Gian Piero Carboni

A rare, life-threatening effort angina and anomalous origin of the left circumflex coronary artery: CT and SPECT findings

In July 2012, a 63-year-old man presented with effort angina occurring in a predictable fashion. He worked as a porter and when carrying heavy loads, angina with palpitations and feeling loss of consciousness, suggested prodromal symptoms of syncope owing to arrhythmia. Stress/rest thallium-201 single-photon emission cardiac tomography (SPECT) revealed inferior and septal wall reversible defects (ischaemia) without ST-depression at peak during a bicycle maximal exercise test. Cardiac CT documented an anomalous origin of the left circumflex coronary artery (ACXCA) arising from the right sinus of Valsalva with an extramural course between the …

Inducible myocardial ischaemia and anomalous origin of the right coronary artery coursing between the aorta and pulmonary artery: a rare, sinister entity

The authors report the case of a 49-year-old man with episodes of chest discomfort. Exercise/rest single-photon emission tomography (SPECT) with technetium-99m sestamibi (MIBI) revealed inferior and septal myocardial ischaemia, and MIBI anterior reverse redistribution, representing damaged myocardium. Cardiac tomography documented anomalous origin of the right coronary artery (ARCA) arising from the left sinus of valsalva coursing between the aorta and pulmonary artery. Myocardial ischaemia and myocardial damage revealed by SPECT are related to the transient coronary flow reduction elicited by the compression of the ARCA that is produced by the great arteries during exercise. The ARCA is a rare condition, but may cause myocardial infarction and sudden death. β-blockers and dihydropyridine calcium-channel blockers may provide cardioprotection from inducible myocardial ischaemia. However, in case of failure of medical cardioprotection, relocation of the ARCA to the appropriate aortic sinus and coronary bypass grafting could be considered as the best options.

Exercise-induced myocardial ischaemia on scintigraphy despite β-blocker therapy in patients with an anomalous origin of the right coronary artery coursing between the aorta and pulmonary artery

In February 2012, a 60-year-old man presented to us with a positive exercise test for ST-depression, which was performed before beginning sports activity. Rest/stress thallium-201 single-photon emission cardiac tomography (SPECT) revealed inferior and lateral wall reversible defects (ischaemia) and a painless ST-depression at peak during a bicycle maximal exercise test. Cardiac tomography (CT) documented an anomalous origin of the right coronary artery (ARCA) arising from the left sinus of Valsalva with an extramural …

A rare cause of abdominal angina

The authors report a case of a young male with median arcuate ligament syndrome (MALS). An abnormally low insertion of the median arcuate ligament fibres caused extrinsic compression and stenosis of the coeliac trunk. However, partial dissection of ligament fibres by laparoscopic surgery did not relieve abdominal angina. Multidetector CT confirmed that MALS did not differ from the preoperative scan. The arcuate ligament compressed the coeliac trunk on expiration, thereby eliciting occlusion of the coeliac trunk. Inspiration induced decompression of the ligament with partial release of occlusion of the coeliac trunk. This leads to hypo-perfusion of intestinal organs and abdominal angina. Considering the severe impairment of quality of life, open surgery for decompression of the coeliac trunk with vascular reconstruction is a reasonable option.

Pitfalls and bugs of nuclear and CT cardiac scans in an extremely obese patient: reasons for using conventional coronary angiography as first-line test

In October 2012, an asymptomatic 54-year-old man, with a body mass index (BMI) of 50 kg/m2, smoking habits, hypertension, dyslipidaemia and family history of coronary artery disease (CAD) presented to us for a clinical work out. Since these conditions indicate high risk of CAD,1 he underwent exercise/rest sestamibi gated single-photon-emission cardiac tomography (G-SPECT). This procedure documented submaximal exercise test and inconclusive anterior wall perfusion defect. A reduced exercise capacity and tissue attenuation characterise obesity and determine doubtful SPECT results (figure 1). A 64-slice cardiac tomography (CT) detected calcium deposits over the anterior descending (LAD) and first diagonal (D1) coronary …

Reversibility of myocardial hypertrophy 8 years after adrenal adenoma excision and drugs and alcohol addiction withdrawal

In November 2005, a 37-year-old patient presented to us with a systolic blood pressure (BP) >180 Hg and a diastolic BP >110 Hg and a history of dramatic hypertensive crises despite adherence to treatment with several antihypertensive drugs. He worked as a waiter in a nightclub where he was exposed to tiredness and fatigue while working nights. He sniffed at least 2 g of cocaine, smoked around 2 g of hashish and drank more than 500 ml of brandy nearly every night. This habit lasted for 5 years. Despite the presence of a positive direct relationship between cocaine, hashish, alcohol abuse …

Ventricular ectopy after exercise and occult ischaemia in a patient with multiple risk factors for ischaemic heart disease and defective anginal warning system

In May 2012, a 73-year-old man presented with effort dyspnoea and chest discomfort, negative exercise test for ST depression and ventricular ectopy after exercise. He had a history of Sjogrens syndrome, diabetes, dyslipidemia, hypertension, chronic obstructive pulmonary disease and was under methotrexate treatment for rheumatoid arthritis. Such diseases imply a severe dysfunctional burden, tend to develop accelerated atherosclerosis, endothelial dysfunction and ischaemic heart disease (IHD).1 ,2 A functional assessment was thus provided with an exercise/rest technetium-99 m tetrofosmin-gated …

Anomalous left main coronary artery origin, silent ischaemia, risk of sudden death: a triad detected by combining coronary CT and dipyridamole SPECT

In March 2013, a 72-year-old male patient presented with angina during strenuous effort (SE), a left bundle branch block, type 2 diabetes and hypertension. He was undergoing treatment with valsartan, metformin and aspirin. Dipyridamole infusion on thallium-201 single-photon emission cardiac tomography (SPECT) detected a septal-inferior reversible defect (figure 1). Coronary tomography revealed the presence of an anomalous left main coronary artery (ALMCO) originating from the opposite sinus of Valsalva and coursing between the aorta (AO) and the pulmonary artery (PA). The right coronary artery (RCA) arose at an acute angle from the same orifice of the ALMCO1 …

Left circumflex arising from the right coronary artery and silent myocardial ischaemic damage: a potentially lethal disarray detected by cardiac CT and SPECT.

In 2012 December, a 68-year-old man presented with mild effort dyspnoea, paroxysmal atrial fibrillation and type 2 diabetes. The ECG was within normal limits. Echocardiography documented septal and inferior left ventricle (LV) hypokinesia. Stress/rest technetium-99m sestamibi (MIBI)-gated, single-photon emission, cardiac tomography revealed septal and inferior wall defects with mild reversibility (figure 1) and reduced contractility. The submaximal exercise test was negative.1 ,2 Cardiac tomography documented an anomalous origin in the left circumflex artery (AOLCX) arising from the right coronary artery and coursing between the aorta and the left atrium (figures 2⇓–4). Direct angiography excluded the presence of atherosclerotic disease. The systolic compression of the AOLCX produced …

Extradural, retro-orbital, arteriovenous malformation as the cause of a long-term history of syncope

In May 2012, a 73-year-old man presented to us with a long-term history of syncope occurring during daily activities, characterised by a rapid onset and spontaneous recovery. He had a history of hypertension and previous coronary stent placement. Technetium-99m sestamibi cardiac scintigraphy and neurological and vestibular assessments were all negative. A head-up tilt test (HTT) and cerebral MRI were then performed. During the HTT, his HR, blood pressure (BP) and cardiac output (CO, l/min) …