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Multi-modality coronary artery imaging in a high risk patient
Matthijs FL Meijs,1,2 Frits HAF de Man,1 Maarten-Jan M Cramer,1 Pieter A Doevendans,1 Mathias Prokop,2 Pieter R Stella1
1 Department of Cardiology, 2 Department of Radiology, University Medical Centre Utrecht
Correspondence to: PA Doevendans
Department of Cardiology, University Medical Centre
Heidelberglaan 100, 3584 CX Utrecht
e-mail: p.doevendans@umcutrecht.nl
A fifty-year-old male patient with a history of transient ischemic attack was referred to the cardiology department for the exclusion of the presence of a cardiac source of emboli. The patient had no cardiac history, and reported no complaints of angina or palpitations. His exercise tolerance was normal. However, the patient had a positive cardiac family history, hypertension and hypercholesterolaemia, and was a smoker. Transoesophageal echocardiography showed no evidence for a cardiac emboli source, but demonstrated a reduced ejection fraction (EF) of 34%.
Given the patient’s high-risk profile and reduced EF, 64-slice computed tomography coronary angiography (CTA) was performed. Coronary CTA demonstrated two significant, calcified stenoses in the proximal and mid-LAD. Invasive coronary angiography (CAG) confirmed these findings. Fractional flow reserve value over the two stenoses was significant at 0.71. Intravascular ultrasound confirmed the presence of two calcified, significant stenoses (proximal LAD laesion 63% stenosis, mid-LAD laesion 60% stenosis).
| Movie 1. 64-slice CT coronary angiography: a three-dimensional reconstruction is used to obtain an overview of general coronary anatomy. |
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 Click the image to view the movie |
| Movie 5. Intravascular ultrasound (IVUS) demonstrated two significant, calcified lesions in the LAD; the loop starts just distal to the second diagonal branch. |
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| Click the image to view the movie |
| Figure 1. Still-frame from IVUS loop, demonstrating a calcified lesion in the proximal LAD, resulting in 63% stenosis. |
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Given the technical difficulty of this bifurcation laesion, it was decided not to perform percutaneous coronary intervention, but off-pump coronary artery bypass grafting.
With the continuous technological progress, non-invasive coronary angiography by CT may become of increasing value in the cardiac diagnostic work-up.
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