C a r d i a c I m a g i n g P i c t o r i a l E s s ay

Tsai et al. MDCT of Ischemic Heart Disease Cardiac Imaging Pictorial Essay

Comprehensive Evaluation of Ischemic Heart Disease Using MDCT

I-Chen Tsai1,2,3,4 Wen-Lieng Lee 2,3,4,5 Chen-Rong Tsao 2,3,4,5 Yen Chang5 Min-Chi Chen1 Tain Lee1,2,3,4 Wan-Chun Liao1
Tsai IC, Lee WL, Tsao CR, et al.

OBJECTIVE. Recently MDCT has become widely used for the evaluation of ischemic heart disease, but clinically the evaluation is primarily focused on the coronary artery only. We describe why and how to comprehensively evaluate the cardiac CT scan, including myocardium, motion, viability, valve, and perfusion aspects related to ischemic heart disease. CONCLUSION. Radiologists should be familiar with the protocol design and comprehensive interpretation of cardiac MDCT to provide comprehensive treatment suggestions for the patients. ardiac MDCT has gradually become popular in recent years, but clinically the evaluation is primarily focused on only the coronary artery [1]. However, the literature and our clinical experience show that many aspects of the heart can be evaluated by MDCT in patients with suspected ischemic heart disease in addition to coronary artery evaluation for example, the study of the myocardium [25], motion [2], viability [35], valves [6], and perfusion [5]. Why Do We Need a Comprehensive Approach for Cardiac CT? Patient 1 A 63-year-old man with a history of singlevessel disease after stenting in the left anterior descending coronary artery (LAD) was referred for evaluation. We found a stent in the middle LAD with total occlusion (Fig. 1). Should we recommend invasive cardiac catheterization for further evaluation and treatment? Many radiologists would suggest catheter coronary angiography if a hemodynamically significant stenotic lesion is seen [1]. But in this patient, the myocardium supplied by the LAD shows decreased perfusion with thinning. In the delayed phase, viability imaging also showed extensive microvascular obstruction and peripheral delayed hyperenhancement, which means the myocardium in the LAD territory was infarcted [35]. To perform cardiac catheterization and revascularize the LAD is treating only the vascular

patency, not the patient. In this patient, medical treatment for symptoms is suggested. Patient 2 A 68-year-old man with chest pain after exercise came to our emergency department for evaluation. Because the ECG, creatinine kinase, and troponin I studies were all negative, stable angina was diagnosed. MDCT was performed before discharge. In the patients circumflex coronary artery, we found a totally occluded lesion (Fig. 2). As a radiologist, what would you do when you see this case? Certainly it would be correct to report a totally occluded coronary artery lesion. But because emergent coronary intervention is indicated, it is especially important to immediately verbally communicate the results to the attending physician and the interventional cardiologist so that percutaneous coronary intervention can be performed as soon as possible. The intended discharge should be cancelled. Viability imaging shows microvascular obstruction in the central region and viable myocardium in the periphery. This means the patient was in the process of an acute myocardial infarction [35]. If he had been discharged without intervention, the entire decreased perfusion area would finally have become infarcted. MDCT Weapons for Ischemic Heart Disease Calcium Scoring The advantage of calcium scoring is its low radiation dose [7], no contrast medium is

Keywords: coronary artery, ischemic heart disease, MDCT, myocardium, viability DOI:10.2214/AJR.07.3484 Received December 2, 2007; accepted after revision January 8, 2008. Department of Radiology, 407, Taichung Veterans General Hospital, No. 160, Section 3, Taichung Harbor Rd., Taichung, Taiwan, ROC. Address correspondence to I. C. Tsai (sillyduck.radiology@gmail.com).
2 Faculty of Medicine, Medical College of Chung Shan Medical University, Taiwan, ROC. 3 Department of Medicine, National Yang Ming University, Taiwan, ROC. 4 1

Institute of Clinical Medicine and Cardiovascular Research Center, National Yang Ming University, Taiwan, ROC. Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan, ROC. CME This article is available for CME credit. See www.arrs.org for more information.

AJR 2008; 191:6472 0361803X/08/191164 American Roentgen Ray Society

64

AJR:191, July 2008

MDCT of Ischemic Heart Disease needed, and the procedure is safe and quick. We can evaluate the patients risk of a coronary event in seconds [7]. But the meaning of the calcium score is epidemiologic, which means the accuracy in an individual patient might not be good. For individual patients, the interscan variability and possible critical stenoses in zero- or very-low-calcium-score patients are the major limitations [8] (Fig. 3). CT Coronary Angiography Many studies have shown the high accuracy of CT coronary angiography in identifying coronary artery stenoses [1]. The imaging protocol and image quality concern [9] are also reported in many review articles. We have only two additional recommendations. The first is that aggressive heart rate control is still needed in most MDCT examinations. Even in high-end dual-source CT, scans obtained during a low heart rate still have better image quality than those during a high heart rate [10]. Second, for radiation dose control, most articles are recommending ECG pulsing [11]. However, we think weightbased tube-current adjustment is even more important. Thus, we use a gradient tube current table for radiation control (Table 1), which could considerably reduce radiation exposure in thin patients. If an occlusion is observed, it is important to differentiate between acute and chronic occlusion. Chronic occlusion is easier to identify, with its focal occlusion and good distal enhancement. The visualization of collaterals depends on the patients condition. If the collateral is epicardial, it is easy to identify (Fig. 4). But if the collateral is intramyocardial, because of the limited contrast-to-noise ratio between the enhanced lumen and the enhanced myocardium, collaterals usually cannot be seen (Fig. 1). Acute occlusion is more difficult to interpret because

TABLE 1: Suggested ECG-Gated Cardiac CT Protocol with Weight-Based Radiation Dose Adjustment
Actual Tube Current (mA) 140 160 200 260 100 125 150 175 200 225 250 275 300 325 350 375 400 425 450 475 400 Effective Tube Current with Pitch of 0.2 and Rotation Time of 0.4 Tube Voltage Second (mAs per slice) (kVp) 280 320 400 520 200 250 300 350 400 450 500 550 600 650 700 750 800 850 900 950 800 80 80 80 80 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 120 140

Body Weight (kg) 03 46 710 1115 1620 2125 2630 3135 3640 4145 4650 5155 5660 6165 6670 7175 7680 8185 8690 91100 > 100

CTDIvol (mGy) 6.0 6.9 8.6 11.1 14.0 17.5 21.0 24.5 28.0 31.5 35.0 38.5 42.0 45.5 49.0 52.5 56.0 59.5 63.0 65.8 83.3

NoteCTDIvol = volume CT dose index.

TABLE 2: Myocardial Assessment Using Comprehensive Approaches of MDCT

Myocardial Conditions in Ischemic Heart Disease Normal viable myocardium Ischemia CT Coronary Angiography Mostly normal or with noncritical stenosis Myocardial Thickness Normal Myocardial Perfusion Normal Decreased attenuation or normal (due to relative poor sensitivity of MDCT for perfusion) Decreased attenuation or normal (due to relative poor sensitivity of MDCT for perfusion) Decreased attenuation Myocardial Motion Normal Decreased contractility, akinesia, or hypokinesia Delayed Phase Normal washout pattern Normal washout pattern

Plaque formation, stenosis, Normal or even chronic occlusion

Hibernation and stunning Stenosis or obvious plaque Normal formation, sometimes or mild with chronic total thinning occlusion Acute myocardial infarction Acute occlusion with poor distal enhancement Normal

Poor, probably akinetic, hypokinetic, or even dyskinetic Poor, mostly hypokinetic or akinetic

Normal washout pattern

Normal washout pattern in penumbra means potentially salvageable; delayed hyperenhancement or defect means infarcted area Delayed hyperenhancement or microvascular obstruction

Chronic myocardial infarction

Stenosis or obstruction

Myocardial thinning

Decreased attenuation

Poor, could be akinetic, hypokinetic, or even dyskinetic

AJR:191, July 2008

65

Tsai et al. it usually presents as a poorly enhanced lumen (Fig. 2). If no particular attention is paid, it is easily missed as a shorter coronary branch. In institutions that rely heavily on postprocessing technologists or automated coronary extraction software, we recommend that the interpreting radiologists at least scroll through the thin axial images before making a formal report. Do not form a conclusion merely on the basis of the postprocessed image. Arterial Phase Myocardial Assessment (Perfusion and Thickness) For myocardial assessment, the most quiescent diastolic phase is recommended for interpretation. We use short axes from the apex to the cardiac base, horizontal and vertical long axes to completely evaluate the heart [25]. The reason for not using the echographically frequently used four-chamber or three-chamber view is their large interobserver variation. Using three- and four-chamber views, it is difficult to precisely define the myocardial segments [12]. Furthermore, the reason for using diastole rather than systole is the poor separation of trabeculation, papillary muscle, and myocardium during systole (Fig. 2). Clearly identifying these structures is important in cardiomyopathy evaluation. We emphasize that a perfusion defect cannot help in differentiating ischemia, hibernation, and infarction. We need myocardial thickness and viability for complete evaluation. Evaluation of myocardial wall thickness is of particular help to patients with chronic myocardial infarction. In measuring the thickness, short axes are recommended [35] because they are objective and reproducible. In patients with severe myocardial infarction who are undergoing coronary arterial bypass grafting, left ventricular wall evaluation is important. With the information gleaned, surgeons can decide whether a concurrent Dor ventriculoplasty or left ventricular aneurysmectomy should be performed. Myocardial Motion Interpretation The interpretation of myocardial motion should match the coronary artery condition and myocardial perfusion to evaluate the impact of the coronary stenosis on the myocardium. We interpret myocardial motion using terminology already established in echocardiography, such as akinesia, hypokinesia, and dyskinesia. With recent rapid advances in workstations, we can use serial short axes to precisely calculate the ejection fraction [2]. According to the blood volume-versuscardiac phase plot, subtle early motion abnormality such as diastolic dysfunction could also be observed (Fig. 5). (See www.arjonline.org for cine images, Figs. S5B and S5D.) When evaluating myocardial motion, if any valvular abnormalities such as aortic valve stenoses or mitral tethering (Fig. 6) are seen, they should also be evaluated [6] because these lesions might have symptoms similar to those of ischemic heart disease. Using this whole-heart approach, we can still give treatment suggestions to patients with patent coronary arteries who present with symptoms. (See www.arjonline.org for cine images, Figs. S6A and S6C.) Viability Imaging Using Delayed Phase Scanning Viability imaging needs an additional delayed phase scan [35], but a low-dose protocol can be used. In our hospital, we use collimation of 32 1.25 mm, tube voltage of 80 kV, weightbased tube current selection with ECG pulsing (70% of the R-R interval), and a 6-minute delay. The radiation dose given is approximately 10% of that for CT coronary angiography. The interpretation of viability should be in agreement with the coronary artery condition, myocardial perfusion, myocardial thick ness, and left ventricular wall motion. Myocardial conditions and their presentations are listed in Table 2. Miscellaneous When a patient presents with symptoms of ischemic heart disease, sometimes the final diagnosis is not atherosclerotic coronary artery disease. In this situation, identifying the underlying problems and providing suggestions for appropriate treatment are the responsibility of the radiologist (Fig. 7). (See www.ajronline.org for cine images, Figs. S7B and S7E.) Conclusion MDCT can potentially serve as a one-stop shop for the evaluation of ischemic heart disease. Radiologists should be familiar with the protocol design and comprehensive interpretation of cardiac MDCT to provide complete treatment suggestions to patients. References
1. Leschka S, Alkadhi H, Plass A, et al. Accuracy of MSCT coronary angiography with 64-slice technology: first experience. Eur Heart J 2005; 26:14821487 2. Raman SV, Shah M, McCarthy B, Garcia A, Ferketich AK. Multidetector row cardiac CT accurately quantifies right and left ventricular size and function compared with cardiac MR. Am Heart J 2006; 151:736744 3. Mahnken AH, Bruners P, Katoh M, Wildberger JE, Gunther RW, Buecker A. Dynamic multisection CT in acute myocardial infarction: preliminary animal experience. Eur Radiol 2006; 16: 746752 4. Lardo AC, Cordeiro MA, Silva C, et al. Contrastenhanced MDCT viability imaging after myocardial infarction: characterization of myocyte death, microvascular obstruction, and chronic scar. Circulation 2006; 113:394404 5. Mahnken AH, Koos R, Katoh M, et al. Assessment of myocardial viability in reperfused acute myocardial infarction using 16-slice CT in comparison to MRI. J Am Coll Cardiol 2005; 45: 20422047 6. Gilkeson RC, Markowitz AH, Balgude A, Sachs PB. MDCT evaluation of aortic valvular disease. AJR 2006; 186:350360 7. Rumberger JA, Simons DB, Fitzpatrick LA, et al. Coronary artery calcium area by electron beam CT and coronary atherosclerotic plaque area: a histopathologic correlative study. Circulation 1995; 92:21572162 8. Rubinshtein R, Gaspar T, Halon DA, Goldstein J, Peled N, Lewis BS. Prevalence and extent of obstructive coronary artery disease in patients with zero or low calcium score undergoing 64-slice cardiac MDCT for evaluation of a chest pain syndrome. Am J Cardiol 2007; 99:472475 9. Pannu HK, Flohr TG, Corl FM, Fishman EK. Current concepts in multidetector row CT evaluation of the coronary arteries: principles, techniques, and anatomy. RadioGraphics 2003; 23[spec no]:S111S125 10. Johnson TR, Nikolaou K, Wintersperger BJ, et al. Dual-source CT cardiac imaging: initial experience. Eur Radiol 2006; 16:14091415 11. Poll LW, Cohnen M, Brachten S, Ewen K, Modder U. Dose reduction in MDCT of the heart by use of ECG-controlled tube current modulation (ECG pulsing): phantom measurements. Rofo 2002; 174:15001505 12. Anderson RH, Razavi R, Taylor AM. Cardiac anatomy revisited. J Anat 2004; 205:159177

66

AJR:191, July 2008

MDCT of Ischemic Heart Disease

Fig. 1 63-year-old man with chronically occluded coronary stent over left anterior descending artery and infarcted myocardium. This case shows importance of comprehensive evaluation of cardiac CT. A, Multiplanar reformatted image of coronary arteries shows coronary stent over middle portion of left anterior descending artery (arrow ). Because this is maximum-intensity-projection image, intrastent assessment is blocked by stent itself. B, Thin-section (0.4 mm) multiplanar reformation for intraluminal assessment shows multiple low-density regions (arrows ) inside stent, indicating intrastent occlusion. C, Short-axis image of diastole in arterial phase shows decreased perfusion and myocardial thinning over anteroseptal wall (between arrows ) compared with remote myocardium (arrowheads ). Cine imaging is provided in Figure S1C in supplemental data online. D, Short-axis image of systole in arterial phase also shows decreased perfusion and myocardial thinning over anteroseptal wall (between arrows ) compared with remote myocardium (arrowheads ). Anteroseptal wall also shows akinesia if compared with C. Note that in systole, differentiating trabeculation, papillary muscle, and myocardium is difficult. E, Short-axis image of 6-minute delayed phase image shows persistent perfusion defect and peripheral delayed hyperenhancement in anteroseptal wall (between arrows ), indicating extensive myocardial infarction in territory of left anterior descending artery. Note remote viable myocardium shows normal washout pattern (arrowhead ). F, Horizontal long-axis image during delayed phase shows thrombus (white arrow ) in left ventricular apex. In arterial phase, it is sometimes difficult to differentiate between left ventricular myocardium and firmly attached mural thrombus. But in delayed phase, because of different contrast medium washout pattern, thrombus (white arrow ) is easily differentiated from normal viable myocardium (black arrow ). Due to lack of blood supply, the thrombus (white arrow ) would present like the microvascular obstruction myocardium (arrowhead ), as delayed perfusion defect. But the thrombus would protrude into the left ventricular cavity, and the delayed defect is located within the myocardium.

AJR:191, July 2008

67

Tsai et al.

Fig. 2 68-year-old man with acute myocardial infarction. This case shows importance of comprehensive evaluation in cardiac CT. A, Multiplanar formatted image shows obstruction of distal circumflex artery (arrows ) and faint enhancement of terminal branch (arrowheads ). It is important to recognize this pattern because inexperienced radiologists or technologists might fail to track entire distal circumflex artery and misinterpret this as a shorter circumflex artery ending at asterisk. B, Short-axis image during diastole in arterial phase shows decreased perfusion over infralateral wall (between arrows ) involving posterior papillary muscles (black arrowhead ). Compare density of anterior (white arrowhead ) and posterior (black arrowhead ) papillary muscle. Involvement of infralateral wall and posterior papillary muscle is prognostic of ischemic mitral regurgitation. See also cine image, Figure S2B, in supplemental data online. C, Short-axis image during systole in arterial phase shows decreased perfusion over infralateral wall (between arrows ), involving posterior papillary muscle (black arrowhead ). In regions with normal systolic wall motion, papillary muscle and compact myocardium are difficult to differentiate because contrast medium between them is squeezed out (white arrowhead ). But in akinetic region (between arrows ), it is still possible to identify papillary muscle (black arrowhead ). D, Short-axis image during delayed phase shows delayed perfusion defect over subendocardium of infralateral wall (between arrows ) and papillary muscle (arrowhead ). Note that delayed defect in this phase is slightly smaller than perfusion defect in arterial phase. Difference between the two indicates ischemic penumbra, which is potentially salvageable by emergent percutaneous coronary intervention. E, Coronary angiography image shows exactly same coronary findings as MDCT; asterisk, arrows, and arrowheads are placed in corresponding places to those in A. Wire indicates course of circumflex artery. See also cine image, Fig. S2E.

68

AJR:191, July 2008

MDCT of Ischemic Heart Disease

Fig. 3 51-year-old man with low calcium score (9.7) who nevertheless has lesion over left anterior descending coronary artery, which is almost totally occluded. A, Multiplanar reformatted image shows neartotal occlusion over middle portion of left anterior descending coronary artery (white arrow ). Note small calcified spot (black arrow ), which was calculated as Agatston calcium score of only 9.7. B, Catheter coronary angiography image shows middle left anterior descending coronary artery lesion (arrow ) exactly the same as on MDCT. Lesion was treated with stent implantation.

Fig. 411-year-old boy with history of Kawasaki disease. A, Volume-rendering image shows chronically occluded proximal right coronary artery (RCA) and good collateral formation (arrows ) from distal left anterior descending artery (LAD) to acute marginal branch (AM) of RCA. In clinical practice, collateral arteries are usually smaller than resolution of current MDCT technology. Also, location is usually intramyocardial, which would be difficult to discern because of lack of contrast resolution between collateral vessels and enhanced myocardium. This collateral (arrows ) is well shown because it is a single large epicardial collateral vessel. B, Multiplanar reformatted image also confirms collateral (white arrows ) between distal LAD and AM of RCA. Also note chronically occluded proximal right coronary artery (arrowheads ). Dashed portion (black arrow ) of collateral is caused by software reconstruction problem. Dashed segment is actually good and patent in both source images (not shown) and volume-rendering images ( A ).

AJR:191, July 2008

69

Tsai et al.

Fig. 577-year-old man with cor pulmonale and suspected diastolic dysfunction of left ventricle (LV). A, Reconstructed large-field-of-view image from original cardiac CT data set shows emphysematous change in both lungs and destroyed right lower lobe (arrow ) due to tuberculosis. Also note, there is no acoustic window for echocardiographic assessment. Window is blocked either by sternum or by emphysematous lungs. B, Four-chamber view shows dilated right ventricle (white double arrow ), especially when compared with left ventricle (black double arrow ). Cine image of four-chamber view is provided as Figure S5B in supplemental data online. C, Blood volume-versus-cardiac phase plot shows slow filling (arrows ) in early diastole (passive filling phase) and fast filling (arrowheads ) in late diastole (atrial kick phase), which indicate diastolic dysfunction. Cardiac motion in short axis is shown in Figure S5C in supplemental data. D, For comparison, note this blood volume-versuscardiac phase plot in another patient of similar age (77 vs 76 years old) and ejection fraction (60.1% vs 62.3%) shows normal diastolic curve, fast passive filling (arrows ), and slow atrial kick (arrowheads ). Cardiac motion in short axis is shown in cine image, Figure S5D, in supplemental data.

A
LV Blood Volume Vs. Phase Vol (mL) ED 50 45 40 35 30 25 40 20 15 10 0 10 20 30 40 50 60 70 80 90 Phase (%) 30 20 0 10 20 30 40 50 60 70 80 90 Phase (%) 60 50 ES Vol (mL) ED 80 70 LV Blood Volume Vs. Phase ES

70

AJR:191, July 2008

MDCT of Ischemic Heart Disease

Fig. 6Valvular disease related to ischemic heart disease. A, 56-year-old man with ischemic heart disease and left ventricular remodeling and dilatation. This mitral view during end-systole is created to align anterior papillary muscle, chordae tendineae, and both leaflets of mitral valve in same plane. Because of left ventricular dilatation, posterior displaced papillary muscle is pulling tendineae (arrows ), which subsequently causes mitral tethering, with an angle between proximal and distal anterior leaflets of mitral valve (dashed line ). This condition leads to poor coaptation between the two leaflets of the mitral valve, and mitral regurgitation is expected. In cine image, Figure S6A in supplemental data online, rigid and limited motion of mitral valve can be clearly visualized. Echocardiography then confirmed severe mitral regurgitation. Mitral annuloplasty was performed. B, End-systole mitral view of postoperative cardiac CT in same patient as in A shows disappearance of angle (dashed line ) and good coaptation. With reduction of diameter of mitral annulus by mitral ring (black arrow ), chordae tendineae (white arrows ) no longer tether anterior leaflet of mitral valve. In cine image, Figure S6B, good motion of mitral valve is seen. This case shows that MDCT can be used even in visualizing valves and chordae tendineae. C, 21-year-old woman with exertional dyspnea who is suspected of having ischemic heart disease. Routine three-chamber view shows thickening and poor coaptation of aortic valve (arrow ). When aortic valve looks somewhat unusual, further evaluation focusing on aortic valve should be undertaken. Cine animation in three-chamber view is provided as Figure S6C in supplemental data. D, Virtual angioscopic image in same patient as in C shows fusion (arrows ) of commissures between noncoronary (N) and right coronary (R) cuspids and between noncoronary (N) and left coronary (L) cuspids. Only commissure between left (L) and right (R) coronary cuspids could fully open (arrowhead ). Unicuspid aortic valve was diagnosed. At echocardiography, severe aortic regurgitation and moderate aortic stenosis were found, which indicated need for valve replacement surgery. E, Excised aortic valve in same patient as in C shows exactly same findings as MDCT. Annotations in this image are same as in D. In this case, if MDCT interpretation had included only CT coronary angiography, diagnosis could have been delayed until an experienced echocardiographer found unicuspid aortic valve and accompanying aortic stenosis and regurgitation.

AJR:191, July 2008

71

Tsai et al.

Fig. 7 Diseases presenting with symptoms of ischemic heart disease that can be diagnosed by comprehensive evaluation with MDCT. A, Sternal dehiscence in 76-year-old man after coronary bypass surgery with recurrent symptoms after 1 month. Volume-rendering image shows nonunion of sternum and sternal dehiscence. Bypass grafts and distal native coronary arteries are patent. B, Midventricular hypertrophic obstructive cardiomyopathy in 72-year-old woman with exertional dyspnea. Horizontal long-axis image during end-systole shows kissing of midventricular myocardium and lumen obliteration (arrow ), making only basal heart an effective chamber. Cine animation is provided as Figure S7B in supplemental data online. C, Echocardiographic images of same patient as in B show diagnosis cannot be established by echocardiography. Hypoechoic presentation of hypertrophied myocardium makes it impossible to differentiate hypertrophied myocardium from left ventricular cavity. If only CT coronary angiography is interpreted, patients diagnosis might be delayed until cardiac MRI or catheter left ventriculography is performed. S = systole, D = diastole. D, Lupus microangiopathy in 42-year-old woman who presented with exertional dyspnea. Previous nuclear perfusion scan shows marked decreased perfusion over lateral wall of left ventricle. Multiplanar reformatted image shows normal coronary arteries. But decreased attenuation over lateral wall (arrows ) and normal obtuse marginal branches seem somewhat unusual. CRX = circumflex artery, LAD = left anterior descending coronary artery, RCA = right coronary artery. E, Delayed phase image of same patient as in D shows infarction over lateral wall (arrow ). Akinetic motion and muscle thinning over corresponding region are shown in cine image, Figure S7E, in supplemental data. Because overlying coronary artery is normal, infarction is considered to be related to capillary damage due to lupus activity. If only coronary arteries are interpreted, patients diagnoses might be delayed until cardiac MRI and catheter coronary angiography are performed. Precise match to exclude possibility of one totally obstructed obtuse marginal branch can only be done with MDCT because of its ability to simultaneously visualize coronary arteries and myocardium. F, Pulmonary artery compressing left main coronary artery. A 36-year-old man presented with exertional dyspnea and was found to have atrial septal defect later. After placement of Amplatz septal occluder (ASO), symptoms persisted. MDCT was performed 2 days later. Multiplanar reformatted image shows left main coronary artery (arrow ) is critically compressed by dilated pulmonary artery because of long-term atrial septal defect. Because pulmonary artery is expected to shrink after closure of atrial septal defect, follow-up is suggested. After discharge, patients symptoms gradually subsided over 3 months. RPA = right pulmonary artery, MPA = main pulmonary artery, RV = right ventricle, LV = left ventricle. F O R YO U R I N F O R M AT I O N

A data supplement for this article can be viewed in the online version of the article at: www.ajronline.org.

F O R YO U R I N F O R M AT I O N

This article is available for CME credit. See www.arrs.org for more information.

72

AJR:191, July 2008