Elisha Barmeir

Myocardial bridge: evaluation on MDCT.

OBJECTIVE The correlation between myocardial bridge and atherosclerotic changes has been controversial. The aim of this study was to evaluate the relation between myocardial bridge and atheromatous coronary artery disease (CAD). MATERIALS AND METHODS Three hundred consecutive subjects who underwent coronary CT angiography (CTA) were included in this study. The prevalence, length, depth, precise location, and concomitant atheromatous changes were evaluated. The group of subjects with myocardial bridge was compared with another subgroup, the control group, which included subjects without myocardial bridge. RESULTS From a total of 300 subjects, 78 subjects (26%) were found to have one myocardial bridge each. The mid left anterior descending artery (LAD) was the most common coronary artery involved (48/78). A significant difference was found between the LAD myocardial bridge group and the control group regarding presence of atheromatous changes in a similar LAD segment proximal to the myocardial bridge (p < 0.0001) and in the severity of atheromatous changes in these segments (mild, p < 0.0001; moderate, p < 0.02; and severe, p < 0.0001). The presence of stenosis in the LAD proximal to the myocardial bridge correlated with the thickness and length of the bridge. CONCLUSION Myocardial bridge predisposes to the development of atherosclerosis in the coronary artery segment proximal to the bridge. This may indicate that myocardial bridge should be considered an anatomic risk factor in the evaluation of CAD.

Coronary artery disease among asymptomatic diabetic and nondiabetic patients undergoing coronary computed tomography angiography.

ObjectivesThe aim of this study was to determine the prevalence and severity of coronary artery disease (CAD) and the plaque composition in asymptomatic diabetic and nondiabetic patients undergoing coronary computed tomography angiography (CCTA). BackgroundCAD is the major cause of death among patients with diabetes. The true prevalence of CAD in asymptomatic diabetic patients, however, remains unknown. Materials and methodsA total of 328 consecutive patients (each with at least one risk factor or abnormal stress-test results) were referred for cardiac evaluation, 42 with diabetes and 286 without diabetes, all asymptomatic for cardiac-related symptoms. Groups were matched for age, sex, and CAD risk factors. CAD was defined as coronary atherosclerosis, with obstructive or nonobstructive lesions. CCTA was performed and findings compared between patients with diabetes and those without. ResultsCAD was present in 39 (93%) diabetic patients and in 211 (73%) nondiabetic patients (P=0.006). Obstructive CAD was more common in diabetic patients than in nondiabetic patients (29 vs. 6.6%, respectively; P<0.0001). In diabetic patients, more coronary segments with atherosclerosis per patient were detected (5.5 segments/patient vs. 2.8 segments/patient in nondiabetics; P<0.0001). The total Agatston score was significantly higher in diabetic patients vs. nondiabetic patients (370±96 and 79.9±16, respectively; P<0.0001). ConclusionOur results indicate a high prevalence (93%) of CAD in asymptomatic diabetic patients with either nonobstructive or obstructive lesions. CCTA may be a useful imaging modality for selecting patients at high risk who would benefit most from further evaluation for subclinical ischemia.

Dimensions and anatomic variations of left main coronary artery in normal population: multidetector computed tomography assessment.

ObjectivesThe aim of our study was to determine the dimensions, morphology and anatomic variations of the left main coronary artery (LMCA) in normal participants, on multidetector computed tomography. BackgroundAccurate imaging of LMCA dimensions and configuration is crucial to avoid misdiagnosis of LMCA disease. Materials and methodsSeventy morphologically normal LMCAs of 70 participants were carefully selected from among 600 consecutive coronary computed tomography angiography studies performed in our institute. LMCA cross-sectional diameters and areas were obtained at three points of each vessel: ostium, midvessel and distal. The length, cross-sectional shape, three-dimensional (3D) morphology and position of origin were studied. Influences of age, body weight, height and body surface area (BSA) on LMCA dimensions were evaluated. ResultsDifferent dimensions in each measured point of the LMCA were detected. Cross-sectional elliptic shape at ostium, mid-LMCA and distal LMCA was found in 66/70 (94%), 51/70 (73%) and 54/70 (77%) of the participants, respectively. On the basis of the 3D presentation, four types of LMCA were identified: biconcave-shape appearance (type 1), tapering morphology (type 2), combined morphology (type 3) and funnel-shape appearance (type 4). Fifty-two of the 70 participants had an LMCA orifice originating in the middle third of the aortic sinus, 15/70 in the posterior third and 3/70 in the anterior third. In men, significant correlation was found between LMCA cross-sectional area and body weight, height and BSA. In women, no correlation was found regarding body weight, height and BSA. ConclusionLMCA is not a simple straight tube but usually has various anatomical configurations, variable dimensions and cross-sectional shapes. Ostial angulation is a normal variant usually associated with the posterior position of the LMCA orifice of origin in the aortic sinus.

Duplicated Ectopic Ureter with Vaginal Insertion: 3D CT Urography with IV and Percutaneous Contrast Administration

WEB This is a Web exclusive article. uplication of the ureters is a common congenital anomaly frequently encountered in children. Complete duplication is most often associated with vesicoureteral reflux, ectopic ureterocele, and ectopic ureteral insertion. Because of poor function and anatomic variations, these anomalies are sometimes difficult to detect on excretory urography, sonography, and voiding cystourethrography (VCUG). Visualization of the course of duplicated ectopic ureters and the insertion of the ureters is of utmost importance for treatment and surgical planning. We present the case of a woman with duplicated ectopic ureter with vaginal insertion. Excretory urography, sonography, and VCUG had failed in visualization of the anatomic course and insertion of the nonfunctioning ectopic ureter. Percutaneous injection of iodinated contrast medium into the dilated collecting system and IV contrast administration was performed during CT examination of the abdomen and pelvis. Postprocessing that included volume-rendered and maximum-intensity-projection reformatted 3D images clearly showed the entire ectopic ureter in various planes. In addition to data about the exact location of the extravesical drainage of the ureter, the study provided information about the anatomic relations between the two ureters and their tortuous intimate course.

Noninvasive assessment of coronary artery ectasia using multidetector computed tomography.

ObjectivesThe aim of this study is to determine the prevalence of coronary artery ectasia and its relationship to atheromatous changes in participants undergoing coronary computed tomography angiography. BackgroundCoronary artery ectasia occasionally encountered on conventional coronary angiography is considered a manifestation of atherosclerosis. MethodsFour hundred consecutive participants, 300 men (mean age 56 years) who underwent coronary computed tomography angiography were evaluated. Coronary artery ectasia was defined as an arterial segment with a diameter of at least 1.5 times the diameter of the adjacent normal coronary artery. The prevalence and location of coronary artery ectasia as well as concomitant atherosclerotic changes were evaluated. The association of coronary artery ectasia with coronary risk factors was also studied. ResultsCoronary artery ectasia was encountered in 31 participants (8%), 29 men. The right coronary artery was most commonly affected with ectasia (50%) and most participants had single-vessel involvement (74%). Twenty-six of 31 participants (84%) had coexisting atheromatous wall changes or insignificant coronary artery disease; four participants out of 31 (13%) had significant coronary artery disease. Coronary artery ectasia thrombosis was found only in one patient (3%). No apparent correlation was present between coronary artery ectasia and diabetes mellitus, hypertension, hyperlipidemia, smoking and family history of coronary artery disease. ConclusionThe prevalence of coronary artery ectasia in consecutive participants who underwent coronary computed tomography angiography is 8%. The right coronary artery was most commonly affected and most participants had single-vessel involvement. Coronary artery ectasia usually is associated with atheromatous changes, but not with significant coronary artery disease. Coronary artery ectasia thrombosis was a rare complication. No specific predisposing factors have been identified.

Huge Pericardial Hemangioma Imaging

A 37-year-old healthy woman presented to our emergency department because of episodes of palpitation and syncope. Her general physical examination was unremarkable. The x-ray of her chest was normal except for bulging near the left border of her heart (Figure 1). Her ECG exhibited sinus tachycardia and short runs of monomorphic ventricular tachycardia. Consequently, the patient was admitted to the cardiology intensive care unit for further investigation. Transthoracic echocardiogram and transesophageal echocardiogram showed a large, rounded, extracardiac hypoechogenic mass within the posterosuperior portion of the heart (Figure 2A). Further evaluation of the mass was performed by cardiac computed tomography angiography using 64-row multidetector computed tomography. Cardiac computed tomography angiography revealed a large, hypodense, epicardial solid mass (9×6×6 cm) with small central areas of enhancement. The mass was located posteriorly to the right ventricle outflow tract and ascending aorta, at the level of the left coronary sinus of Valsalva, causing compression and displacement of the left atrium and the left superior pulmonary vein. In addition, …

Coronary artery disease among hypertensive patients undergoing coronary computed tomography angiography.

Objective Coronary artery disease (CAD) is a leading cause of morbidity and mortality in hypertensive patients. However, the true prevalence of CAD in hypertensive patients is unknown. The aim of our study was to investigate the relationship between CAD and hypertension in patients undergoing coronary computed tomography (CT) angiography (CCTA). Methods Three hundred and fifty-two consecutive patients were referred for cardiac evaluation, 125 with hypertension and 227 without hypertension. There were no statistical differences between the groups in several parameters: age, sex, and CAD risk factors. CAD was defined as coronary atherosclerosis, with obstructive or nonobstructive lesions. CCTA was performed, and findings were compared between patients with hypertension and those without. Results CAD was present in 103 (82%) hypertensive and 164 (72%) normotensive patients (P < 0.0001). Obstructive CAD was twice as common in hypertensive patients, and they had more plaques per coronary segment than did normotensive patients. Patients with hypertension duration of at least 10 years had more segments with CAD. Conclusion CAD is more prevalent and severe in hypertensive patients than in normotensive patients. CAD severity increases with hypertension duration. CCTA may help to identify high-risk patients needing further evaluation for subclinical ischemia.

Chronic Constrictive Pericarditis

Abdel-Rauf Zeina, MD,∗ Majed Odeh, MD,† Elisha Barmeir, MD∗ ∗Department of Radiology & MAR Imaging Institute; †Department of InternalMedicine A, Bnai ZionMedical Center, Faculty of Medicine, TechnionIsrael Institute of Technology, Haifa, Israel Address for correspondence: Abdel-Rauf Zeina, MD Department of Radiology Bnai Zion Medical Center 47 Golomb St., P.O. Box 4940 Haifa 31048, Israel raufzeina3@hotmail.com,

Coronary CT Angiography Findings in Patients with Ambiguous Left Main Coronary Artery Disease

Left main coronary artery (LMCA) stenosis is a high risk subset of coronary artery disease; however, its occurrence may be misjudged by coronary angiography. Coronary CT angiography (CCTA) was performed on 5 patients with clinically highly suspicious and angiographically borderline LMCA disease (ostial: 3 patients, mid: 1 patient and distal: 1 patient). A cross-sectional CCTA image was used to calculate the diameter stenosis. The quantitative coronary angiography (QCA) reference diameter (RD) correlated well with CCTA RD in all 5 patients. However, the lesion site minimal lumen diameter (MLD) by QCA correlated less well with that obtained by CCTA. The grade of stenosis measured by CCTA was significantly lower than that measured by QCA. Morphologically, three patients had LMCA ostial angulation (with minimal atheromatous changes), one patient had a biconcave configuration of the LMCA (with normal vessel wall) and one other had a tapering-morphology of the LMCA (with minimal atheromatous changes). In conclusion, CCTA may have a complementary diagnostic role in patients with angiographically ambiguous or inconclusive LMCA lesions and therefore it should be considered in the assessment of selected patients before they undergo coronary bypass surgery. In order to validate CCTA for main stem stenosis a proper gold standard, such as IVUS, is required.