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Anomalous coronary arteries

a) SCMR official document standardized acquisition guidelines – relevant extract

1. LV structure and function module to look for wall motion abnormalities
   a. Add repeat horizontal long axis with high temporal resolution sequence (≤ 20 ms per phase) to accurately determine quiescent period of RCA
2. Navigator-gated, 3D, free-breathing, MRA sequence:
   a. Transaxial slices spanning from level of proximal main pulmonary artery down to the middle of the right atrium (entire cardiac coverage if desired). Slice thickness 1–1.5mm; acquired spatial resolution in-plane of 1.0 mm or less.
   b. Slices – typically 50–80, as needed to encompass vessels of interest.
   c. Adjust trigger delay and acquisition window according to observed quiescent coronary period.
   d. Parallel acquisition preferred
   e. Navigator placed over the right hemi-diaphragm.
   f. Optional – contrast to increase vessel conspicuity
3. Optional -
   a. breathhold techniques if poor image quality or navigators unavailable or of poor quality
   b. T2-prepared sequence may be useful

b) SCMR official document reporting recommendations – relevant extract

Coronary Arterial Segments
It is recommended that when examining the course of anomalous coronary arteries, the origin and course of the coronary artery segments be reported, as well as the length of the segments visualized.  If anomalous artery is intramural, it should be noted. If a study is performed for the purpose of identifying coronary artery or bypass graft anatomy, the patency of these conduits should be indicated.

c) Standardized web based images

Anomalous coronaries 
Case notes: Case from Leeds University, John Greenwood. A 58yr old female was referred with atypical chest pain symptoms for 4 months. She had a past medical history of hypertension, migraine, epilepsy and was an ex-smoker.
During exercise tolerance testing she developed 1mm of ST depression after 8mins of a Bruce protocol (106% THR). X-ray angiography revealed: LMS, LAD, and LCx all normal. The RCA arose from the left coronary sinus, but there was no luminal disease. A SPECT scan was reported as normal. 
C MR using the Leeds protocol (see how we do coronary imaging) clearly demonstrated the aberrant RCA with an anterior course (passing between the RVOT and the aortic root). However, at repeated follow up she has remained entirely asymptomatic with an unrestricted exercise capacity.

Excluding coronary involvement by Kawasakis
Case notes: Case from the Heart Hospital, Anna Herrey, James Moon. A 22 year old female with a possible ASD associated with an interatrial septal aneurysm and a past history of Kawasakis at the age of 8.  This scan uses FLASH cines to interrogate the IAS, Qp:Qs which excluded a significant shunt and coronary imaging using the Leeds protocol, above.  Reconstruction using Osirix showed clean coronaries without aneurysms, resolving any possible overlap with the coronary veins (not easy to do on the raw images).  The CMR scan therefore answered 2 questions that would have otherwise have had residual uncertainty or required invasive investigation.

d) Case of the Week example(s)

Number 09-08: Syncopal Event in a Case of Kawasaki's
History: Kawasaki's Disease and Atrial Septal Aneurysm. Single imaging modality for complete assessment.

Number 06-06: What course the RCA?
History: A 56 year old female, atypical chest pain and collapse.

e) Expert opinion – ‘How we do’

"How I do" anomalous coronaries (Gavin Bainbridge, Sven Plein, John Greenwood, Leeds)

f) Relevant Online Talks

Free talks

Plaque Imaging - Anything is New?
By Marc Sirol - Paris, France
Recorded at EuroCMR 2009 Athens

MR of the Coronary Arteries
By Peter Danias - Athens, Greece
Recorded at EuroCMR 2009 Athens

Coronary MRA: current status/challenges
By Jennifer Keegan
Recorded at EuroCMR 2008

Members only talks - general

Coronary CT: current State
By Lucia Kroft - Leiden University Medical Centre
Recorded at SCMR 2009 Sunday Parallel Session: Coronary CT/MR

How To: CMR Coronary Imaging
By Kraig Kissinger - Beth Israel Deaconess
Recorded at SCMR 2008: Technicians Workshop

MR/CT Coronary Plaque Characterization
By Eric Larose - Hospital Laval
Recorded at SCMR 2008: Technicians Workshop

Members only talks - cutting edge

Molecular MRI of Coronary Atherosclerosis and Vascular Injury
By Rene Botnar - King's College London
Recorded at SCMR 2009 Basic Science - Molecular MRI

g) Relevant papers (starting point):
Post JC, van Rossum AC, Bronzwaer JG, de Cock CC, Hofman MB, Valk J, Visser CA. Magnetic resonance angiography of anomalous coronary arteries. A new gold standard for delineating the proximal course? Circulation. 1995;92:3163-71.
Taylor AM, Thorne SA, Rubens MB et al. Coronary artery imaging in grown-up congenital heart disease: Complementary role of MR and X-ray coronary angiography. Circulation 2000;101:1670–8.
Bunce NH, Lorenz CH, Keegan J, Lesser J, Reyes EM, Firmin DN, Pennell DJ. Coronary artery anomalies: assessment with free-breathing three-dimensional coronary MR angiography. Radiology. 2003;227:201-8.