Wk 9, Case 2 - Review

Patient History
A 22-year-old male presents with a recent abnormal ECG and echocardiogram with evidence of right ventricular dilatation, with a TEE non diagnostic for shunt anatomy due to poor acoustic windows. Given persistent shortness of breath and chest pain request for Cardiac CT to evaluate for atrial level shunt and rule out anomalous coronary artery anatomy.

Findings
TECHNIQUE: Coronary CT Angiography
Prospective ECG gating Cardiac; data acquisition between 70-75% of the R-R interval
IVCM: 100mL Visipaque at 5 mL/s, 40mL saline at 5mL/sec
Medication: Sublingual nitroglycerin 0.8 mg, 200mg oral metoprolol
Heart rate: 50 bpm
Rhythm: sinus rhythm
Artifacts: None
The technical quality of the scan: good.

CORONARY FINDINGS:
The left and right coronary ostia are in a normal anatomic position. The coronary anatomy is co-dominant.

LEFT MAIN:
The left main coronary artery is a short, large caliber vessel that bifurcates into the LAD, LCX. There is no plaque or stenosis in the left main.

LEFT ANTERIOR DESCENDING (LAD):
The LAD is a large caliber vessel and gives rise to one diagonal branch and wraps around the apex. There is no plaque or stenosis in the LAD and its branches.

LEFT CIRCUMFLEX (LCX):
The LCX is a large co-dominant vessel which gives rise to two OM branches before terminating as a posterolateral branch. There is no plaque or stenosis in the LCX or its branches.

RIGHT CORONARY ARTERY (RCA):
The RCA is a large co-dominant vessel and gives rise to small marginal branches before terminating as a posterior descending artery. There is no plaque or stenosis in the RCA.

NON-CORONARY CARDIAC FINDINGS:
Chambers: Normal left ventricular cavity size. Normal left atrial size. Dilated right ventricle and right atrium. No evidence of an atrial level shunt.

Myocardium: Normal wall thickness.

Valves: Trileaflet aortic valve with normal leaflet thickness. Normal mitral valve structure and with mild leaflet thickening.

Pericardium: No pericardial effusion, calcification, or thickening.

Aorta: No aortic rupture, aneurysm, dissection, intramural hematoma.

Pulmonary arteries: Normal in size with no central pulmonary embolism.

Pulmonary veins: There is partial anomalous pulmonary venous return with the right lower pulmonary vein emptying into the inferior vena cava with dextraposition of the heart, and right lung hypoplasia (Scimitar syndrome).

Impressions
1. Normal coronary anatomy with a co-dominant circulation.
2. There is partial anomalous pulmonary venous return with the right lower pulmonary vein emptying into the inferior vena cava with dextraposition of the heart, and right lung hypoplasia (Scimitar syndrome).
3. Dilated right sided cardiac chambers indicative of a significant right to left shunt.