Diagnostic performance of coronary computed tomography angiography stenosis score for coronary stenosis.

BACKGROUND: Coronary computed tomography angiography stenosis score (CCTA-SS) is a proposed diagnosis score that considers the plaque characteristics, myocardial function, and the diameter reduction rate of the lesions. This study aimed to evaluate the diagnostic performance of the CCTA-SS in seeking coronary artery disease (CAD). METHODS: The 228 patients with suspected CAD who underwent CCTA and invasive coronary angiography (ICA) procedures were under examination. The diagnostic performance was evaluated with the receiver operating curve (ROC) for CCTA-SS in detecting CAD (defined as a diameter reduction of ≥ 50%) and severe CAD (defined as a diameter reduction of ≥ 70%). RESULTS: The area under ROC (AUC) of CCTA-SS was 0.909 (95% CI: 0.864-0.943), which was significantly higher than that of CCTA (AUC: 0.826; 95% CI: 0.771-0.873; P = 0.0352) in diagnosing of CAD with a threshold of 50%. The optimal cutoff point of CCTA-SS was 51% with a sensitivity of 90.66%, specificity of 95.65%, positive predictive value of 98.80%, negative predictive value of 72.13%, and accuracy of 91.67%, whereas the optimal cutoff point of CCTA was 55%, and the corresponding values were 87.36%, 93.48%, 98.15%, 65.15%, and 88.60%, respectively. With a threshold of 70%, the performance of CCTA-SS with an AUC of 0.927 (95% CI: 0.885-0.957) was significantly higher than that of CCTA with an AUC of 0.521 (95% CI: 0.454-0.587) (P < 0.0001). CONCLUSIONS: CCTA-SS significantly improved the diagnostic accuracy of coronary stenosis, including CAD and severe CAD, compared with CCTA.

A rare coronary anomaly: The single left coronary artery with coronary artery fistula draining into the right ventricular outflow tract.

A previously healthy 9-year-old girl was referred to us for the evaluation of a murmur on a routine clinical examination. Routine electrocardiogram and chest x-ray were normal. The cardiac enzymes were normal. Combining ultrasound and CCTA, it was confirmed that the hemodynamics of the heart was a left-to-right shunt and that RVOT stole blood from the left ventricle through the single coronary artery (SCA).

A hitherto unreported combination of pulmonary stenosis, single coronary artery anomaly, and coronary sinus to left atrial communication.

BACKGROUND: We report a hitherto unreported combination of pulmonary stenosis, single coronary artery anomaly and coronary sinus to left atrial communication. Our case highlights the important value of coronary computed tomographic angiography and transthoracic echocardiography for the diagnosis of such anomalies and guidance for proper management. METHODS AND RESULTS: A 64-year-old male presented chest tightness and shortness of breath for 2 days. Transthoracic echocardiography revealed a thickened pulmonary valve leaflet and subvalvular outflow tract stenosis, colour flow Doppler showed a significant accelerated blood flow in the pulmonary artery cavity originating from the subvalvular outflow tract, continuous wave Doppler revealed the transpulmonary valvular pressure gradient of 63mmHg. Computed tomographic angiography image reveals thickened pulmonary valve leaflets and subvalvular outflow tract stenosis, single coronary artery anomaly and levoatriocardinal vein. The patient underwent percutaneous pulmonary valve balloon dilatation, the post-procedural course was uneventful. DISCUSSION: Pulmonary stenosis can occur as part of more congenital cardiac malformations or as rare primary isolated pulmonary stenosis, which includes the valvular, sub-valvular, or supra-valvular pulmonary stenosis. Single coronary artery anomalies are very rare, anomalous right coronary artery originates from proximal to mid-left anterior descending coronary artery is one such single coronary artery anomaly, in most cases, it is asymptomatic, diagnosed incidentally, and a benign entity has a better prognosis except if the right coronary artery is passing between the aorta and pulmonary artery. This course of the right coronary artery anomaly is malignant. Coronary sinus to left atrial communication includes a direct or indirect communication. The direct communication is described as a partial or complete absence of the roof between the coronary sinus and left atrium, as it is well known as the unroofed coronary sinus syndrome. The indirect communication is an anomalous bridging vein communicating the coronary sinus to the left atrium, which can be distinguished from classical unroofed coronary sinus syndrome. The venous collateral channel communication between the coronary sinus to the left atrium by a bridging vein is also categorized as a variant type of unroofed coronary sinus syndrome. Understanding coronary venous variations has significant clinical implications particularly in the realm of electrophysiology. The anatomical variations can have important consequences for procedures such as biventricular pacing and trans-coronary vein ablations. CONCLUSION: Pulmonary stenosis combined with single coronary artery anomaly and bridging vein communication between the coronary sinus and the left atrium is an extremely rare. Coronary computed tomographic angiography and transthoracic echocardiographyplay an important role the diagnosis of such anomalies and guidance for clinical Treatment.

A rare congenital anomaly: Anomalous fibromuscular cord of the left atrium.

BACKGROUND: Left atrial anomalous fibromuscular cord is a rare congenital anomaly, which exists in a small proportion of the general population. Although its clinical significance remains largely unknown, it is generally considered a benign entity. We report a case of incidental finding of left atrial fibromuscular cord without structural cardiac abnormalities or hemodynamic obstruction. METHODS AND RESULTS: A-39-year-old female presented with palpitations for more than 10 years. Electrocardiogram and laboratory tests showed no unremarkable. Transthoracic echocardiography revealed an abnormal linear structure connecting the interatrial septum and the left atrial free wall, color Doppler flow imaging did not show hemodynamic obstruction. Cardiac contrast-enhanced computed tomography images showed the string-like structure associated with calcification, connecting the interatrial septum and the ridge around the orifice of the left inferior pulmonary vein. Sagittal multiplanar reconstructed image showed a dot-like structure located in the left atrial cavity. DISCUSSION: Left atrial anomalous fibromuscular cord is a rare congenital anomaly, which is also known as left atrial anomalous fibromuscular cord, left atrial false tendon, accessory chordae tendineae, or left atrial aberrant band. The clinical significance is unclear. Some cases have been reported that the fibromuscular cord, which do not have pathological significance. It has also been reported that it may be associated with supraventricular arrhythmias, patent foramen ovale, and Chiai's network. In some patients, attachment to the mitral chord can lead to mitral valve insufficiency and murmur. Nevertheless, a detailed understanding the anomalous anatomical characteristics of the anomalous cord may help us to better predict an unexpected difficulty in catheter manipulation, and potential arrhythmogenicity. CONCLUSION: Transthoracic echocardiography and cardiac computed tomography angiography have an important imaging value for the diagnosis of the left atrial anomalous fibromuscular cord, including its origin, course, or whether associated with other cardiovascular malformations.

An aberrant draining of the anterior interventricular part of the great cardiac vein into the superior vena cava.

BACKGROUND: Abnormalities in drainage of the great cardiac vein (GCV) are interesting due to its rarity and likely to be underreported, with most cases found incidentally in cardiac imaging and autopsy studies. We report a case with anomalous drainage of the GCV into the LA, and the rest of the cardiac veins are draining normally. METHODS AND RESULTS: A 60-year-old male presented with heart palpitations for half a month. Electrocardiogram and laboratory tests showed no abnormalities. He was recommended for coronary computed tomography angiography (CCTA). The maximum intensity projection image of CCTA showed that the GCV draining into the left atrium, the rest of the cardiac veins, and coronary vein sinus were draining into the right atrium normally. Volume-rendered image of coronary CT angiography showed that the GCV originated in the upper third of the anterior interventricular sulcus and drained directly into the left atrium. DISCUSSION: Abnormalities in drainage of the GCV are interesting due to its rarity and likely to be underreported. Only a few cases have been reported that the aberrant drainage of the GCV, with draining into the anterior cardiac veins, the left internal thoracic vein, the superior vena cava, the right atrium, and the LA. The abnormality of GCV is an often neglected aspect of CCTA imaging, it can be better displayed in the venous phase of coronary catheter angiography. The awareness of which may be critically important for procedures that require venous access such as coronary surgery requiring retrograde cardioplegia, surgical ablation of aberrant conducting pathways, pacemaker insertion, and valves surgery. CONCLUSION: This variant of the GCV is interesting due to its rarity. CCTA has important diagnostic imaging value in abnormalities of the origin, course, and termination of the GCVs, the variant can be better displayed in the venous phase of coronary catheter angiography.

A rare variant of the great cardiac vein draining directly into the left atrium.

BACKGROUND: Abnormalities in drainage of the GCV are interesting due to its rarity and likely to be underreported, with most cases found incidentally in cardiac imaging and autopsy studies.We report a case with anomalous drainage of the GCV into the LA, and the rest of the cardiac veins are draining normally. METHODS AND RESULTS: A 60-year-old male presented with heart palpitations for half a month. Electrocardiogram and laboratory tests showed no abnormalities. He was recommended for coronary computed tomography angiography (CCTA). The maximum intensity projection image of CCTA showed that the great cardiac vein draining into the left atrium, the rest of the cardiac veins and coronary vein sinus were draining into the right atrium normally. Volume-rendered image of coronary CT angiography showed that the GCV originated in the upper third of the anterior interventricular sulcus and drained directly into the left atrium. DISCUSSION: Abnormalities in drainage of the GCV are interesting due to its rarity and likely to be underreported. Only a few cases have been reported that the aberrant drainage of the GCV, with draining into the anterior cardiac veins, the left internal thoracic vein, the superior vena cava, the right atrium, and the LA. The abnormality of GCV is an often neglected aspect of CCTA imaging, it can be better displayed in the venous phase of coronary catheter angiography. The awareness of which may be critically important for procedures that require venous access such as coronary surgery requiring retrograde cardioplegia, surgical ablation of aberrant conducting pathways, pacemaker insertion, and valves surgery. CONCLUSION: CCTA has important diagnostic imaging value in abnormalities of the origin, course and termination of the great cardiac veins, the awareness of which may be critically important for procedures that require venous access.

An abscess of mitral aortic intervalvular fibrosa mimicking an intracardiac mass.

BACKGROUND: Abscess of the mitral-aortic intervalvular fibrosa (MAIVF) is a rare occurrence, with its most frequently described causative associations being active or prior endocarditis, prosthetic valves, or native valves with anomalies. We report a case of infective endocarditis (IE) complicated by an abscess of the MAIVF without valvular involvement. This case highlights the importance of this rare clinical entity and of the multimodality imaging approach in reaching an accurate diagnosis and differential diagnosis. METHODS AND RESULTS: A 35-year-old male presented with fatigue and intermittent high-grade fever for a 2-week duration. IE was suspected based on a clinical exam. Transthoracic echocardiography (TTE) demonstrated heterogeneous mass with a size of about 2.9 cm × 2.3 cm coming from the MAIVF, mimicking an intracardiac mass. Color Doppler flow Imaging showed the mass without communication with the surrounding cardiovascular cavities. Cardiac computed tomography angiography (CCTA) revealed a large low-density mass without any enhancement, which was situated adjacent to the left ventricular tract with a severely compressed left atrial chamber. The patient underwent cardiac mass removal under extracorporeal circulation. During the procedure, a large abscess was found to be located in MAIVF. The postoperative course was uneventful. DISCUSSION: The abscess of MAIVF is a rare entity with a high risk of developing the pseudoaneurysm of MAIVF (p-MAIVF). The periaortic spread of the abscess is a dynamic process in which the inflammation of the deep tissue causes, in the first stage, a MAIVF thickening, which eventually progresses with the formation of an abscess, and subsequently, a pseudoaneurysm. Complications of p-MAIVF include rupture into the left atrium, aorta, or pericardial space leading to hemopericardium, tamponade, and death. The major differential diagnosis for abscess of MAIVF includes p-MAIVF an intracardiac mass. TTE plays a key role in the diagnosis and differential diagnosis of abscesses of MAIVF. CCTA can be a useful adjunct to further characterize abscess spread, three-dimensional spatial relationships with other cardiac structures for preoperative planning, as well as in the evaluation of potential complications such as coronary artery compromise and communication with the aorta, left atrium, or pericardial space. Surgical management is recommended in complicated, symptomatic patients to prevent further expansion of abscesses or pseudoaneurysms. CONCLUSION: The abscess of MAIVF is a rare complication of endocarditis and surgical trauma in the MAIVF area, TTE remains a first-line imaging modality for clinically suspected periaortic abscess or other IE complications. CCTA has a complementary role to echocardiography in identification, characterization, and preoperative planning.

A rare unclassified coronary anomaly: Right coronary artery with dual ostia origin from the right aortic sinus of Valsalva.

BACKGROUND: The dual ostia of coronary artery is extremely rare entity. We present a case of old woman with right coronary artery with dual ostia origin from the right aortic sinus of Valsalva. METHODS AND RESULTS: A 52-year-old woman presented with discontinuous chest tightness and palpitation. she was referred to coronary computed tomography angiography (CCTA). The CCTA suggested an anomalous right coronary artery (RCA) origin from the right sinus of Valsalva (RSV) with dual ostia. DISCUSSION: The dual ostia of coronary anomaly is extremely rare entity. Though catheter angiography may be performed for preoperative identification of coronary anomalies, it is limited in the description of the relationship of the coronary arteries to the cardiac structures and great vessels. CCTA can help in noninvasive characterization of coronary anomalies with respect to their origin, course, and spatial relations. Interventional cardiologists and cardiac surgeons should be aware of the new coronary anomaly for appropriate procedural planning and intra-procedural management. CONCLUSION: The important imaging valueof CCTA can help in noninvasive characterization of coronary anomalies with respect to their origin, course, and spatial relations.

A newly described variation of normal coronary: Dual origin of the circumflex artery from the main stem of the left coronary artery.

BACKGROUND: The dual origin of the circumflex artery from the main stem of the left coronary artery is rare variation of normal coronary, which is not reported in previous literature. We report a case of old man with the dual origin of the circumflex artery from the main stem of the left coronary artery. METHODS AND RESULTS: A 58-year-old man presented with chest pain and dyspnea. The echocardiogram and Laboratory examination are no obvious abnormalities. He was referred to coronary computed tomography angiography (CCTA). The CCTA showed the proximal circumflex artery forming a Y-shaped bifurcation with the dual origin of the main stem of the left coronary artery. DISCUSSION: The dual origin of the circumflex artery is extremely rare variation of normal coronary. Though catheter angiography may be performed for preoperative identification of various coronary artery, it is limited in the description of the relationship of the coronary arteries to the cardiac structures and great vessels. CCTA can help in noninvasive characterization of coronary anomalies with respect to their origin, course, and spatial relations. The preoperative findings of various coronary artery are very important for achieving an accurate diagnosis and formulating the appropriate procedural planning and intraprocedural management. CONCLUSION: CCTA findings of various CAAs are is important for achieving an accurate diagnosis and formulating the appropriate procedural planning and intraprocedural management.

A rare pulmonary-to-systemic venous connection associated with the partially anomalous pulmonary venous connection.

BACKGROUND: We report an extremely rare case of pulmonary-to-systemic venous connection associated with the partially anomalous pulmonary venous connection. Our case highlights that computed tomography angiography has a significant diagnostic and differential value for this rare anomaly. METHODS AND RESULTS: A 32-year-old male presented with chest discomfort for 2 weeks. The electrocardiogram and laboratory were unremarkable abnormalities. Transthoracic echocardiography suggested an enlargement of the right atrium and right ventricle. Cardiac computed tomography angiography images showed partial anomalous drainage of the right superior pulmonary vein into the superior caval vein, and a large pulmonary-to-systemic venous connection from the right middle pulmonary vein into the superior vena cava resulting in left atrial to systemic venous shunt. The patient underwent a successful thoracoscopic correction of partially anomalous pulmonary venous connection. Post-procedural course was uneventful, and he was discharged after 7 days. DISCUSSION: Pulmonary-to-systemic venous connection may also be called a levoatriocardinal vein. The embryological origin of this venous connection is an abnormal persistency of the splanchnic plexus connecting the pulmonary venous plexus and the cardinal system. The diagnosis of these rare types of the pulmonary to systemic communications has important clinical implications. We report an extremely rare case with pulmonary-to-systemic venous connection from the right middle pulmonary vein into the superior caval vein, although the connection might have been considered a levoatriocardinal vein, there is no separate formation of the right middle pulmonary vein at the time of existence of the splanchnic plexus, so it is inappropriate to explain the collateral channel encountered in our patient on the basis of an embryological remnant, a more appropriate term for these anomalies would be a "pulmonary-to-systemic collateral vein". Because the venous collateral pathway may be a source of the persistent left-to-right shunt and cause clinical manifestations of chronic right heart volume overload later in life. Therefore, we have performed successful thoracoscopic correction of partial anomalous pulmonary venous drainage. The Post-procedural course was uneventful. CONCLUSION: The pulmonary-to-systemic venous connection associated with the partially anomalous pulmonary venous connection is a rare congenital malformation. Computed tomography angiography as a noninvasive imaging method plays an important diagnostic and differential value for this entity.

CTA analysis of 482 cases of coronary artery fistula: A large-scale imaging study.

OBJECTIVE: The prevalence of coronary artery fistula (CAF) based on coronary angiography has been reported. However, with the popularity of coronary computerized tomography angiography (CTA), CAFs have been found more and more by chance. The purpose of this study was to determine the prevalence and types of CAFs detected by coronary CTA, and to explore the differences in the size of fistulas, the number of complicated aneurysms, and fistulas among different types. MATERIALS AND METHODS: From January 2016 to December 2020, 96,037 patients underwent coronary CTA in our hospital. The prevalence of CAF was retrospectively evaluated, The origin, course, and drainage site of CAF and coexisting abnormalities were analysed. The conventional treatments and follow-up DSCT images were also evaluated. Analyze the difference between the coronary-pulmonary artery fistula (CPAFs) group (380) and the coronary-cameral fistula (CCF) group (99). RESULTS: Among 96,037 patients, 482 (0.5%) patients (male 232 and 250 female) had CAF. The types of CAF detected. The pulmonary artery was the most common site of drainage (380/482, 78.8%). Of the 99 CCFs, coronary to the left ventricle is the most common pattern in CCF (34/482, 7.0%). Single origins are more common in CAF (n = 361, 74.9%), multiple origins are more common in CPAFs than in CCF. There were statistically significant differences in the stoma diameter (2.4 ± 1.1 mm vs. 5.4 ± 4.3 mm p < .05), aneurysm complicated (85 cases [85/380] vs. 50 cases [50/99]), the size of aneurysm (8.8 ± 5.7 mm vs. 19.1 ± 11.6 mm, p < .05), and single fistula (261 [261/380] vs. 96 [96/99], p < .05). Most of the 380 CPAFs patients received conservative treatment (350/380, 92.1%), While the 59 CCF patients (59/93, 63.4%) were treated. CONCLUSIONS: Different from previous reports, the prevalence of CAF in coronary CTA is 0.5%, the incidence of CPAFs is the highest, and the incidence of the left ventricular fistula is higher in CCF. Compared with CPAFs, CCF fistulas were more likely to be associated with a larger diameter of draining, larger aneurysms, single fistula pattern. Coronary artery CTA is a useful and noninvasive imaging method to detect CAF, which is of great significance for the detection of small fistulas and the surgical guidance of complex CAF.