Title CT Coronary Visualizing Truncation of the Septal Perforator Branch of the Left Anterior Descending Artery Authors Brennan Lanier, MD. Nicolas Tolat, MD. Sheela Sheth, MD. Hanyuan Shi, MD. Introduction The septal branches of the left anterior descending artery perforate the interventricular septum and supply the anterior two-thirds of the septum from the base to the apex as well as the bundle of His. Occlusion and stenosis of the septal perforators can lead to angina, arrhythmia, ischemia, and ventricular failure. We illustrate a case here of unexplained cardiac arrest in a young male patient with significant findings of truncated septal perforator branch on CT coronary angiogram as well as on catheterization. Case Presentation A 25 year-old man, previously healthy, presented to the hospital after witnessed cardiac arrest. Initial EKG on the field was reported as 4-5 mm ST elevations in inferior and anterolateral leads. CPR was started, and the patient was shocked once for ventricular fibrillation. ROSC was obtained and the patient was then taken emergently for catheterization. Left heart catheterization showed intramyocardial course of the mid LAD with septal vessel with flow limitation of unknown etiology. RAO ventriculography showed LVEF of 35-40% with anterior wall motional abnormalities. There was suspicion for dissection that recannulated, occlusion, or spasm that led to transfer to our hospital for further management. A dedicated CT coronary angiography (Figure) showed abrupt truncation of the 1st septal perforator branch of the LAD, 3 mm from its origin. However, transthoracic echocardiogram showed restored LVEF to 55% without wall motion abnormalities. The patient remained hemodynamically stable and so was discharged with aspirin and carvedilol without further coronary intervention. Discussion Septal perforator truncation on imaging can be due to thrombotic occlusion (leading to ST- segment elevation myocardial infarction), stenotic lesions, dissection, and spasm. These perforator branches can be treated with balloon angioplasty, stenting, and medical management. Revascularization can be challenging due to small vessel caliber of the perforators. It is unclear in this case what the exact truncation is due to, although the patient had no more symptoms of chest pain or shortness of breath in the hospital. Conclusion A CT Coronary scan can capture truncation of septal perforators of the LAD; however, more testing is needed to elucidate the exact pathology of such truncation.
Made with FlippingBook Digital Publishing Software