(Circulation. 1995;92:3163-3171.)
© 1995 American Heart Association, Inc.
Articles |
From the Departments of Cardiology (J.C.P., A.C.v.R., J.G.F.B., C.C.d.C., C.A.V.), Clinical Physics and Engineering (M.B.M.H.), and Radiology (J.V.), Free University Hospital and the Institute for Cardiovascular Research of the Free University, Amsterdam/Interuniversity Cardiology Institute of the Netherlands, Utrecht.
| Abstract |
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Methods and Results In a selected group of 38 patients, 19 of them having an anomalously originating coronary artery, a fast MR angiographic technique was used to study the proximal coronary anatomy. Blinded analysis of randomly ordered MR studies was performed independently by two observers. Both origin and proximal course of the coronary arteries were defined. Two cardiologists reviewed all x-ray coronary angiograms. After the separate analyses, a final consensus result was defined for each patient. In 37 patients, successful MR coronary angiography could be performed. Interobserver agreement for determining both origin and proximal course was 100%. An x-ray coronary angiogram was available in 36 patients. In 3 patients (all with an anomalous left main coronary artery originating from the right aortic sinus), there was disagreement about the proximal course between the results of MR and x-ray coronary angiography. Review of these cases demonstrated that MR angiography had unambiguously visualized the proximal coronary artery course, whereas the results of x-ray angiography had been equivocal. Thus, sensitivity and specificity for detecting anomalous coronary arteries and delineating their proximal course were 100%.
Conclusions These data suggest that fast MR angiography is highly accurate in determining the origin and delineating the proximal course of anomalous coronary arteries, even in those cases in which x-ray coronary angiographic diagnosis is difficult or even erroneous.
Key Words: angiography magnetic resonance imaging arteries coronary disease heart defects, congenital
| Introduction |
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MR coronary angiography is a novel noninvasive technique that has proved to be accurate in the imaging of proximal coronary anatomy in patients.16 17 18 The free choice of the imaging plane is an advantage over the limited possibilities of angulation in conventional coronary angiography. Also, MR angiography is a tomographic technique that is potentially better in elucidating three-dimensional anatomy than a projection technique. Both features might be of particular value in the imaging of anomalous proximal coronary anatomy. Its ability to demonstrate anomalously arising coronary arteries has been reported in only a few cases.19 20 21 22 In all but one, conventional "black-blood" spin-echo techniques were used, in contrast to newer "bright-blood" gradient-echo angiographic techniques, which are superior for coronary imaging. We performed a blinded study in which the results of a fast gradient-echo technique, breathhold two-dimensional MR angiography, were compared with those of conventional x-ray contrast angiography in the demonstration of anomalous coronary anatomy. Given the earlier reported angiographic capabilities of the technique and the particular advantages of MR imaging techniques mentioned above, we postulated that MR angiography would be capable of depicting anomalous coronary anatomy and delineating precisely the proximal course of anomalous arteries.
| Methods |
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Two-dimensional MR Angiography
Imaging was performed on a
whole-body imaging system
(Magnetom SP, Siemens Medical Systems) operating at 1.5 T. A standard
circularly polarized radiofrequency receiver coil was used. Patients
were positioned prone with their chests against the surface coil.
Signal acquisition was ECG triggered and gated to mid
diastole. A flow-compensated gradient-echo sequence
with incrementing excitation flip angle (
=22° to 90°) and
k-space segmentation was used, with an echo time of 7.0 ms and a
repetition time of 12.6 ms. The principles of this technique have been
described.23 The field of view was 260x260
mm2, and matrix size was 144x256, resulting in an
in-plane spatial resolution of 1.8x1.0 mm2. Slice
thickness was 4 mm. Nine phase-encoding steps per cardiac cycle
were obtained, resulting in a scan time of 16 cardiac cycles per image.
This was performed during a breathhold in end expiration. One
fat-selective saturation pulse per cardiac cycle was applied before
the imaging pulse train to suppress the strong signal from epicardial
fat surrounding the coronary arteries.
Imaging Protocol
In all patients, a standard imaging protocol was used. First, a
series of 1-mm overlapping parallel transverse images was obtained at
the level of the aortic root, followed by a series of oblique images
perpendicular to the transverse plane and oriented through the left and
right atrioventricular grooves. We have previously
shown that in this set of images, the proximal epicardial
coronary arteries are accurately imaged.24 Total
imaging time was up to 45 minutes on average.
Image
Analysis
All images were stored without patient data on optical disk.
Studies were marked with a seven-digit number that was also
assigned to the x-ray contrast angiography. After imaging of all
patients had been completed, images were magnified, mounted in
oscillating cine loops to optimize the apprehension of the continuity
of coronary arteries, and recorded in random order on VHS
videotape. Analysis of the MR studies from videotape was
performed independently by two investigators. These observers were
blinded to the results of conventional x-ray contrast angiography.
Proximal coronary anatomy was classified as normal or
anomalous. In case of anomalous anatomy, the anomaly was
specified, describing (1) the aortic sinus from which the anomalous
artery originated and (2) the proximal course of the artery in relation
to the aorta and pulmonary trunk. After completion of
independent analysis of all patients, a comparison of the
results from both observers was made to discuss potential differences
in opinion until consensus was reached.
X-ray Contrast Coronary Angiography
Conventional x-ray
contrast coronary angiographic
studies from all patients, performed by the Judkins or the Sones
technique, were reviewed independently by two cardiologists from the
cardiac catheterization laboratory who were blinded to
the MR angiography findings. They described the origin and proximal
course of all coronary arteries. After independent review, the
results of both reviewers were compared, and any difference in opinion
was discussed until a consensus about origin and proximal course of all
coronary arteries was reached.
Comparison of MR Angiography and X-ray Contrast
Angiography
After completion of the analyses, the consensus results
of the different techniques were compared for the individual patients.
In a final meeting of the Catheterization Laboratory
cardiologists and the MR angiographers, incongruent assessments of
coronary artery origin and proximal course by both techniques
were reevaluated, and a final consensus result for each patient was
defined.
| Results |
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For the 19
patients judged to have an anomalous origin of at least one
of their coronary arteries, no difference in opinion existed
between the two observers concerning either the origin or the proximal
course of these anomalous arteries. Four patients were judged to have
an anomalous origin of the LMCA from the right coronary sinus
(either a common ostium with the RCA or a separate ostium), 2 taking a
retroaortic course to the left (Fig 1
), 1 an
interarterial course between the aorta and
pulmonary trunk (Fig 2
), and 1 an anterior free
wall course over the right ventricular outflow tract. In 11
patients, an anomalous origin of the LCx from the right aortic sinus
was detected, with a retroaortic course of the anomalous artery in all
patients. An LAD arising anomalously from the right aortic sinus,
taking a septal course to the interventricular groove,
was found in 1 patient (Fig 3
). In
this patient, the LCx also arose anomalously from the right aortic
sinus (taking a retroaortic course). In 4 patients, an anomalous RCA
with an origin adjacent to the commissure between the right and left
coronary cusps was found, all taking an
interarterial course to the right
atrioventricular groove (Fig 4
). The
results for the 19 patients judged by MR angiography to have anomalous
coronary anatomy are summarized in the
Table
.
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X-ray Angiography
From one of the patients included, the
original x-ray
coronary angiogram could not be traced by the referring
cardiologist. Furthermore, the two independent observers reviewing all
x-ray coronary angiograms both judged that the
coronary angiogram of 1 patient could not be analyzed
because it was an incomplete study. Of the remaining 36 films, observer
A judged 19 angiograms to show normal coronary anatomy
and 17 to show anomalously arising coronary arteries, whereas
observer B judged 20 to show normal and 16 to show anomalous
anatomy. Interobserver agreement for differentiating anomalous
from normal coronary anatomy was 97%.
In 5 of the patients, there was difference in opinion about the site of origin of an (anomalous) artery. In 4 of these 5 patients, the disagreement consisted of one of the observers having labeled the origin of an anomalous artery as "unclear," whereas the other had specified an anomalous origin (in 3 patients, an anomalous origin of the RCA from or from above the left sinus and in 1 patient, an anomalous origin of the LCx from the right aortic sinus). In the remaining patient, observer B judged the proximal coronary anatomy to be normal, whereas observer A judged an anomalous origin of the RCA from or from above the left sinus to be present (patient 31).
In 6 patients, a difference in opinion existed about the proximal course of the anomalous artery. Again, 3 of these 6 differences consisted of one of the observers labeling the course as "unclear." In 1, the incongruence was caused by one observer labeling the coronary artery as normal while the other did not (patient 31). In the remaining 2 patients, there was a true difference in opinion concerning the proximal course of the anomalous artery: In patient 5, observer A defined the course of an anomalous LMCA from the right aortic sinus as interarterial, whereas observer B judged the artery to take an anterior free wall course over the right ventricular outflow tract to the left. In patient 28, observer A judged an anomalous LMCA from the right sinus to take a proximal course through the septum, whereas observer B described the course as retroaortic.
In a second joint session, the angiograms that
had been classified
differently were revised by both observers together, and a consensus
could be reached in all cases. The consensus results for the individual
patients judged to have anomalous coronary anatomy are
listed in the Table
.
Comparison Between X-ray Angiography and MR
Angiography
To reach consensus about the definite origin and course of
all
coronary arteries, a final joint session of
catheterization laboratory cardiologists and MR
angiographers was organized. A consensus was obtained for all
patients.
There was 100% agreement between x-ray angiography and MR angiography in differentiating patients with anomalous coronary anatomy from patients with normal anatomy. Also, no differences existed between the consensus results of MR angiography and x-ray angiography concerning the origin of the anomalous coronary arteries.
In 3 patients, however, differences of opinion
existed about the
proximal course of an anomalous artery. In patient 5, the consensus
result of x-ray angiography was an anomalous LMCA from the right
aortic sinus, taking an interarterial course between
the aorta and pulmonary trunk. MR angiography demonstrated the
anomalous LMCA to cross over the pulmonary trunk to the left,
subsequently bifurcating into an LAD and an LCx. In patient 25, the
proximal course of the anomalous LAD was defined as
interarterial by x-ray angiography, whereas a
septal course of this artery to the interventricular
groove was demonstrated by MR angiography (Fig 3
). A similar
disagreement existed in patient 28, in whom the course of the anomalous
LMCA was judged to be septal by x-ray angiography, whereas an
interarterial course between the aorta and
pulmonary trunk was depicted by MR angiography (Fig 2
). After a
joint review of these cases, it was unanimously decided that MR
angiography had unambiguously delineated the proximal course of these
anomalous arteries, whereas on conventional x-ray angiograms,
interpretation of this course had been difficult and erroneous.
In the patient from whom the x-ray angiography could not be traced by the referring cardiologist (patient 11), MR angiography showed an anomalous origin of the LCx from the right aortic sinus, taking a retroaortic course. In patient 24, whose x-ray angiography was judged to be not analyzable because only the LAD had been visualized and no selective injection of the RCA had been performed, MR angiography showed an anomalous LCx arising together with the RCA from a common ostium posteriorly in the right aortic sinus. In the patient in whom no MR angiography could be performed because she was unable to hold her breath, x-ray angiography showed normal coronary anatomy.
| Discussion |
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Previous Work
The few previous reports on the capability of
MR imaging
techniques to demonstrate anomalously originating coronary
arteries have documented only incidental cases as yet. In all but one,
conventional "black-blood" spin-echo techniques were
used.19 20 21 22 Other
authors have reported the imaging of
coronary artery aneurysms25 26 and
fistulas26 27 28 with MR techniques.
After the introduction of gradient-echo techniques for coronary artery imaging in 1991, a rapid further development of these "bright-blood" MR coronary angiographic techniques occurred.16 23 29 30 31 32 33 34 35 36 In this study, an MR coronary angiographic technique that was shown earlier to be successful in patients16 was used to demonstrate aberrant coronary arteries.
Clinical Value
The proximal course of an aberrant coronary
artery is of
major importance in defining the associated risk of myocardial
infarction or sudden cardiac
death.5 6 7 8 9 10 11 12
Thus, unambiguous
visualization of this course is important. The increased-risk
interarterial course must be discriminated from the
rather innocent septal, retroaortic, and anterior free wall courses in
any patient with a coronary anomaly. However, delineating the
proximal course of an anomalous coronary artery from a
conventional x-ray coronary angiogram may be
difficult,7 8 12 13 14 15
and misdiagnosis has been
reported to occur in up to 50% of patients.13 In the
present study, this was illustrated again: delineation of the
proximal course of an anomalous artery was erroneous in 3 of 19
patients (16%).
MR angiography seems to be a highly accurate, noninvasive diagnostic tool in patients with or suspected of having anomalous coronary anatomy. Its indications may include (1) patients who have undergone conventional x-ray contrast coronary angiography and in whom uncertainty exists concerning the precise delineation of the course of an aberrant coronary artery; (2) investigation of patients in whom total proximal occlusion or congenital absence of a major epicardial coronary artery is suspected but anomalous origin of the artery cannot be excluded; (3) a primary investigation in adolescent and young patients who present with angina, arrhythmias, or syncope on severe exercise; (4) workup before cardiac surgery of patients with an uncertain course of an anomalous coronary artery to avoid the risk of trauma to the aberrant artery37 38 ; and (5) the screening of certain subgroups of individuals who, because of the presence of an interarterially coursing aberrant coronary artery, run an especially increased mortality risk, eg, highly competitive athletes.39
Comparison With Other Noninvasive Imaging Techniques
Other
noninvasive or semi-invasive techniques reported to be
capable of imaging anomalous coronary arteries are
echocardiography and ultrafast computed
tomography.
The use of transthoracic two-dimensional echocardiography seems to be limited,15 40 41 42 43 although in pediatric populations the results have been better.44 45 46 Transesophageal echocardiography seems much more sensitive in diagnosing anomalous coronary arteries and delineating their course,15 42 43 but it is semi-invasive.
A single case of anomalous left coronary artery demonstrated by electron-beam computed tomography has recently been reported.47 Drawbacks of this technique include the still necessary intravenous infusion of contrast agent and exposure to ionizing radiation. Only transverse images can be obtained.
Limitations
Study design. Because the vast
majority of coronary
artery anomalies are found accidentally during coronary
angiography and because the incidence of coronary anomalies is
low, we intended to design a study protocol that guaranteed the
inclusion of sufficient coronary anomalies and at the same time
complied with the requirements of a blinded study. Although the pretest
likelihood of encountering anomalous anatomy in this patient
group was of course far higher than in normal clinical practice, we
believe that this fact has not weakened the main findings of this
study.
In the diagnosis of anomalous coronary anatomy, the ultimate gold standard is pathology. This, of course, was not attainable. Instead, the consensus of both catheterization laboratory cardiologists and MR angiographers, after review and comparison of a patient's conventional x-ray angiography and MR angiography, was considered to be the standard in this study.
Rhythm disturbances. One of the limitations of MR angiography is the dependence on a regular heart rhythm. All patients in our study had sinus rhythm. It can be expected that the ability of MR angiography to delineate an anomalous course in patients with atrial fibrillation will be worse because of the degrading of image quality that will occur.
Breathholding. The success of fast gradient-echo MR coronary angiography in depicting the coronary arteries depends on the capability of the patient to hold his or her breath for the period of 16 cardiac cycles (with the technique we used). Only 1 patient was not able to hold her breath, which resulted in severe respiratory motion artifacts that precluded visualization of the coronary arteries. A coarser matrix or more phase-encoding steps per RR interval may be used to shorten the period of breathholding.
Contraindications. MR imaging is contraindicated in patients with pacemakers, intracranial surgical clips, or intraocular metal debris. A few patients experience claustrophobic reactions inside the MR system, which may preclude MR imaging.
Conclusions
Delineating the proximal course of anomalous
coronary
arteries from a conventional x-ray angiogram may sometimes be
difficult or even erroneous. There is a need for a noninvasive
diagnostic technique capable of unequivocally defining this
proximal course. In this study, fast gradient-echo MR angiography
proved to be very accurate in detecting the anomalies and delineating
the proximal course. MR angiography appears to be a very useful adjunct
to conventional coronary angiography and, with confirmation of
these results in larger series, might even be considered a new gold
standard in the imaging of the proximal course of anomalous
coronary arteries.
| Selected Abbreviations and Acronyms |
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| Acknowledgments |
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| Footnotes |
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Received July 31, 1995; revision received September 28, 1995; accepted October 1, 1995.
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J. Datta, C. S. White, R. C. Gilkeson, C. A. Meyer, S. Kansal, M. L. Jani, R. C. Arildsen, and K. Read Anomalous Coronary Arteries in Adults: Depiction at Multi-Detector Row CT Angiography Radiology, June 1, 2005; 235(3): 812 - 818. [Abstract] [Full Text] [PDF] |
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A. M. Taylor, S. Dymarkowski, P. Hamaekers, R. Razavi, M. Gewillig, L. Mertens, and J. Bogaert MR Coronary Angiography and Late-Enhancement Myocardial MR in Children Who Underwent Arterial Switch Surgery for Transposition of Great Arteries Radiology, February 1, 2005; 234(2): 542 - 547. [Abstract] [Full Text] [PDF] |
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D. J. Pennell, U. P. Sechtem, C. B. Higgins, W. J. Manning, G. M. Pohost, F. E. Rademakers, A. C. van Rossum, L. J. Shaw, and E. K. Yucel Clinical indications for cardiovascular magnetic resonance (CMR): Consensus Panel report Eur. Heart J., November 1, 2004; 25(21): 1940 - 1965. [Full Text] [PDF] |
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J. A.C. Lima and M. Y. Desai Cardiovascular magnetic resonance imaging: Current and emerging applications J. Am. Coll. Cardiol., September 15, 2004; 44(6): 1164 - 1171. [Abstract] [Full Text] [PDF] |
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A. R. Deibler, R. S. Kuzo, M. Vohringer, E. E. Page, R. E. Safford, J. N. Patton, G. E. Lane, R. L. Morin, and T. C. Gerber Imaging of Congenital Coronary Anomalies With Multislice Computed Tomography Mayo Clin. Proc., August 1, 2004; 79(8): 1017 - 1023. [Abstract] [PDF] |
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C. Hague, G. Andrews, and B. Forster MDCT of a Malignant Anomalous Right Coronary Artery Am. J. Roentgenol., March 1, 2004; 182(3): 617 - 618. [Full Text] [PDF] |
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S. Mavrogeni, G. Papadopoulos, M. Douskou, S. Kaklis, I. Seimenis, P. Baras, P. Nikolaidou, C. Bakoula, E. Karanasios, A. Manginas, et al. Magnetic resonance angiography isequivalent to X-Ray coronary angiography for the evaluation of coronary arteries in kawasaki disease J. Am. Coll. Cardiol., February 18, 2004; 43(4): 649 - 652. [Abstract] [Full Text] [PDF] |
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G J Heatlie and K Pointon Cardiac magnetic resonance imaging Postgrad. Med. J., January 1, 2004; 80(939): 19 - 22. [Abstract] [Full Text] [PDF] |
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M. J. Budoff, S. Achenbach, and A. Duerinckx Clinical utility of computed tomography and magnetic resonance techniques for noninvasive coronary angiography J. Am. Coll. Cardiol., December 3, 2003; 42(11): 1867 - 1878. [Abstract] [Full Text] [PDF] |
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B. J. Maron Sudden Death in Young Athletes N. Engl. J. Med., September 11, 2003; 349(11): 1064 - 1075. [Full Text] [PDF] |
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G. M. Pohost, L. Hung, and M. Doyle Clinical Use of Cardiovascular Magnetic Resonance Circulation, August 12, 2003; 108(6): 647 - 653. [Full Text] [PDF] |
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A. Hejmadi and D. J. Sahn What is the most effective method of detecting anomalous coronary origin in symptomatic patients? J. Am. Coll. Cardiol., July 2, 2003; 42(1): 155 - 157. [Full Text] [PDF] |
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N. H. Bunce, C. H. Lorenz, J. Keegan, J. Lesser, E. M. Reyes, D. N. Firmin, and D. J. Pennell Coronary Artery Anomalies: Assessment with Free-breathing Three-dimensional Coronary MR Angiography Radiology, April 1, 2003; 227(1): 201 - 208. [Abstract] [Full Text] [PDF] |
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B. Giorgi, S. Dymarkowski, F. E. Rademakers, F. Lebrun, and J. Bogaert Single Coronary Artery as Cause of Acute Myocardial Infarction in a 12-Year-Old Girl: A Comprehensive Approach with MR Imaging Am. J. Roentgenol., December 1, 2002; 179(6): 1535 - 1537. [Full Text] [PDF] |
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B. Giorgi, S. Dymarkowski, F. Maes, M. Kouwenhoven, and J. Bogaert Improved Visualization of Coronary Arteries Using a New Three-Dimensional Submillimeter MR Coronary Angiography Sequence with Balanced Gradients Am. J. Roentgenol., October 1, 2002; 179(4): 901 - 910. [Abstract] [Full Text] [PDF] |
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P. Angelini, J. A. Velasco, and S. Flamm Coronary Anomalies: Incidence, Pathophysiology, and Clinical Relevance Circulation, May 21, 2002; 105(20): 2449 - 2454. [Full Text] [PDF] |
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G. F. Greil, M. Stuber, R. M. Botnar, K. V. Kissinger, T. Geva, J. W. Newburger, W. J. Manning, and A. J. Powell Coronary Magnetic Resonance Angiography in Adolescents and Young Adults With Kawasaki Disease Circulation, February 26, 2002; 105(8): 908 - 911. [Abstract] [Full Text] [PDF] |
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W. Y. Kim, P. G. Danias, M. Stuber, S. D. Flamm, S. Plein, E. Nagel, S. E. Langerak, O. M. Weber, E. M. Pedersen, M. Schmidt, et al. Coronary Magnetic Resonance Angiography for the Detection of Coronary Stenoses N. Engl. J. Med., December 27, 2001; 345(26): 1863 - 1869. [Abstract] [Full Text] [PDF] |
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J. A. Davis, F. Cecchin, T. K. Jones, and M. A. Portman Major coronary artery anomalies in a pediatric population: incidence and clinical importance J. Am. Coll. Cardiol., February 1, 2001; 37(2): 593 - 597. [Abstract] [Full Text] [PDF] |
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P J de Feyter, K Nieman, P van Ooijen, and M Oudkerk IMAGING TECHNIQUES: Non-invasive coronary artery imaging with electron beam computed tomography and magnetic resonance imaging Heart, October 1, 2000; 84(4): 442 - 448. [Full Text] |
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K. Rajappan, N. G. Bellenger, L. Anderson, and D. J. Pennell The role of cardiovascular magnetic resonance in heart failure Eur J Heart Fail, September 1, 2000; 2(3): 241 - 252. [Abstract] [Full Text] [PDF] |
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M. Regenfus, D. Ropers, S. Achenbach, W. Kessler, G. Laub, W. G. Daniel, and W. Moshage Noninvasive detection of coronary artery stenosis using contrast-enhanced three-dimensional breath-hold magnetic resonance coronary angiography J. Am. Coll. Cardiol., July 1, 2000; 36(1): 44 - 50. [Abstract] [Full Text] [PDF] |
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W. G. Hundley, L. D. Hillis, C. A. Hamilton, R. J. Applegate, D. M. Herrington, G. D. Clarke, G. A. Braden, M. S. Thomas, R. A. Lange, R. M. Peshock, et al. Assessment of Coronary Arterial Restenosis With Phase-Contrast Magnetic Resonance Imaging Measurements of Coronary Flow Reserve Circulation, May 23, 2000; 101(20): 2375 - 2381. [Abstract] [Full Text] [PDF] |
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C. Basso, B. J. Maron, D. Corrado, and G. Thiene Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1493 - 1501. [Abstract] [Full Text] [PDF] |
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A. M. Taylor, S. A. Thorne, M. B. Rubens, P. Jhooti, J. Keegan, P. D. Gatehouse, F. Wiesmann, F. Grothues, J. Somerville, and D. J. Pennell Coronary Artery Imaging in Grown Up Congenital Heart Disease : Complementary Role of Magnetic Resonance and X-Ray Coronary Angiography Circulation, April 11, 2000; 101(14): 1670 - 1678. [Abstract] [Full Text] [PDF] |
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E. K. Yucel, C. M. Anderson, R. R. Edelman, T. M. Grist, R. A. Baum, W. J. Manning, A. Culebras, and W. Pearce Magnetic Resonance Angiography : Update on Applications for Extracranial Arteries Circulation, November 30, 1999; 100(22): 2284 - 2301. [Full Text] [PDF] |
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W. G. Hundley, C. A. Hamilton, G. D. Clarke, L. D. Hillis, D. M. Herrington, R. A. Lange, R. J. Applegate, M. S. Thomas, J. Payne, K. M. Link, et al. Visualization and Functional Assessment of Proximal and Middle Left Anterior Descending Coronary Stenoses in Humans With Magnetic Resonance Imaging Circulation, June 29, 1999; 99(25): 3248 - 3254. [Abstract] [Full Text] [PDF] |
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S. Achenbach, W. Moshage, D. Ropers, J. Nossen, and W. G. Daniel Value of Electron-Beam Computed Tomography for the Noninvasive Detection of High-Grade Coronary-Artery Stenoses and Occlusions N. Engl. J. Med., December 31, 1998; 339(27): 1964 - 1971. [Abstract] [Full Text] [PDF] |
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MRI CORONARY ANGIOGRAPHY: ON THE HORIZON? Journal Watch (General), December 15, 1995; 1995(1215): 1 - 1. [Full Text] |
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