Presentation
Syncope, intermediate cardiovascular risk, hypertension, calcified aortic valve on echo.
Patient Data
Technique
patient premedication: beta blocker and nitrates
acquisition method: step and shoot (prospective acquisition)
contrast injection protocol: triphasic injection
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image reconstruction:
standard iterative reconstruction with edge correction
dual-energy maps (see next study)
Findings
anomalous origin of the circumflex artery from right coronary sinus with a retroaortic course
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right coronary arterial dominance:
circumflex artery from right coronary sinus
large posterior descending artery (PDA and right posterolateral branch (RPLB)
Plaque burden:
coronary calcium score: ~400
segment involvement score (SIS): 7 segments
Right coronary artery (RCA):
gives off a double posterior descending artery (PDA) and a posterolateral branch (RPLB)
multiple calcified plaques in the proximal and middle segments with no or minimal stenosis
no plaques or stenoses in the distal segment, PDA and RPLB
Circumflex artery (CX): two obtuse marginal branches and left posterolateral branch
several non-stenotic calcified plaques in the proximal segment
long mixed plaque with moderate stenosis (D: ~50-69%; area: ~70%) of the OM2
no plaques or stenoses in the thin OM1 and posterolateral branch
Left anterior descending artery (LAD): two strong diagonal branches (D1 & D2)
mixed plaque with mild stenosis (25-49%) in the proximal segment
myocardial bridge in the distal segment (length: ~15 mm; depth: ~2 mm)
Aortic valve:
calcified
small diastolic aortic regurgitant orifice area ~3 mm² at 73-83% of the RR interval
Impression
anomalous origin of the circumflex artery from right coronary sinus with two adjacent ostia and a retroaortic course
heavy amount of plaque - CAC-DRS A3/N3 and V3/N3
mild non-obstructive coronary artery disease - CAD-RADS 3/P3/E
small myocardial bridge of the left anterior descending artery
aortic valve calcification with mild aortic insufficiency possibly mixed valve disease
Exam courtesy: Yvonne Kühn (radiographer)
MonoE 80 keV
virtual monoenergetic images, synthesized at a level of 80 keV
reconstructions in a soft tissue algorithm with a window setting of C:400 W:1000
Conventional + MonoE 80 overlay
conventional images, reconstructed with a standard soft tissue filter and supplemented with a color-coded MonoE 80 overlay ranging from -100 to 900 (C:400 W:1000)
this setting can be also nicely used to illustrate calcium
the RAC sign originally described for the 4-chamber view
Conventional + MonoE 40 overlay
conventional images, reconstructed with a standard soft tissue filter and supplemented with a color-coded MonoE 40 overlay ranging from -600 to 1400 (C:400 W:2000)
the luminal signal intensity of the mildly stenotic segments in the OM2 and the LAD looks fairly normal, which is interesting
Case Discussion
An anomalous origin of the circumflex artery from the right coronary sinus with a retroaortic course namely posterior and inferior to the left ventricular outflow tract is a relatively common coronary anomaly 1-4. In contrast to an interarterial coronary course, which has been associated with an increased risk of sudden cardiac death, this anomaly is considered benign 1-3.
An appearance that has been originally described for visualization of a retroaortic course of an anomalous coronary artery for the 4-chamber view on echocardiography is the "RAC sign" 5.
For the patient's non-obstructive coronary artery disease, we recommended aggressive risk factor modification and preventive therapy. Further stress testing with regard to the moderate stenosis of the obtuse marginal branch in the setting of symptoms is being considered. The patient is already receiving a beta-blocker, which would be a pharmacologic treatment option with regard to the myocardial bridge if this is suspected to be a contributing factor to the patient's symptoms 6.
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