A 77-year-old male patient, non-allergic, ex-smoker, with a personal history of dilated cardiomyopathy of enolic origin, for which he underwent orthotopic cardiac transplantation nine years ago. In NYHA functional class I since the last annual check-up. The electrocardiogram showed normal sinus rhythm at 95 beats per minute (bpm), signs of left atrial dilatation and bifascicular block with right bundle branch block and left bundle branch hemiblock. Chest X-ray showed median sternotomy sutures, atheromatosis at the level of the atrial arch and cardiovascular silhouette within normal limits. A mildly hyperinflated chest suggestive of pulmonary emphysema with bilateral hilar prominence that appeared vascular was described. Transthoracic echocardiography showed that the global and regional systolic function of the transplanted heart was preserved (ejection fraction, EF: 0.61). An end-diastolic volume (EDV) of 73 ml, end-systolic volume (ESV) of 28 ml and myocardial mass of 93 grams were estimated. The ventricular filling pattern was that of the transplanted heart. There were no signs of elevated filling pressure. Dobutamine stress echocardiography was normal. The ischaemia challenge test was negative for myocardial ischaemia.
In order to study the coronary arteries and to rule out graft vasculopathy, FDCT coronary angiography was performed with the following parameters: 120 kV, 350 mAs effective for each tube, CTDIvol= 41 mGy. Seventy ml of iodinated contrast (Iomeron 400, 400 mgI/ml, Bracco, Milan, Italy) was administered through a right antecubital vein. During the scan the subject's mean heart rate was 80 bpm (range 78-83 bpm). The duration of apnoea was eight seconds. This examination showed left dominance with normal coronary arteries, without significant stenosis. The right coronary artery was of thin calibre, especially in its middle and distal thirds. An intermediate branch or bisector was observed as an anatomical variant. Calculation of left ventricular function by HRCT showed parameters superimposable to those obtained by echocardiography. Cardiac function was within normal limits with EF: 0.61, VTD 61 ml, VTS 24 ml and myocardial mass of 88 grams. No regional contractility abnormalities were observed. Since stress echocardiography was negative for myocardial ischaemia and non-invasive FDCT coronary angiography showed normal epicardial coronary arteries, conventional coronary angiography was discouraged.