms, their respective anomalies (origins and proximal courses), and ultimate therapy are listed in Table 1. All of the studies were completed at our institution with
a
Department of Internal Medicine, Division of Cardiovascular Diseases, and bDepartment of Radiology, Baylor University Medical Center/ Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas. Manuscript received November 21, 2005; revised manuscript received and accepted February 1, 2006. * Corresponding author: Tel: 214-841-2030; fax: 214-841-2015. E-mail address: [email protected] (J.M. Schussler). 0002-9149/06/$ – see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.amjcard.2006.02.046
either a 16-slice (8 patients) or a 64-slice (8 patients) MSCT (Lightspeed 16 or VCT-64, GE Medical Systems, Milwaukee, Wisconsin) scanner. A volume data set was acquired for the 16-slice MSCT (collimation 12 ⫻ 0.75 mm, gantry rotation time 420 ms, table feed 2.8 mm/rotation, tube voltage 120 kV) scan and the 64-slice MSCT (collimation 64 ⫻ 0.625 mm, gantry rotation time 350 ms, table feed 9.6 mm/rotation, tube voltage 120 kV) scan, covering the distance from the carina to the diaphragm, with retrospective electrocardiographic gating for image reconstruction. Nonionic contrast (approximately 100 to 120 ml) was injected at a rate of 3 to 4 ml/s. Images were reconstructed with a slice thickness of 0.625 mm. All of the scans were successful in acquiring the images. With the aid of 3-dimensional volume rendering, 6 anomalous right coronary arteries, 4 anomalous left circumflex coronary arteries, 4 single coronary arteries, and 2 anomalous left main coronary arteries were all clearly defined with regard to their origins and courses (Table 1). Examples of the anomalies are shown in Figures 1 to 5. Patients 1 to 4 and 8 underwent coronary artery bypass grafting. Although the proximal courses of the anomalous right coronary arteries of patients 5 to 7 were between the aorta and the pulmonary trunk, none had objective signs of myocardial ischemia. Therefore, a revascularization procedure was not recommended. Patient 11 was noted to have significant atherosclerosis of the anomalous circumflex and the native left anterior descending coronary artery, and therefore coronary artery bypass grafting was recommended. Patient 12 underwent percutaneous coronary intervention for a narrowed right coronary artery. Two of the 4 patients with single coronary arteries (patients 13 and 14) underwent coronary artery bypass grafting for significant multivessel coronary artery disease. ••• www.AJConline.org
Congenital Heart Disease/CTCA for Coronary Anomalies
403
Figure 1. Three-dimensional volume-rendered image (A) and axial image (B) from patient 8’s MSCT scan showing the origin and interarterial course of the anomalous right coronary artery (RCA) from the left sinus of Valsalva (LSV). Using 3-dimensional rendering, the slitlike ostium of the anomalous RCA, ⬎ and its relation to the left main (LM) coronary artery, is shown from inside the aorta (AO) (C, D). PA ⫽ pulmonary artery; RSV ⫽ right sinus of Valsalva.
Figure 2. Patient 9’s anomalous circumflex artery originating from the right sinus of Valsalva is shown by conventional coronary angiography (A), an axial image (B), and 3-dimensional rendering (C). LCCA ⫽ left circumflex coronary artery; RCA ⫽ right coronary artery.
Figure 3. Patient 13’s single coronary artery is shown originating from the right sinus of Valsalva and branching into the left (arrow) and right (arrowhead) coronary arteries. Conventional angiography (A), axial images (B), and 3-dimensional rendering (C) are shown.
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The American Journal of Cardiology (www.AJConline.org)
Figure 4. Patient 14’s single coronary artery is shown by conventional angiography (A), a 3-dimensional volume-rendered model with the pulmonary trunk removed (B), and an axial image (C) showing the origin (black arrow) and course between the great vessels (white arrow). The bifurcation of the single coronary artery is shown (D) with a view from inside the ostium. LM ⫽ left main; RCA ⫽ right coronary artery.
Figure 5. Patient 15’s single coronary artery is shown by conventional cine angiography (A, B), a 3-dimensional reconstruction with the pulmonary trunk removed (C), and an axial image showing the origin of the single coronary artery from the left sinus of Valsalva and the proximal course of the right coronary artery (RCA) between the aorta (AO) and the pulmonary artery (PA) (D). LA ⫽ left atrium; LAD ⫽ left anterior descending; LCCA ⫽ left circumflex coronary artery; OM ⫽ obtuse marginal.
Congenital Heart Disease/CTCA for Coronary Anomalies
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Table 1 Clinical information of 16 patients who underwent multislice computed tomographic scans with anomalous coronary arteries Patient No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Age (yrs)/Sex
Coronary Artery Narrowed ⬎50% (No. Narrowed)
Substernal Chest Pain
Coronary Anomaly
57 F 63 M 49 M 53 F 53 M 55 F 56 F 67 F 40 M 51 F 54 F 72 F 58 F 66 M 67 F 71 M
0 0 0 0 0 0 0 ⫹ (2) 0 0 ⫹ (2) ⫹ (1) ⫹ (2) ⫹ (3) 0 ⫹ (1)
⫹ ⫹ ⫹ 0 ⫹ ⫹ 0 ⫹ ⫹ ⫹ ⫹ ⫹ ⫹ ⫹ ⫹ ⫹
LMCA from RSV LMCA from RSV RCA from LSV RCA from LSV RCA from LSV RCA from LSV RCA from LSV RCA from LSV LCCA from RSV LCCA from RCA LCCA from RSV LCCA from RCA SCA from RSV SCA from RSV SCA from LSV SCA from RSV
Course of Anomalous Artery Between PT Between PT Between PT Between PT Between PT Between PT Between PT Between PT Retroaortic Retroaortic Retroaortic Retroaortic Between PT Between PT Between PT Between PT
and and and and and and and and
aorta aorta aorta aorta aorta aorta aorta aorta
and and and and
aorta aorta aorta aorta
Revascularization (Type) ⫹ (CABG) ⫹ (CABG) ⫹ (CABG) ⫹ (CABG) 0 0 0 ⫹ (CABG) 0 0 ⫹ (CABG) ⫹ (PCI) ⫹ (CABG) ⫹ (CABG) 0 ⫹ (PCI)
⫹ ⫽ present; 0 ⫽ not present; CABG ⫽ coronary artery bypass grafting; LCCA ⫽ left circumflex coronary artery; LMCA ⫽ left main coronary artery; LSV ⫽ left sinus of Valsalva; PT ⫽ pulmonary trunk; PCI ⫽ percutaneous coronary intervention; RCA ⫽ right coronary artery; RSV ⫽ right sinus of Valsalva; SCA ⫽ single coronary artery.
We performed our early studies using 16-slice MSCT scanners and our later studies using 64-slice MSCT scanners to evaluate the patients in this case series. With an increase in the number of detector arrays, current MSCT scanners allow a decrease in scan time, dramatically improving the temporal resolution of a single scan.5 The patients in the present series provide examples of how CTCA can complement coronary angiography in defining the courses of several different anomalous coronary arteries. Establishing the proximal courses of these anomalous coronary arteries is of particular importance in determining whether surgical correction is needed.4 Cardiac catheterization findings, once considered the “gold standard” for the evaluation of coronary artery pathology, were inconclusive. Ultimately, the origins and courses of these anomalies were defined by CTCA. Although this has been described previously,7–15 we offer our case series as additional validation of CTCA, and we propose that noninvasive coronary angiography by MSCT scanning is the new gold standard for the evaluation of anomalous coronary arteries. In the future, CTCA may be a key component of a yet-to-be-determined screening algorithm for patients suspected to have “high-risk” coronary artery anomalies, including those in whom anomalous coronary arteries have acute bends and courses between the pulmonary trunk and aorta. In young patients presenting with exertional syncope, angina, or sudden cardiac death, many authorities would suggest performing invasive coronary angiography.16 –18 Given its low risk, noninvasive nature, and accuracy in identifying the relation of the coronary arteries to surrounding structures, we propose that CTCA is the test of choice in this clinical situation and that it could become part of the routine evaluation of such patients.
1. Angelini P, Velasco JA, Flamm S. Coronary anomalies: incidence, pathophysiology, and clinical relevance. Circulation 2002;105:2449 –2454. 2. Maron BJ. Sudden death in young athletes. N Engl J Med 2003;349: 1064 –1075. 3. Maron BJ, Epstein SE, Roberts WC. Causes of sudden death in competitive athletes. J Am Coll Cardiol 1986;7:204 –214. 4. Serota H, Barth CW III, Seuc CA, Vandormael M, Aguirre F, Kern MJ. Rapid identification of the course of anomalous coronary arteries in adults: the “dot and eye” method. Am J Cardiol 1990;65:891– 898. 5. Rodenwaldt J. Multislice computed tomography of the coronary arteries. Eur Radiol 2003;13:748 –757. 6. Schussler JM, Dockery WD, Moore TR, Johnson KB, Rosenthal RL, Stoler RC. Computed tomographic coronary angiography: experience at Baylor University Medical Center/Baylor Jack and Jane Hamilton Heart and Vascular Hospital. Proc Bayl Univ Med Cent 2005;18:228 –233. 7. Barriales-Villa R, Moris C. Usefulness of helical computed tomography in the identification of the initial course of coronary anomalies. Am J Cardiol 2001;88:719. 8. Cademartiri F, Mollet N, Nieman K, Szili-Torok T, de Feyter PJ. Images in cardiovascular medicine. Right coronary artery arising from the left circumflex demonstrated with multislice computed tomography. Circulation 2004;109:e185– e186. 9. Cademartiri F, Nieman K, Raaymakers RH, de Feyter PJ, Flohr T, Alfieri O, Krestin GP. Non-invasive demonstration of coronary artery anomaly performed using 16-slice multidetector spiral computed tomography. Ital Heart J 2003;4:56 –59. 10. Datta J, White CS, Gilkeson RC, Meyer CA, Kansal S, Jani ML, Arildsen RC, Read K. Anomalous coronary arteries in adults: depiction at multi-detector row CT angiography. Radiology 2005;235:812– 818. 11. Deibler AR, Kuzo RS, Vohringer M, Page EE, Safford RE, Patron JN, Lane GE, Morin RL, Gerber TC. Imaging of congenital coronary anomalies with multislice computed tomography. Mayo Clin Proc 2004;79:1017–1023. 12. Dirksen MS, Bax JJ, Blom NA, Schalij MJ, Jukema WJ, Vliegen HW, van der Wall EE, de Roos A, Lamb HJ. Detection of malignant right coronary artery anomaly by multi-slice CT coronary angiography. Eur Radiol 2002;12(suppl):S177–S180. 13. Horisaki T, Yamashita T, Yokoyama H, Urasawa K, Kitabatake A. Three-dimensional reconstruction of computed tomographic images of
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The American Journal of Cardiology (www.AJConline.org)
anomalous origin of the left main coronary artery from the pulmonary trunk in an adult. Am J Cardiol 2003;92:898 – 899. 14. Jessurun GA, Willemsen MH, Vercoutere RA, Boonstra PW, Tio RA. Single coronary artery: a reappraisal. J Invasive Cardiol 2004; 16:40 – 41. 15. van Ooijen PM, Dorgelo J, Zijlstra F, Oudkerk M. Detection, visualization and evaluation of anomalous coronary anatomy on 16-slice multidetector-row CT. Eur Radiol 2004;14:2163–2171.
16. Angelini P. Coronary artery anomalies— current clinical issues: definitions, classification, incidence, clinical relevance, and treatment guidelines. Tex Heart Inst J 2002;29:271–278. 17. Bader RS, Goldberg L, Sahn DJ. Risk of sudden cardiac death in young athletes: which screening strategies are appropriate? Pediatr Clin North Am 2004;51:1421–1441. 18. Basso C, Corrado D, Thiene G. Coronary artery anomalies and sudden death. Card Electrophysiol Rev 2002;6:107–111.
We retrospectively reviewed the clinical data and imaging studies of 16 patients who underwent CTCA from May 2003 to October 2005 specifically for the purpose of evaluating anomalous coronary arteries. In these 16 patients, CTCA was requested by cardiologists after invasive coronary angiograms suggested the presence of coronary artery anomalies. The patients’ clinical data with regard to presenting symptoms, their respective anomalies (origins and proximal courses), and ultimate therapy are listed in Table 1. All of the studies were completed at our institution with
a
Department of Internal Medicine, Division of Cardiovascular Diseases, and bDepartment of Radiology, Baylor University Medical Center/ Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas. Manuscript received November 21, 2005; revised manuscript received and accepted February 1, 2006. * Corresponding author: Tel: 214-841-2030; fax: 214-841-2015. E-mail address: [email protected] (J.M. Schussler). 0002-9149/06/$ – see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.amjcard.2006.02.046
either a 16-slice (8 patients) or a 64-slice (8 patients) MSCT (Lightspeed 16 or VCT-64, GE Medical Systems, Milwaukee, Wisconsin) scanner. A volume data set was acquired for the 16-slice MSCT (collimation 12 ⫻ 0.75 mm, gantry rotation time 420 ms, table feed 2.8 mm/rotation, tube voltage 120 kV) scan and the 64-slice MSCT (collimation 64 ⫻ 0.625 mm, gantry rotation time 350 ms, table feed 9.6 mm/rotation, tube voltage 120 kV) scan, covering the distance from the carina to the diaphragm, with retrospective electrocardiographic gating for image reconstruction. Nonionic contrast (approximately 100 to 120 ml) was injected at a rate of 3 to 4 ml/s. Images were reconstructed with a slice thickness of 0.625 mm. All of the scans were successful in acquiring the images. With the aid of 3-dimensional volume rendering, 6 anomalous right coronary arteries, 4 anomalous left circumflex coronary arteries, 4 single coronary arteries, and 2 anomalous left main coronary arteries were all clearly defined with regard to their origins and courses (Table 1). Examples of the anomalies are shown in Figures 1 to 5. Patients 1 to 4 and 8 underwent coronary artery bypass grafting. Although the proximal courses of the anomalous right coronary arteries of patients 5 to 7 were between the aorta and the pulmonary trunk, none had objective signs of myocardial ischemia. Therefore, a revascularization procedure was not recommended. Patient 11 was noted to have significant atherosclerosis of the anomalous circumflex and the native left anterior descending coronary artery, and therefore coronary artery bypass grafting was recommended. Patient 12 underwent percutaneous coronary intervention for a narrowed right coronary artery. Two of the 4 patients with single coronary arteries (patients 13 and 14) underwent coronary artery bypass grafting for significant multivessel coronary artery disease. ••• www.AJConline.org
Congenital Heart Disease/CTCA for Coronary Anomalies
403
Figure 1. Three-dimensional volume-rendered image (A) and axial image (B) from patient 8’s MSCT scan showing the origin and interarterial course of the anomalous right coronary artery (RCA) from the left sinus of Valsalva (LSV). Using 3-dimensional rendering, the slitlike ostium of the anomalous RCA, ⬎ and its relation to the left main (LM) coronary artery, is shown from inside the aorta (AO) (C, D). PA ⫽ pulmonary artery; RSV ⫽ right sinus of Valsalva.
Figure 2. Patient 9’s anomalous circumflex artery originating from the right sinus of Valsalva is shown by conventional coronary angiography (A), an axial image (B), and 3-dimensional rendering (C). LCCA ⫽ left circumflex coronary artery; RCA ⫽ right coronary artery.
Figure 3. Patient 13’s single coronary artery is shown originating from the right sinus of Valsalva and branching into the left (arrow) and right (arrowhead) coronary arteries. Conventional angiography (A), axial images (B), and 3-dimensional rendering (C) are shown.
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The American Journal of Cardiology (www.AJConline.org)
Figure 4. Patient 14’s single coronary artery is shown by conventional angiography (A), a 3-dimensional volume-rendered model with the pulmonary trunk removed (B), and an axial image (C) showing the origin (black arrow) and course between the great vessels (white arrow). The bifurcation of the single coronary artery is shown (D) with a view from inside the ostium. LM ⫽ left main; RCA ⫽ right coronary artery.
Figure 5. Patient 15’s single coronary artery is shown by conventional cine angiography (A, B), a 3-dimensional reconstruction with the pulmonary trunk removed (C), and an axial image showing the origin of the single coronary artery from the left sinus of Valsalva and the proximal course of the right coronary artery (RCA) between the aorta (AO) and the pulmonary artery (PA) (D). LA ⫽ left atrium; LAD ⫽ left anterior descending; LCCA ⫽ left circumflex coronary artery; OM ⫽ obtuse marginal.
Congenital Heart Disease/CTCA for Coronary Anomalies
405
Table 1 Clinical information of 16 patients who underwent multislice computed tomographic scans with anomalous coronary arteries Patient No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Age (yrs)/Sex
Coronary Artery Narrowed ⬎50% (No. Narrowed)
Substernal Chest Pain
Coronary Anomaly
57 F 63 M 49 M 53 F 53 M 55 F 56 F 67 F 40 M 51 F 54 F 72 F 58 F 66 M 67 F 71 M
0 0 0 0 0 0 0 ⫹ (2) 0 0 ⫹ (2) ⫹ (1) ⫹ (2) ⫹ (3) 0 ⫹ (1)
⫹ ⫹ ⫹ 0 ⫹ ⫹ 0 ⫹ ⫹ ⫹ ⫹ ⫹ ⫹ ⫹ ⫹ ⫹
LMCA from RSV LMCA from RSV RCA from LSV RCA from LSV RCA from LSV RCA from LSV RCA from LSV RCA from LSV LCCA from RSV LCCA from RCA LCCA from RSV LCCA from RCA SCA from RSV SCA from RSV SCA from LSV SCA from RSV
Course of Anomalous Artery Between PT Between PT Between PT Between PT Between PT Between PT Between PT Between PT Retroaortic Retroaortic Retroaortic Retroaortic Between PT Between PT Between PT Between PT
and and and and and and and and
aorta aorta aorta aorta aorta aorta aorta aorta
and and and and
aorta aorta aorta aorta
Revascularization (Type) ⫹ (CABG) ⫹ (CABG) ⫹ (CABG) ⫹ (CABG) 0 0 0 ⫹ (CABG) 0 0 ⫹ (CABG) ⫹ (PCI) ⫹ (CABG) ⫹ (CABG) 0 ⫹ (PCI)
⫹ ⫽ present; 0 ⫽ not present; CABG ⫽ coronary artery bypass grafting; LCCA ⫽ left circumflex coronary artery; LMCA ⫽ left main coronary artery; LSV ⫽ left sinus of Valsalva; PT ⫽ pulmonary trunk; PCI ⫽ percutaneous coronary intervention; RCA ⫽ right coronary artery; RSV ⫽ right sinus of Valsalva; SCA ⫽ single coronary artery.
We performed our early studies using 16-slice MSCT scanners and our later studies using 64-slice MSCT scanners to evaluate the patients in this case series. With an increase in the number of detector arrays, current MSCT scanners allow a decrease in scan time, dramatically improving the temporal resolution of a single scan.5 The patients in the present series provide examples of how CTCA can complement coronary angiography in defining the courses of several different anomalous coronary arteries. Establishing the proximal courses of these anomalous coronary arteries is of particular importance in determining whether surgical correction is needed.4 Cardiac catheterization findings, once considered the “gold standard” for the evaluation of coronary artery pathology, were inconclusive. Ultimately, the origins and courses of these anomalies were defined by CTCA. Although this has been described previously,7–15 we offer our case series as additional validation of CTCA, and we propose that noninvasive coronary angiography by MSCT scanning is the new gold standard for the evaluation of anomalous coronary arteries. In the future, CTCA may be a key component of a yet-to-be-determined screening algorithm for patients suspected to have “high-risk” coronary artery anomalies, including those in whom anomalous coronary arteries have acute bends and courses between the pulmonary trunk and aorta. In young patients presenting with exertional syncope, angina, or sudden cardiac death, many authorities would suggest performing invasive coronary angiography.16 –18 Given its low risk, noninvasive nature, and accuracy in identifying the relation of the coronary arteries to surrounding structures, we propose that CTCA is the test of choice in this clinical situation and that it could become part of the routine evaluation of such patients.
1. Angelini P, Velasco JA, Flamm S. Coronary anomalies: incidence, pathophysiology, and clinical relevance. Circulation 2002;105:2449 –2454. 2. Maron BJ. Sudden death in young athletes. N Engl J Med 2003;349: 1064 –1075. 3. Maron BJ, Epstein SE, Roberts WC. Causes of sudden death in competitive athletes. J Am Coll Cardiol 1986;7:204 –214. 4. Serota H, Barth CW III, Seuc CA, Vandormael M, Aguirre F, Kern MJ. Rapid identification of the course of anomalous coronary arteries in adults: the “dot and eye” method. Am J Cardiol 1990;65:891– 898. 5. Rodenwaldt J. Multislice computed tomography of the coronary arteries. Eur Radiol 2003;13:748 –757. 6. Schussler JM, Dockery WD, Moore TR, Johnson KB, Rosenthal RL, Stoler RC. Computed tomographic coronary angiography: experience at Baylor University Medical Center/Baylor Jack and Jane Hamilton Heart and Vascular Hospital. Proc Bayl Univ Med Cent 2005;18:228 –233. 7. Barriales-Villa R, Moris C. Usefulness of helical computed tomography in the identification of the initial course of coronary anomalies. Am J Cardiol 2001;88:719. 8. Cademartiri F, Mollet N, Nieman K, Szili-Torok T, de Feyter PJ. Images in cardiovascular medicine. Right coronary artery arising from the left circumflex demonstrated with multislice computed tomography. Circulation 2004;109:e185– e186. 9. Cademartiri F, Nieman K, Raaymakers RH, de Feyter PJ, Flohr T, Alfieri O, Krestin GP. Non-invasive demonstration of coronary artery anomaly performed using 16-slice multidetector spiral computed tomography. Ital Heart J 2003;4:56 –59. 10. Datta J, White CS, Gilkeson RC, Meyer CA, Kansal S, Jani ML, Arildsen RC, Read K. Anomalous coronary arteries in adults: depiction at multi-detector row CT angiography. Radiology 2005;235:812– 818. 11. Deibler AR, Kuzo RS, Vohringer M, Page EE, Safford RE, Patron JN, Lane GE, Morin RL, Gerber TC. Imaging of congenital coronary anomalies with multislice computed tomography. Mayo Clin Proc 2004;79:1017–1023. 12. Dirksen MS, Bax JJ, Blom NA, Schalij MJ, Jukema WJ, Vliegen HW, van der Wall EE, de Roos A, Lamb HJ. Detection of malignant right coronary artery anomaly by multi-slice CT coronary angiography. Eur Radiol 2002;12(suppl):S177–S180. 13. Horisaki T, Yamashita T, Yokoyama H, Urasawa K, Kitabatake A. Three-dimensional reconstruction of computed tomographic images of
406
The American Journal of Cardiology (www.AJConline.org)
anomalous origin of the left main coronary artery from the pulmonary trunk in an adult. Am J Cardiol 2003;92:898 – 899. 14. Jessurun GA, Willemsen MH, Vercoutere RA, Boonstra PW, Tio RA. Single coronary artery: a reappraisal. J Invasive Cardiol 2004; 16:40 – 41. 15. van Ooijen PM, Dorgelo J, Zijlstra F, Oudkerk M. Detection, visualization and evaluation of anomalous coronary anatomy on 16-slice multidetector-row CT. Eur Radiol 2004;14:2163–2171.
16. Angelini P. Coronary artery anomalies— current clinical issues: definitions, classification, incidence, clinical relevance, and treatment guidelines. Tex Heart Inst J 2002;29:271–278. 17. Bader RS, Goldberg L, Sahn DJ. Risk of sudden cardiac death in young athletes: which screening strategies are appropriate? Pediatr Clin North Am 2004;51:1421–1441. 18. Basso C, Corrado D, Thiene G. Coronary artery anomalies and sudden death. Card Electrophysiol Rev 2002;6:107–111.