Diagnosis of a “Single” Coronary Artery and Determination of Functional Significance of Concomitant Coronary Artery Disease
Apreviously healthy 71-year-old man with chest pain occurring irregularly during the last 6 months was referred to cardiac magnetic resonance imaging (MRI); a prior exercise ECG was reported to be normal.
Whole-heart coronary MR angiography revealed a single, common ostium of the right and left coronary artery arising from the right anterior sinus with anomalous course of the left coronary artery between the aorta and pulmonary artery, which is by definition considered a “single” coronary artery.1 Concomitant obstructive coronary disease of both vessels (Figure 1A and 1B, Movie I, and Movie II) was seen.
During the same session, adenosine perfusion imaging and dobutamine stress testing were performed. On cine MRI, regional wall motion and left ventricular function at rest were normal. Adenosine stress perfusion demonstrated an extensive inducible perfusion deficit most prominent in inferior and inferolateral segments (Figure 2A and Movie III). During high-dose dobutamine stress MRI, an inducible wall motion abnormality was detected in the corresponding myocardial territory (Figure 2B and Movie IV).
Invasive coronary angiography confirmed the anatomic findings (Figure 1C), and stenting of the distal segment of the dominant right coronary artery was performed successfully.
The case demonstrated that combined cardiac MRI before cardiac catheterization is feasible and allows characterization of both coronary anomaly with concomitant coronary disease and its functional significance. Because conventional exercise tests often produce conflicting results in patients with coronary anomalies alone or in combination with obstructive coronary disease, comprehensive MR examinations may be useful to gain deeper insight into the pathophysiology of myocardial ischemia in such patients.
The online-only Data Supplement can be found at http://circ.ahajournals.org/cgi/content/full/113/9/e386/DC1.