C a r d i o p u l m o n a r y I m a g i n g • R ev i ew

Sundaram et al.
Reporting of Cardiac MDCT

Cardiopulmonary Imaging
Review
Anatomy and Terminology
for the Interpretation and
Reporting of Cardiac MDCT:
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Part 1, Structured Report,

FOCUS ON:

Coronary Calcium Screening,

and Coronary Artery Anatomy
Baskaran Sundaram1 OBJECTIVE. In this part one of a two-part article, we aim to illustrate our understanding
Smita Patel of and approach to comprehensive cardiac CT reporting, cardiac CT technique, and coronary
Naama Bogot calcium scoring CT, as well as normal and anomalous coronary artery anatomy.
Ella A. Kazerooni CONCLUSION. Structured cardiac CT reporting is important to effectively commu-
nicate with referring clinicians. Knowledge of cardiac CT technique, cardiac anatomy, and
Sundaram B, Patel S, Bogot N, Kazerooni EA standard anatomic and physiologic terminology can assist the reader in creating a consistent
and comprehensive cardiac CT report.

Keywords: cardiac CT, coronary CT angiography,
CT reporting
DOI:10.2214/AJR.08.1177
Received May 7, 2008; accepted after revision
September 2, 2008.
Gold Medal Exhibit Award for Education Exhibit at the
2006 annual meeting of the American Roentgen Ray
Society, Vancouver, BC, Canada.
1 curacy, and negative predictive value using
All authors: Division of Cardiothoracic Radiology,
Department of Radiology, University of Michigan Health
System, Cardiovascular Center, Rm. 5481, 1500 E Medical
Center Dr., Ann Arbor, MI 48109-5868. Address
correspondence to B. Sundaram (sundbask@umich.edu).
CME
This article is available for CME credit.
See www.arrs.org for more information.
AJR 2009; 192:574–583
0361–803X/09/1923–574
© American Roentgen Ray Society
C
ardiovascular disease has been
the leading cause of mortality in
the United States since 1958 [1].
Coronary artery disease (CAD)
leads the group of cardiovascular diseases in
contributing to mortality. Many noninvasive
tests are used to evaluate patients with sus-
pected CAD, including the exercise treadmill
test, echocardiography, myocardial perfusion
scintigraphy, and electron-beam CT (EBCT).
Invasive catheter coronary angiography with
or without intravascular sonography is re-
served for patients with a sufficiently high
probability of disease to warrant this more in-
vasive and more expensive test with its associ-
ated risk of morbidity and mortality [2–4].
Recent advances in CT technology allow non-
invasive coronary CT angiography (CTA) and
left ventricular (LV) functional assessment.
Since its introduction, coronary CTA has be-
come increasingly accepted as a quick and
safe noninvasive coronary artery evaluation
tool. Coronary artery stenosis detection, ac-
coronary CTA are more impressively per-
formed with 64-MDCT scanners than with
16- or 4-MDCT scanners [5, 6]. Further im-
provements are being explored in areas such
as better CT resolution (both spatial and tem-
poral), dual-source CT [7–16], CT radiation
dose reduction, and the feasibility of coronary
CTA in patients with suboptimal heart rates
[17–19]. The usefulness of coronary CTA as a
comprehensive diagnostic tool has also been
recently explored in the emergent manage-
ment of patients with acute chest pain [20–27].
Early experience on feasibility and usefulness
of coronary CTA using 320 detector rows has
been reported [28, 29]. Recently, the prognos-
tic value of coronary CTA has also been re-
ported in a large group of patients [30].
To perform the coronary CTA examina-
tion, interpret, and create a structured coro-
nary CTA report of findings, it is important to
have a good understanding of the coronary
CTA procedure, anatomy, pathology, and the
standard descriptions used in the reference
cardiac tests such as invasive catheter coro-
nary angiography and echocardiography. In
the current climate of increasing utilization of
cross-sectional imaging for various indica-
tions [31], multiple professional organizations,
including the American College of Radiology
(ACR) and the American College of Cardiol-
ogy (ACC), recently worked together to estab-
lish appropriateness criteria for both cardiac
CT and MRI [6]. We recommend these crite-
ria be used as a resource in practice for deter-
mining the appropriateness of these examina-
tions. Recently, the ACR and the North
American Society for Cardiovascular Imag-
ing (NASCI) together published a white paper
on the structured reporting of coronary CTA
[32]. Efforts from professional societies to
standardize various facets of cardiac imaging
continue to increase [33, 34].
A Structured Cardiac CT Report
Our current comprehensive cardiac report
is composed of clinical indications for the
examination, a description of examination
technique and imaging findings, and a final

574 AJR:192, March 2009


summary or impression that enumerates the
salient coronary and noncoronary cardiac and
ex­tracardiac findings. The reporting style that
we follow is shown in Appendices 1–3.
In our reports, we aim to explicitly de-
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scribe the cardiac CT protocol used. We pre-
fer to document all pharmaceutical agents
used for heart rate and rhythm control
(β-blockers, calcium blockers) and sublin-
gual nitroglycerin used for temporary coro-
nary artery dilatation, including the dose,
timing, and route of administration. We also
mention the heart rate and rhythm during the
acquisition because of their impact on the ac-
curacy of coronary CTA.
Generally, for a typical coronary CTA ex-
amination, the prescribed scan range extends
from the angle of the carina to below the car-
diac apex; for patients with coronary artery
bypass grafts (CABGs) or who are having a
combined coronary artery and thoracic aorta
CT evaluation, the cranial extent of the scan
zone is shifted superiorly to include the ori-
gins of the subclavian and internal mamma-
ry arteries. The method used to determine
the scan delay time from the beginning of the
IV contrast bolus is specified, whether it is a
region of interest (ROI)–based trigger or a
timing bolus performed with an ROI placed
at the aortic root.
With respect to IV contrast administration,
the type, concentration, quantity, rate, and
route of administration, as well as canula size,
are usually included. In our reports, we also
specify the format of the IV contrast bolus
used—specifically, whether a biphasic or a
triphasic technique is used. A biphasic tech-
nique uses saline as the second phase of the
bolus, immediately after the contrast injec-
tion, to completely wash out contrast material
from the right heart chambers and to elimi-
nate streak artifacts across the deep right
atrioventricular groove in which the right cor-
onary artery (RCA) sits. In a triphasic bolus,
contrast material is followed by a mixture of
saline and contrast material, so that there is
some visualization of the morphology of the
right heart chamber. For example, “80 mL of
low-osmolar IV contrast material (370 mg I/
mL of iodine concentration) was adminis-
tered at 5 mL/s via a 20-gauge canula placed
in the right antecubital fossa using a triphasic
technique.” Right upper extremity venous ac-
cess is preferred to avoid dense contrast mate-
rial pooling in the left brachiocephalic vein
and resulting in streak artifacts that could po-
tentially obscure aortic arch anatomy, great
vessel origins, and internal mammary artery
AJR:192, March 2009 575
Reporting of Cardiac MDCT
grafts when scanning a CABG patient; this is
less important if the scan range is confined to
the native coronary arteries.
The type of ECG gating is also specified,
including prospective ECG triggering for the
calcium score acquisition and either prospec-
tive ECG triggering or retrospective gating
for coronary CTA. Radiation dose-reduction
mea­sures used, including tube current modu-
lation techniques, are also mentioned in our
reports. Typically, in patients with a fixed R-R
interval, tube current modulation is used, with
the mA being reduced at the phases of the R-R
interval that are generally not used for view-
ing the coronary arteries. In patients with a
normal stable sinus rhythm and a heart rate of
65 beats per minute or lower, we acquire im-
ages only at the LV end-diastole during the
cardiac cycle. This technique significantly re-
duces the radiation dose without compromis-
ing image quality, but it sacrifices the dynam-
ic cardiac functional data. LV end-diastole is
when there is relatively little motion and the
greatest coronary artery blood flow, when the
coronary arteries are usually the most opti-
mally visualized. LV end-systole is the second
relatively motion-free part of the cardiac cycle
and may be used when LV end-diastole is in-
sufficient, particularly for evaluation of the
vertical portions of the RCA and left circum-
flex (LCX) coronary artery.
The computer workstation and the soft-
ware version used to review the images may
also be documented. If any specific quantifi-
cation software is used to evaluate degree of
coronary artery stenosis and plaque charac-
terization, that may also be stated for the
reader to understand the reliability of the re-
sults. We mention the use of advanced image
postprocessing, such as creation of long- and
short-axis multiplanar reformations (MPRs),
curved MPRs, and volume-rendered images
for coronary artery assessment. We also de-
scribe quantitative and qualitative functional
analysis of the LV using dynamic images in
standard cardiac viewing planes, aortic valve
anatomy, and, if performed, measurements
of the areas of aortic valve stenosis and re-
gurgitant orifices.
CT Calcium Score
Background and Rationale
Calcium scoring with CT has been in use
for more than 20 years. This noninvasive ac-
quisition does not use IV contrast material
and is performed at a relatively low radiation
dose compared with coronary CTA. It is used
to detect and quantify coronary artery calcifi-
cation (CAC) [35]. CAC is an established
marker of atherosclerosis [36]. Amorphous
hydroxyapatite deposits advance to differen-
tiation of cells in the vessel wall to osteoblasts
[37]. Although CAC is a specific indicator of
the presence of coronary artery atherosclero-
sis, it represents only the calcified or healed
plaque, not the full burden of plaque. CAC is
estimated to represent approximately 10–20%
of the total atherosclerotic plaque burden [38].
Patients who have CAC are more likely to
have noncalcified plaque that is prone to rup-
ture, leading to acute thrombosis, than pa-
tients without CAC [38]. CAC is a predictor of
coronary events, myocardial infarction, and
death [39]. Despite extensive research, the
clinical indications and usefulness of calcium
scoring have remained controversial.
CAC scoring was developed and used ini-
tially exclusively with EBCT scanners and
validated with both radiologic–histopatho-
logic correlation and multiple population-
based studies [36, 40]. EBCT enabled ultra-
fast scanning of the heart using an electron
beam and a stationary tungsten target. Ex-
aminations were acquired at 50 or 100 milli-
seconds per slice, with nonoverlapping 3- to
5-mm slices, and a fixed mAs (≈ 60–65
mAs) with prospective ECG triggering at
one selected point in the R-R interval—usu-
ally end-diastole—to eliminate cardiac mo-
tion and blurring [38, 41]. Because EBCT
scanners have limited clinical applications,
they are not widely used today. With advanc-
es in MDCT technology, MDCT has become
the primary CT platform for CT studies of
CAC [42].
Calcium Scoring on MDCT
Technique—MDCT scanners with 4 or
more detectors are recommended, with tem-
poral resolution of 500 milliseconds or less
[35]. Examinations are performed in the
craniocaudal direction to cover the heart
from the pulmonary trunk through the apex.
The CT table is advanced in a steplike axial
fashion. If a 16-MDCT scanner is used, scan
duration is approximately 6–10 seconds; if
all 16 detectors are used, collimation is ei-
ther 0.5–0.75 mm width or 1.0–1.5 mm
width. The suggested mA is 100, which may
be reduced to as little as 55 mA [43]. When
using 64-MDCT scanners, generally the
gantry rotation time is 0.35 seconds, colli-
mation is 64 × 0.625 mm, and reconstructed
slice thickness is set at 2.5 mm, although
there may be variations in technique depend-
ing on the CT manufacturer. As with EBCT,

Fig. 1—55-year-old
man with atypical chest
pain had focal calcified
plaque (arrow) on this
unenhanced coronary
CT examination. After
manual identification of
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calcified plaque in mid
portions of right coronary
artery, quantification
software estimates
Agatston-Janowitz score
of 24 and volume score
of 18.
prospective ECG triggering is used, with a
radiation dose of approximately 1.5 mSv for
men and 1.8 mSv for women [44]. Few arti-
cles report coronary calcium scoring using
the current 64-MDCT scanners [45–48].
Postprocessing and calcium quantifica-
tion—The calcium score is generated using
software specifically designed for this pur-
pose (Fig. 1). Semiquantitative scores are
based on a section-by-section analysis of the
CT images [49]. There are three scoring
methods: the Agatston-Janowitz score, the
volume score, and the mass score. The Agat-
ston-Janowitz score was the initial method
for calcium quantification and is the most
widely used. To be included in the Agatston-
Janowitz score, CAC must reach a threshold
of 130 HU and cover an area of at least 1 mm2;
calcifications that are lower in attenuation or
smaller in size are not included in the score.
The score of each calcification is calculated
by multiplying the area of the CAC by an at-
tenuation-weighting factor based on the high-
est HU value of the CAC, a score ranging
from 1 to 4. A vessel score is the sum of all
CAC scores of that vessel, and the total cal-
cium score is the total of all CAC scores from
all vessels [49]. This method has been in use
the longest, and its prognostic implications
have been the most studied, but it has several
limitations. First, it was developed for EBCT
and must be modified for MDCT. It is often
reported on MDCT as the Agatston score
equivalent. Second, the measurement is non-
linear because of the attenuation-weighting
factor. And third, there is high interscan vari-
ability because of partial volume averaging
effect and dependence on slice thickness and
spacing [50]. In the volume score method,
the volume of all pixels with an identified
ROI of 130 HU or more is included [51]. In
576 AJR:192, March 2009
Sundaram et al.
the mass method, pixel volume measuring
130 HU or more is multiplied by its attenua-
tion in Hounsfield units, and the total calcu-
lated value is divided by 100 [52]. The vol-
ume and mass calcium scoring methods are
less variable than the Agatston-Janowitz
method [50].
Clinical Indications and Implications of the CAC
Calcium scoring with CT has been exten-
sively tested for reliability and validity. A re-
cently published updated clinical expert con-
sensus document by the ACC and the
American Heart Association (AHA) lists the
recommended clinical indications for calci-
um scoring [42] (Appendix 4). Calcium scor-
ing is not recommended in asymptomatic pa-
tients at high or low risk for CAD because it
does not affect medical management and de-
cision making [42]. Because the clinical out-
come of plaque progression, its relationship
to quantifiable stenosis, and the effect of
modifying therapy on plaque progression are
unknown, plaque follow-up with calcium
scoring is not recommended.
Large focal calcifications significantly im-
pair evaluation of the underlying lumen in
coronary CTA, whereas diffusely scattered
small calcifications do not. Significant ob-
structive coronary artery stenosis may be un-
recognized in plaque having an Agatston-
Janowitz calcium score of 400 or more [53].
Few researchers have attempted to define the
impact of coronary calcium on the accuracy
of coronary CTA [54–56].
Calcium scoring quantifies the calcified
plaque alone. It does not directly visualize
the vessel lumen, does not provide an esti-
mate of coronary artery stenosis, and does
not detect noncalcified plaque. The impor-
tance of CAC to an individual is reported as
the percentile rank by sex, based on large co-
horts of asymptomatic individuals who have
undergone CAC assessment. A calcium score
of 0 implies a low probability for significant
obstructive CAD and future cardiac events
[42]. However, it does not mean that a patient
has no noncalcified or unstable plaque or that
the probability of a future coronary event is 0
[57]. A positive calcium score correlates with
the amount of plaque and is an independent
predictor of obstructive CAD [58]. The high-
er the calcium score, the greater the amount
of plaque and the higher the relative risk for
cardiac events [59]. The presence of any
measurable calcium increases the risk of a
cardiac event in 3–5 years by nearly 4 times
[42]. Although a positive score is a specific
marker for the presence of CAD and has a
high negative predictive value of 86–90% for
obstructive coronary disease, it is not specif-
ic for obstructive CAD [35].
Normal Coronary Artery Anatomy
Evaluation of the coronary arteries begins
with an axial review of their origin and prox-
imal course. There are three sinuses of Val-
salva, the right sinus of Valsalva or the ante-
rior sinus, the left sinus of Valsalva or the
posterior sinus, and the noncoronary sinus
[60] (Fig. 2). The RCA and the left main cor-
onary artery (LM) arise from their respec-
tive aortic sinuses of Valsalva. On axial im-
ages, the LM arises at a level that is cephalad
to the RCA.
Fig. 2—48-year-old man with chest pain, elevated
cardiac enzymes, and normal ECG. Axial maximum-
intensity-projection CT image of aortic root shows
origin of right coronary artery (straight arrow) from
right coronary sinus and left main coronary artery
(curved arrow) from left coronary sinus. Arrowhead
indicates noncoronary sinus. RA = right atrium, LA =
left atrium, RVOT = right ventricular outflow tract.
 Reporting of Cardiac MDCT

ventricular groove, curving posteriorly at the
acute margin of the right ventricle (RV) and
bifurcating into the posterior descending ar-
tery (PDA) and the posterolateral LV branch-
es at the crux of the heart. The RCA supplies
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the left anterior descending (LAD) and LCX
coronary arteries (Figs. 2 and 5A). The LM
may be short or long, varying in length from 5
to 20 mm [61]. Occasionally, the LM trifur-
cates, with the middle branch known as the

Fig. 3—47-year-old woman with hyperlipidemia and
hypertension. Volume-rendered image of right lateral
view of heart created from IV contrast-enhanced
ECG-gated coronary CT angiography image shows
right coronary artery (curved arrow) coursing in right
atrioventricular groove. Right lateral surface of right
ventricle is perfused by acute marginal branches 1
(straight arrow) and 2 (arrowhead).
Right Coronary Artery
The RCA (Figs. 2, 3, and 4A) courses ante-
riorly and laterally from its ostium at the right
sinus of Valsalva and runs in the right atrio-
the RV free wall. The proximal branches of
the RCA are the conus and sinoatrial branch-
es. The conus branch arises from the RCA in
half of the population and directly from the
aortic root in the other half. The sinoatrial
nodal branch arises from the RCA in 60% of
people and from the LCX in 40%. The other
branches of the RCA include the acute mar-
ginal branches and the atrioventricular nodal
branch. The PDA runs in the posterior inter-
ventricular groove and supplies the posterior
third of the septum. The posterolateral LV
branches supply the posterior surface of the
LV. The RCA is divided into proximal, mid,
and distal portions, with the proximal portion
extending from the origin to the acute margin-
al origin, the mid portion extending from the
acute marginal origin to the horizontal por-
tion in the posterior right atrioventricular
groove, and the distal portion extending be-
yond that.
Left Main and Left Anterior Descending
Coronary Arteries
The LM arises from the left sinus of Val-
salva and divides into its two main branches,
ramus intermedius (Fig. 5B). The LAD cours-
es anteriorly and inferiorly in the anterior in-
terventricular groove to the apex of the heart,
giving rise to septal perforators and diagonals.
The septal perforators run perpendicular to
the LAD and supply the anterior two thirds of
the septum. The diagonals, of which there
may be up to six, are numbered sequentially
as they arise (D1, D2, and so forth). The diag-
onals run on the epicardial surface of the heart
and supply the anterolateral portion of the LV.
The LAD has proximal, mid, and distal por-
tions. The proximal portion runs from the ori-
gin to the first septal perforator or first diago-
nal, the mid portion runs from there to the
second diagonal, and the distal portion is dis-
tal to the second diagonal origin.
Left Circumflex Artery
The LCX runs along the left atrioventricu-
lar groove and in 80–85% of the population
terminates at the obtuse margin of the heart
after giving rise to the first obtuse marginal
(OM1) branch (Figs. 4B and 5A). The LCX
supplies the lateral aspect of the LV. The pri-
mary branches of the LCX are the OM arter-

A B C
Fig. 4—Volume-rendered images of posterior view of heart of three patients in whom posterior descending artery (PDA) (arrowhead) and posterolateral left ventricular
(LV) branches (straight arrows) define dominant patterns of coronary circulation.
A, Image in 52-year-old woman shows both PDA and posterolateral LV branches originate from distal right coronary artery (RCA) (curved arrow), suggesting right
coronary circulation dominance.
B, Image in 68-year-old man shows PDA and posterolateral LV branches arise from distal left circumflex coronary artery (LCX) (curved arrow), suggesting left coronary
circulation dominance.
C, Image in 50-year-old man shows PDA and posterolateral LV branches originate from RCA (curved arrow) and LCX, respectively, suggesting codominance (balanced
dominance) of coronary circulation.

AJR:192, March 2009 577

 Sundaram et al.

Fig. 5—Volume-rendered images of anterior view

of heart in two patients in left anterior oblique
projection showing left coronary circulation.
A, Image in 58-year-old man with multiple cardiac
ischemic risk factors who presented with chest pain
shows left main artery (curved arrow), left anterior
descending (LAD) artery (arrowhead), and left
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circumflex artery (straight arrow). LAD also gives rise

to diagonal branches.
B, Image in 70-year-old woman shows ramus
intermedius branch (arrow).

ies, numbered sequentially as they arise
(OM1, OM2, and so forth). The LCX may
also continue posteriorly to the crux of the
heart; it gives rise to the PDA, the atrioven-
tricular nodal branch, and the posterolateral
LV branches. The LCX is divided into proxi-
mal and distal portions in relation to the ma-
jor OM branch origin.
The dominance of the coronary circula-
tion is determined by the circulation that
gives rise to the atrioventricular nodal artery,
the PDA, and the posterolateral LV branches
(Fig. 4). Eighty to 85% of the population
have right coronary circulation dominance,
8–10% have left coronary dominance, and
7–8% have codominance (balanced domi-
nance), in which the PDA and the postero-
lateral LV branches originate respectively
from the RCA and LCX (Fig. 4).
On coronary CTA, coronary artery seg-
ments can be reported in a standardized fash-
A B
ion using the widely followed AHA coronary
artery segmentation model defining 15 seg-
ments in which the proximal, mid, and distal
portions of the RCA are respectively segments
1–3; the PDA is segment 4; the LM is segment
5; the proximal, mid, and distal LAD are seg-
ments 6–8; the D1 and D2 are segments 9 and
10; the proximal and distal LCX are segments
11 and 13; the OM artery is segment 12; the
posterolateral LV branch is segment 14; and
the PDA, if present as a branch of the LCX, is
segment 15 [62].
Anomalous Coronary Artery Anatomy
Anomalies of the coronary arteries are
rare, occurring in 0.3–5.6% of the popula-
tion, and are often an incidental finding in
asymptomatic patients [63]. Most coronary
anomalies do not have an adverse clinical
outcome; however, the origin of a coronary
artery from the opposite sinus of Valsalva, or
a coronary artery with an interarterial course
of the proximal segment between the aortic
root and the RV outflow tract or pulmonary
artery can be potentially fatal. Hence, an in-
terarterial course is considered malignant,
whereas the retroaortic and prepulmonic
courses are considered either benign or non-
malignant. However, it is important to recog-
nize the retroaortic course in patients who
may potentially undergo surgery of the aortic
root or the ascending aorta (Figs. 6 and 7).
Accurate diagnosis of a coronary artery
anomaly is important, particularly in young
athletes or in young military recruits, because
up to one third of cardiac-related deaths in
that age group are related to such anomalies
[64]. For many years the diagnosis of coro-
nary anomalies was made on invasive catheter
coronary angiography or at autopsy. However,
the course of anomalous coronary arteries is
often difficult to determine at invasive cathe-

Fig. 6—Malignant course of coronary artery.

A, Oblique axial maximum-intensity-projection image
of aortic root in 14-year-old competitive male athlete
with exertional chest pain and palpitations shows
right coronary artery (curved arrow) arising from
left sinus of Valsalva (straight arrow) and coursing
in malignant fashion between right coronary sinus
(arrowhead) and right ventricular outflow tract
(RVOT). This anomalous coronary course was
surgically corrected.
B, Axial contrast-enhanced image at aortic root in
30-year-old woman shows left main coronary artery
(arrowhead) arising from right coronary sinus (arrow)
and coursing between RVOT and aortic root in
malignant fashion.
A B

578 AJR:192, March 2009

 Reporting of Cardiac MDCT

Fig. 7—73-year-old man with suspected anomalous

coronary artery on catheter angiography. MPA = main
pulmonary artery.
A, Oblique axial maximum-intensity-projection image of
aortic root shows origin of left circumflex artery (curved
arrow) arising from right coronary sinus and coursing
between aortic root and left atrium (LA) in nonmalignant
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(retroaortic) course. Straight arrow indicates right

coronary artery; arrowhead, left anterior descending
artery.
B, Volume-rendered right anterior oblique image shows
left anterior descending artery (arrowhead) coursing
anterior to main pulmonary trunk in nonmalignant
(prepulmonic) course. Arrow indicates right coronary
artery.

A B

artery anomalies and their significance. In

part 2 of this article [71], we discuss coro-
nary artery atherosclerotic disease and car-
diac function assessment.

ter coronary angiography. CT is now consid-
ered the test of choice for evaluating the course
of anomalous coronary arteries [65]. When
evaluating anomalous coronary arteries, it is
important to define the origin and course.
Coronary anomalies can be due to variations
of origin, course, intrinsic coronary anatomy,
and, rarely, termination [66, 67].
Coronary arteries are distributed along
the epicardial surface of the heart and are
surrounded by epicardial fat. When a coro-
nary artery segment tunnels through myo-
cardium, resulting in a submyocardial coro-
nary course that is preceded and succeeded
by an extramyocardial course, it is termed
“myocardial bridging” [68] (Fig. 8). Myo-
cardial bridging is more readily identifiable
on coronary CTA than on invasive catheter
coronary angiography [69]. Systolic com-
pression of myocardial bridging is found to
References
Fig. 8—44-year-old man with intermittent
nonspecific chest pain. Curved reformatted image
of mid left anterior descending artery shows
short segment of intramyocardial course (arrow)
preceded and succeeded by extramyocardial course,
suggesting myocardial bridging. LV = left ventricle.
correlate better with the depth than with the
length of the submyocardial segment [69].
Myocardial bridging may have a physiologic
limitation in coronary blood flow [70]; how-
ever, its significance remains debatable [68].
Summary
In conclusion, we have illustrated our
comprehensive approach to reporting coro-
nary CTA findings that includes patient prep-
aration, acquisition technique, coronary cal-
cium scoring, and normal and anomalous
coronary artery anatomy. This article may
provide fundamental information and im-
prove the understanding of coronary CTA
reporting pertaining to the background of
CT coronary imaging, the calcium scoring
technique, clinical indications for and impli-
cations of calcium scoring, coronary artery
anatomy, and an introduction to the coronary
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Appendices follow on next page
 Sundaram et al.

APPENDIX 1:  Our Structured Cardiac CT Report Template

CT Coronary Calcium Scoring:
• LMA = ( ), LAD = ( ), LCX = ( ), RCA = ( ), PDA = ( )
• Total calcium score = ( ) using the AJ-130 method and ( ) volume score
• ( ) percentile rank for age and gender, meaning that ( )% of patients of the same age and gender will have a higher score
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Coronary CT Angiography:
• Coronary arterial dominance (right, left, codominant)
• Left main, LAD and diagonals, LCX and obtuse marginal, RCA and posterior descending, ramus intermedius, and any anatomic
variants
• Quantification of stenoses (mild < 50%/mod 50–70%/severe > 70%)
Cardiac Structure, Morphology, and Function:
• Evaluation of short- and long-axis LV cines demonstrates (normal regional left ventricular wall motion) or (hypokinesis, akinesis, or
dyskinesis; specify wall or if global)
• LV functional parameters: end-diastolic volume, end-systolic volume, stroke volume, cardiac output, ejection fraction, LV mass
Summary:
1. Total coronary calcium score = ( ).
2. (Normal coronary arteries or specify abnormality).
3. (Normal or abnormal) left ventricular wall motion. LV ejection fraction = ( ).
4. (Normal or abnormal) cardiac chamber size.
Note—LMA = left main artery, LAD = left anterior descending artery, LCX = left circumflex artery, RCA = right coronary artery, PDA =
posterior descending artery, AJ-130 method = Agatston-Janowitz score of 130 HU, mod = moderate, LV = left ventricle.

APPENDIX 2:  Coronary CT Angiography, Technical Details

• Pharmaceutical agents (quantity, route, rate of administration)
• Cardiac rate, rhythm, scan coverage zone
• Scan delay time method, biphasic/triphasic bolus technique
• IV contrast: name, concentration, quantity, rate, and route
• Prospective/retrospective ECG gating techniques
• Radiation dose-reduction measures
• Computer workstation viewing software

Appendices continue on next page

582 AJR:192, March 2009

 Reporting of Cardiac MDCT

APPENDIX 3: Coronary CT Findings

Coronary Arteries:
• Calcium score with age/sex percentile rank
• Coronary artery origin, course, and dominance
• Atherosclerosis (plaque composition, luminal narrowing)
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Noncoronary Cardiovascular Structures:

• Quantitative evaluation of left ventricle (LV)
– Stroke volume (SV), ejection fraction (EF), cardiac output (CO), end-diastolic and end-systolic volumes (EDV and ESV)
• Qualitative evaluation of LV wall motion
• Cardiac chamber size and morphology (LV mass)
• Cardiac valve morphology
• Pericardium
• Other cardiovascular structures
– Aorta, pulmonary artery tree, and pulmonary veins
– Superior and inferior venae cavae
– Coronary veins
Noncardiovascular Structures:
• Lungs, pleura, airways
• Esophagus, mediastinal and hilar lymph nodes
• Diaphragm, body wall including osseous structures
• Upper abdominal contents (organs, bowel loops, mesentery)

APPENDIX 4: Recommended Use for Calcium Scoring CT

Asymptomatic Patients:
• Intermediate risk for coronary artery disease; total calcium score > 400 raises risk to high, justifying lifestyle modification
and pharmacological therapy maximization
Symptomatic Patients:
• A screeening tool before performing invasive procedures
• Functional testing (such as stress test) is not possible or is inconclusive
Note—Adapted from [42].

F O R YO U R I N F O R M AT I O N
• The reader’s attention is directed to part 2 of this article, titled “Anatomy and Terminology for the Interpretation
and Reporting of Cardiac MDCT: Part 2, CT Angiography, Cardiac Function Assessment, and Noncoronary and
Extracardiac Findings,” which appears on page 584.
• This article is available for CME credit. See www.arrs.org for more information.

AJR:192, March 2009 583

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