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Lau WR, Lee PT, Koh CH. Coronary Artery Anomalies - State of the Art Review. Curr Probl Cardiol 2023; 48:101935. [PMID: 37433414 DOI: 10.1016/j.cpcardiol.2023.101935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 07/13/2023]
Abstract
Coronary artery anomalies (CAAs) comprise a wide spectrum of anatomic entities, with diverse clinical phenotypes. We present a case of an anomalous right coronary artery arising from the left aortic sinus with an interarterial course, a potentially fatal condition that can precipitate ischemia and sudden cardiac death. CAAs are increasingly detected in adults, mostly as incidental findings in the course of cardiac evaluation. This is due to the expanding use of invasive and noninvasive cardiac imaging, usually in the work-up for possible CAD. The prognostic implications of CAAs in this group of patients remain unclear. In AAOCA patients, appropriate work-up with anatomical and functional imaging should be performed for risk stratification. An individualized approach to management should be adopted, considering symptoms, age, sporting activities and the presence of high-risk anatomical features and physiologic consequences (such as ischemia, myocardial fibrosis, or cardiac arrhythmias) detected on multimodality imaging or other functional cardiac investigations. This comprehensive and up to date review seeks to crystallize current data in the recent literature, and proposes a clinical management algorithm for the clinician faced with the conundrum of managing such conditions.
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Affiliation(s)
- Wei Ren Lau
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Phong Teck Lee
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS School of Medicine, National University of Singapore, Singapore
| | - Choong Hou Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore; Duke-NUS School of Medicine, National University of Singapore, Singapore; Changi Aviation Medical Centre, Changi General Hospital, Singapore.
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2
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Bigler MR, Gräni C. Editorial commentary: To screen or not to screen - and other pending questions within the enigma of coronary artery anomalies. Trends Cardiovasc Med 2023; 33:529-530. [PMID: 35690297 DOI: 10.1016/j.tcm.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/04/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Marius Reto Bigler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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3
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Gräni C, Bigler MR, Kwong RY. Noninvasive Multimodality Imaging for the Assessment of Anomalous Coronary Artery. Curr Cardiol Rep 2023; 25:1233-1246. [PMID: 37851270 DOI: 10.1007/s11886-023-01948-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE OF REVIEW Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital coronary anomaly with the potential to cause myocardial ischemia and adverse cardiac events. The presence of AAOCA anatomy itself does not necessarily implicate a need for revascularization. Therefore, the purpose of this review is to assess how noninvasive comprehensive anatomic- and physiologic evaluation may guide patient management. RECENT FINDINGS The assessment of AAOCA includes an accurate description of the anomalous origin/vessel course including anatomical high-risk features such as a slit-like ostium, proximal narrowing, elliptic vessel shape, acute take-off angle, intramural course, and possible concomitant coronary atherosclerosis and hemodynamics. Various cardiac imaging modalities offer unique advantages and capabilities in visualizing these anatomical and functional aspects of AAOCA. This review explored the role of noninvasive multimodality imaging in the characterization of AAOCA by highlighting the strengths, limitations, and potential applications of the current different cardiac imaging methods, with a focus on the pathophysiology of myocardial ischemia and stress testing protocols.
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Affiliation(s)
- Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marius R Bigler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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4
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Warner ED, Gulati A, Halpern E, Fischman DL, Ruggiero NJ, Keith SW, Layser RB, McCarey M, Savage MP. Clinical Outcomes in Adult Patients With an Anomalous Right Coronary Artery from the Left Sinus of Valsalva. Am J Cardiol 2023; 204:122-129. [PMID: 37541148 DOI: 10.1016/j.amjcard.2023.07.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 08/06/2023]
Abstract
An anomalous origin of the right coronary artery from the opposite sinus of Valsalva with an intramural course (R-ACAOS-IM) may cause sudden cardiac death in children and adolescents. However, the natural history and management of patients in whom this anomaly is detected later during adulthood remains uncertain. The goals of this study were to assess the impact of an R-ACAOS-IM on the clinical outcomes in an adult population and to determine if adult patients with this anomaly who do not have significant coronary artery disease (CAD) can be managed safely without surgical intervention. A database review identified patients aged >35 years with anomalous coronary arteries diagnosed by cardiac catheterization or coronary computed tomography angiography. The outcomes of patients with R-ACAOS-IM were compared with patients with anomalous left circumflex coronary arteries with retroaortic course (LCx-RA) (an anomaly not associated with ischemic events). The primary outcome was all-cause mortality. The study population consisted of 185 patients aged 59 ± 12 years. Clinical characteristics were similar in the R-ACAOS-IM (n = 88) and LCx-RA (n = 97) groups. At a follow-up of 6.6 ± 4.5 years, there was no difference in mortality (hazard ratio 0.64, 95% confidence interval 0.32 to 1.28, p = 0.20) when adjusted for gender, age, and CAD. A subgroup analysis of 88 patients with no obstructive CAD managed nonoperatively found no difference between the LCx and R-ACAOS-IM groups in mortality (hazard ratio 2.45, 95% confidence interval 0.45 to 13.40, p = 0.30). There was no significant difference between the 2 groups in the composite outcome of death, nonfatal myocardial infarction, or survived cardiac arrest. The outcome of adult patients who have anomalous R-ACAOS-IM are similar to patients who have anomalous LCx-RA with a known benign course. In conclusion, these results suggest that most patients who survive this anomaly into adulthood may be managed conservatively without intervention.
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Affiliation(s)
- Eric D Warner
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Aishwarya Gulati
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ethan Halpern
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - David L Fischman
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nicholas J Ruggiero
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Scott W Keith
- Division of Biostatistics, Department of Pharmacology Physiology and Cancer Biology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Robert B Layser
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Radiology, Chesapeake Regional Medical Center, Chesapeake, Virginia
| | - Melissa McCarey
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael P Savage
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania.
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Stark AW, Giannopoulos AA, Pugachev A, Shiri I, Haeberlin A, Räber L, Obrist D, Gräni C. Application of Patient-Specific Computational Fluid Dynamics in Anomalous Aortic Origin of Coronary Artery: A Systematic Review. J Cardiovasc Dev Dis 2023; 10:384. [PMID: 37754814 PMCID: PMC10532130 DOI: 10.3390/jcdd10090384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 09/28/2023] Open
Abstract
Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital heart condition with fixed and dynamic stenotic elements, potentially causing ischemia. Invasive coronary angiography under stress is the established method for assessing hemodynamics in AAOCA, yet it is costly, technically intricate, and uncomfortable. Computational fluid dynamics (CFD) simulations offer a noninvasive alternative for patient-specific hemodynamic analysis in AAOCA. This systematic review examines the role of CFD simulations in AAOCA, encompassing patient-specific modeling, noninvasive imaging-based boundary conditions, and flow characteristics. Screening articles using AAOCA and CFD-related terms prior to February 2023 yielded 19 publications, covering 370 patients. Over the past four years, 12 (63%) publications (259 patients) employed dedicated CFD models, whereas 7 (37%) publications (111 patients) used general-purpose CFD models. Dedicated CFD models were validated for fixed stenosis but lacked dynamic component representation. General-purpose CFD models exhibited variability and limitations, with fluid-solid interaction models showing promise. Interest in CFD modeling of AAOCA has surged recently, mainly utilizing dedicated models. However, these models inadequately replicate hemodynamics, necessitating novel CFD approaches to accurately simulate pathophysiological changes in AAOCA under stress conditions.
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Affiliation(s)
- Anselm W. Stark
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.W.S.); (I.S.); (A.H.); (L.R.)
| | - Andreas A. Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, 8091 Zurich, Switzerland;
| | | | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.W.S.); (I.S.); (A.H.); (L.R.)
| | - Andreas Haeberlin
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.W.S.); (I.S.); (A.H.); (L.R.)
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.W.S.); (I.S.); (A.H.); (L.R.)
| | - Dominik Obrist
- ARTORG Center for Biomedical Engineering Research, Faculty of Medicine, University of Bern, 3008 Bern, Switzerland;
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (A.W.S.); (I.S.); (A.H.); (L.R.)
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Formato GM, Agnifili ML, Arzuffi L, Rosato A, Ceserani V, Zuniga Olaya KG, Secchi F, Deamici M, Conti M, Auricchio F, Bedogni F, Frigiola A, Lo Rito M. Morphological Changes of Anomalous Coronary Arteries From the Aorta During the Cardiac Cycle Assessed by IVUS in Resting Conditions. Circ Cardiovasc Interv 2023; 16:e012636. [PMID: 37417226 PMCID: PMC10348625 DOI: 10.1161/circinterventions.122.012636] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Anomalous aortic origin of coronary artery (AAOCA) with intramural segment is associated with risk of sudden cardiac death, probably related to a compressive mechanism exerted by the aorta. However, the intramural compression occurrence and magnitude during the cardiac cycle remain unknown. We hypothesized that (1) in end diastole, the intramural segment is narrower, more elliptic, and has greater resistance than extramural segment; (2) the intramural segment experiences a further compression in systole; and (3) morphometry and its systolic changes vary within different lumen cross-sections of the intramural segment. METHODS Phasic changes of lumen cross-sectional coronary area, roundness (minimum/maximum lumen diameter), and hemodynamic resistance (Poiseuille law for noncircular sections) were derived from intravascular ultrasound pullbacks at rest for the ostial, distal intramural, and extramural segments. Data were obtained for 35 AAOCA (n=23 with intramural tract) after retrospective image-based gating and manual lumen segmentation. Differences between systolic and end-diastolic phases in each section, between sections of the same coronary, and between AAOCA with and without intramural tract were assessed by nonparametric statistical tests. RESULTS In end diastole, both the ostial and distal intramural sections were more elliptical (P<0.001) than the reference extramural section and the correspondent sections in AAOCA without intramural segment. In systole, AAOCA with intramural segment showed a flattening at the ostium (-6.76% [10.82%]; P=0.024) and a flattening (-5.36% [16.56%]; P=0.011), a narrowing (-4.62% [11.38%]; P=0.020), and a resistance increase (15.61% [30.07%]; P=0.012) at the distal intramural section. No-intramural sections did not show morphological changes during the entire cardiac cycle. CONCLUSIONS AAOCA with intramural segment has pathological segment-specific dynamic compression mainly in the systole under resting conditions. Studying AAOCA behavior with intravascular ultrasound during the cardiac cycle may help to evaluate and quantify the severity of the narrowing.
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Affiliation(s)
| | - Mauro Luca Agnifili
- Department of Clinical and Interventional Cardiology (M.L.A., L.A., M.D., F.B.), University of Pavia, Italy
| | - Luca Arzuffi
- Department of Clinical and Interventional Cardiology (M.L.A., L.A., M.D., F.B.), University of Pavia, Italy
| | - Antonio Rosato
- 3D and Computer Simulation Laboratory (G.M.F., A.R.), University of Pavia, Italy
| | - Valentina Ceserani
- IRCCS Policlinico San Donato, Milan, Italy. Department of Civil Engineering and Architecture, University of Pavia, Italy (V.C., M.C., F.A.)
| | | | - Francesco Secchi
- Department of Radiology (F.S.), University of Pavia, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy (F.S.)
| | - Miriam Deamici
- Department of Clinical and Interventional Cardiology (M.L.A., L.A., M.D., F.B.), University of Pavia, Italy
| | - Michele Conti
- IRCCS Policlinico San Donato, Milan, Italy. Department of Civil Engineering and Architecture, University of Pavia, Italy (V.C., M.C., F.A.)
| | - Ferdinando Auricchio
- IRCCS Policlinico San Donato, Milan, Italy. Department of Civil Engineering and Architecture, University of Pavia, Italy (V.C., M.C., F.A.)
| | - Francesco Bedogni
- Department of Clinical and Interventional Cardiology (M.L.A., L.A., M.D., F.B.), University of Pavia, Italy
| | - Alessandro Frigiola
- Department of Congenital Cardiac Surgery (K.G.Z.O., A.F., M.L.R.), University of Pavia, Italy
| | - Mauro Lo Rito
- Department of Congenital Cardiac Surgery (K.G.Z.O., A.F., M.L.R.), University of Pavia, Italy
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7
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Bigler MR, Kadner A, Räber L, Ashraf A, Windecker S, Siepe M, Padalino MA, Gräni C. Therapeutic Management of Anomalous Coronary Arteries Originating From the Opposite Sinus of Valsalva: Current Evidence, Proposed Approach, and the Unknowing. J Am Heart Assoc 2022; 11:e027098. [PMID: 36205254 DOI: 10.1161/jaha.122.027098] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) are a challenge because of their various anatomic and clinical presentation. Although the prevalence is low, the absolute numbers of detected ACAOS are increasing because of the growing use of noninvasive anatomical imaging for ruling out coronary artery disease. As evidence-based guidelines are lacking, treating physicians are left in uncertainty for the optimal management of such patients. The sole presence of ACAOS does not justify surgical correction, and therefore a thorough anatomic and hemodynamic assessment is warranted. Invasive and noninvasive multimodality imaging provides information to the clinical question whether the presence of ACAOS is an innocent coincidental finding, is responsible for the patient's symptoms, or even might be a risk for sudden cardiac death. Based on recent clinical data, focusing on the pathophysiology of patients with ACAOS, myocardial ischemia is dependent on both the extent of fixed and dynamic components, represented by anatomic high-risk features. These varying combinations should be considered individually in the decision making for the different therapeutic options. This state-of-the-art review focuses on the advantages and limitations of the common contemporary surgical, interventional, and medical therapy with regard to the anatomy and pathophysiology of ACAOS. Further, we propose a therapeutic management algorithm based on current evidence on multimodality invasive and noninvasive imaging findings and highlight remaining gaps of knowledge.
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Affiliation(s)
- Marius Reto Bigler
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Alexander Kadner
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery Inselspital Bern Switzerland
| | - Lorenz Räber
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Afreed Ashraf
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Stephan Windecker
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Matthias Siepe
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery Inselspital Bern Switzerland
| | - Massimo Antonio Padalino
- Section of Pediatric and Congenital Cardiac Surgery, Department of Cardio-Thoracic and Vascular Sciences, and Public Health University of Padova, Medical School Padova Italy
| | - Christoph Gräni
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
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8
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Koppel CJ, Verheijen DBH, Kiès P, Egorova AD, Lamb HJ, Voskuil M, Jukema JW, Koolbergen DR, Hazekamp MG, Schalij MJ, Jongbloed MRM, Vliegen HW. A comprehensive analysis of the intramural segment in interarterial anomalous coronary arteries using computed tomography angiography. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac031. [PMID: 35919578 PMCID: PMC9277063 DOI: 10.1093/ehjopen/oeac031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/08/2022] [Accepted: 04/25/2022] [Indexed: 11/12/2022]
Abstract
Abstract
Aims
An anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) with an interarterial course can be assessed using computed tomography angiography (CTA) for the presence of high-risk characteristics associated with sudden cardiac death. These features include a slit-like ostium, acute angle take-off, proximal luminal narrowing, and an intramural segment. To date, no robust CTA criteria exist to determine the presence of an intramural segment. We aimed to deduct new CTA parameters to distinguish an intramural course of interarterial ACAOS.
Methods and results
Twenty-five patients with an interarterial ACAOS (64% female, mean age 46 years, 88% right ACAOS) from two academic hospitals were evaluated. Inclusion criteria were the availability of a preoperative CTA scan (0.51 mm slice thickness) and peroperative confirmation of the intramural segment. Using multiplanar reconstruction of the CTA, the distance between the lumen of the aorta and the lumen of the ACAOS [defined as ‘interluminal space’ (ILS)] was assessed at 2 mm intervals along the intramural segment. Analysis showed a mean ILS of 0.69 ± 0.15 mm at 2 mm from the ostium. At the end of the intramural segment where the ACAOS becomes non-intramural, the mean ILS was significantly larger (1.27 ± 0.29 mm, P < 0.001). Interobserver agreement evaluation showed good reproducibility (intraclass correlation coefficient 0.77, P < 0.001). Receiver operator characteristic analysis demonstrated that at a cut-off ILS of <0.95 mm, an intramural segment can be diagnosed with 100% sensitivity and 84% specificity.
Conclusion
The ILS is introduced as a novel and robust CTA parameter to identify an intramural course of interarterial ACAOS. An ILS of <0.95 mm is indicative of an intramural segment.
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Affiliation(s)
- Claire J Koppel
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center , Leiden , The Netherlands
| | - Diederick B H Verheijen
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center , Leiden , The Netherlands
| | - Philippine Kiès
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center , Leiden , The Netherlands
| | - Anastasia D Egorova
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center , Leiden , The Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center , Leiden , The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht , Utrecht , The Netherlands
| | - J Wouter Jukema
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center , Leiden , The Netherlands
| | - Dave R Koolbergen
- Department of Cardiothoracic Surgery, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center , Leiden , The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center , Leiden , The Netherlands
| | - Martin J Schalij
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center , Leiden , The Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center , Leiden , The Netherlands
- Department of Anatomy & Embryology, Leiden University Medical Center , Leiden , The Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, CAHAL, Center for Congenital Heart Disease Amsterdam-Leiden, Leiden University Medical Center , Leiden , The Netherlands
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Bashyal K, Koirala B, Bhattarai A, Baral RK, Khakural P, Shakya S, Kadel PB. Spectrum of coronary anomalies and their categorical approach: rare case series. J Surg Case Rep 2022; 2022:rjac310. [PMID: 35794994 PMCID: PMC9252329 DOI: 10.1093/jscr/rjac310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 06/02/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
The incidence of coronary artery anomalies (CAAs) is 0.2–1.2% of the population. Its paradox of being a rare entity with presentation ranging from sudden cardiac death, congestive heart failure, myocardial infarction to being clinically silent, asserts a challenge to its treating physician. Among the various major categories of CAA, we describe four different types of these anomalies in our retrospective evaluation over 2 years. They include – coronary cameral fistula with coronary aneurysm, congenital atresia of left main, anomalous aortic origin of left anterior descending (LAD) and circumflex artery (LCx) with malignant LAD course, anomalous origin of left coronary artery from pulmonary artery (ALCAPA). Although the child with ALCAPA succumbed despite every possible and available timely efforts, other patients had good postoperative recovery and a brief hospital stay.
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Affiliation(s)
- Krishnaprasad Bashyal
- Department of Cardiac Surgery , Manmohan Cardiothoracic Vascular and Transplant Center, TUTH, Kathmandu, Nepal
| | - Bhagawan Koirala
- Department of Cardiac Surgery , Manmohan Cardiothoracic Vascular and Transplant Center, TUTH, Kathmandu, Nepal
| | - Anil Bhattarai
- Department of Cardiac Surgery , Manmohan Cardiothoracic Vascular and Transplant Center, TUTH, Kathmandu, Nepal
| | - Ravi Kumar Baral
- Department of Cardiac Surgery , Manmohan Cardiothoracic Vascular and Transplant Center, TUTH, Kathmandu, Nepal
| | - Prabhat Khakural
- Department of Cardiac Surgery , Manmohan Cardiothoracic Vascular and Transplant Center, TUTH, Kathmandu, Nepal
| | - Samir Shakya
- Department of Pediatric Cardiology , Manmohan Cardiothoracic Vascular and Transplant Center, TUTH, Kathmandu, Nepal
| | - Prashiddha Bikram Kadel
- Department of Cardiac Surgery , Manmohan Cardiothoracic Vascular and Transplant Center, TUTH, Kathmandu, Nepal
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10
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Schiavone M, Gobbi C, Gasperetti A, Zuffi A, Forleo GB. Congenital Coronary Artery Anomalies and Sudden Cardiac Death. Pediatr Cardiol 2021; 42:1676-1687. [PMID: 34459947 DOI: 10.1007/s00246-021-02713-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
Coronary artery anomalies (CAAs) are a heterogeneous group of rare congenital diseases whose features and pathophysiological mechanisms are extremely variable, ranging from silent anomalies to sudden cardiac death (SCD) in the most severe cases. Although rare, congenital CAAs confer a high risk of myocardial ischemia and SCD, especially in young, previously "healthy" athletes during or immediately after vigorous exertion. Although some high-risk features that may lead to SCD have been identified, specific pathophysiological mechanisms related to SCD still remain poorly understood. When a CAA is incidentally diagnosed, optimal SCD risk stratification remains challenging, particularly in cases of anomalous aortic origin of a coronary artery arising from the opposite aortic sinus of Valsalva (ACAOS). In recent times, invasive imaging with intravascular ultrasound has gained a role in further identifying high-risk anatomic features; it has been integrated with traditional, non-invasive anatomic imaging evaluations, typically high-quality echocardiography, and cardiac magnetic resonance. Multidisciplinary programs and specific SCD risk scores should be developed in an endeavor to choose the right therapeutic approach, either clinical or interventional/surgical. Intravascular ultrasound is an extremely useful tool to evaluate vessel stenosis, even if prospective studies are still required to further validate this diagnostic strategy. In the present review, we aimed to analyze the pathophysiology and the clinical impact of ACAOS. We also summarized the predominant mechanisms for interference with normal coronary artery function, which might contribute to the onset of life-threatening arrhythmias and SCD.
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Affiliation(s)
- Marco Schiavone
- Cardiology Unit, ASST Fatebenefratelli Sacco - Luigi Sacco University Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy.
| | - Cecilia Gobbi
- Department of Cardiology, Saint Martin Private Hospital Center, Caen, France
| | - Alessio Gasperetti
- Cardiology Unit, ASST Fatebenefratelli Sacco - Luigi Sacco University Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy.,Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrea Zuffi
- Department of Cardiology, Saint Martin Private Hospital Center, Caen, France
| | - Giovanni Battista Forleo
- Cardiology Unit, ASST Fatebenefratelli Sacco - Luigi Sacco University Hospital, University of Milan, Via G.B. Grassi, 74, 20157, Milan, Italy
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11
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Abstract
Anomalous origin of right coronary artery with interarterial course (ARCA-IA) is a risk factor for sudden death and other cardiac complications. Surgical correction remains its gold standard treatment. We describe clinical characteristics, workup, surgical techniques and outcomes of ARCA-IA at our center. A retrospective analysis of cardiovascular database was performed. From March 2005 through January 2011, 11 patients with mean age of 53 ± 18 years were diagnosed with ARCA-IA. Reported symptoms included chest pain (64%), arrhythmia [27%; i.e. atrial flutter (9%), recurrent supraventricular tachycardia (9%), ventricular tachycardia (9%)], syncope (18%), dyspnea (9%) and aborted sudden cardiac death (9%). Chest pain (n = 7) was episodic and lasted longer than 6 months before diagnosis. Initial diagnosis was made at coronary computed tomography in two patients and at cardiac catheterization in nine patients. Four patients had positive stress test and were subsequently found to have ARCA-IA at cardiac catheterization. There was no operative mortality. Surgery (bypass with ligation of native vessel or translocation and reimplantation) was performed in seven patients. Three patients refused surgery, and in one patient, surgery was not considered due to comorbidities. Symptom relief was noted in all surgical patients. At mean follow-up of 36 months, two patients had noncardiac-related deaths whereas nine were asymptomatic. There were no deaths reported in patients treated surgically. Definitive surgery is indicated in symptomatic ARCA-IA and is associated with excellent long-term outcome. RCA dominance in ARCA-IA is an adverse marker with increased symptoms; this hypothesis should be tested in larger studies.
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12
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Adam EL, Generoso G, Bittencourt MS. Anomalous Coronary Arteries: When to Follow-up, Risk Stratify, and Plan Intervention. Curr Cardiol Rep 2021; 23:102. [PMID: 34196813 DOI: 10.1007/s11886-021-01535-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Coronary artery anomalies are a diverse group of entities, ranging from benign variations of normal anatomy to life-threatening conditions. There is, however, no universal consensus in their classification, risk stratification, and management. The aim of this review is to develop a straightforward clinical approach for the assessment and care of patients with anomalous coronary arteries. RECENT FINDINGS Autopsy series and population screening studies have recently provided useful clinical data on the prevalence and outcomes of coronary anomalies. Also, findings on coronary computed tomography angiography, magnetic resonance imaging, and invasive angiography, enriched with fractional flow reserve and intravascular ultrasound, have allowed identification of several high-risk features associated with specific coronary anomalies. Management of patients with anomalous coronary arteries requires an individualized approach based on clinical, physiological, and anatomic features. High-quality studies are paramount for further development of this fascinating field.
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Affiliation(s)
| | - Giuliano Generoso
- University Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Marcio Sommer Bittencourt
- University Hospital, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
- DASA, Sao Paulo, Brazil.
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13
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Meijer FMM, Kiès P, Verheijen DBH, Vliegen HW, Jongbloed MRM, Hazekamp MG, Lamb HJ, Egorova AD. Computed Tomography Derived Coronary Triangulated Orifice Area-Deduction of a New Parameter for Follow-up After Surgical Correction of Anomalous Aortic Origin of Coronary Arteries and Call for Validation. Front Cardiovasc Med 2021; 8:668503. [PMID: 34250037 PMCID: PMC8263932 DOI: 10.3389/fcvm.2021.668503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/25/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction: Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus of Valsalva is a rare congenital abnormality. Computed tomography angiography (CTA) is primarily used as a diagnostic tool to evaluate the anatomy and identify potentially malignant AAOCA variants. Limited data is available on the role of CTA during postoperative follow-up. We aimed to develop an objective CTA derived parameter for diagnostic evaluation and follow-up after surgical correction of AAOCA and correlate the anatomical features to the postoperative outcome. Methods: All consecutive patients who underwent surgical repair of AAOCA from 2001 to 2018 and had pre and postoperative CTA imaging available were included. A retrospective analysis of the pre- and postoperative CTA and the outcomes was performed. The origin and course of the anomalous coronary artery and the ostial dimensions were evaluated and correlated with restenosis of operated coronary artery. To allow an accurate evaluation of the effective orifice area at diagnosis and after surgical repair we deduce and propose a new parameter—the coronary triangulated orifice area (CTOA). Results: Out of the 54 patients who underwent surgical treatment for AAOCA, 11 fulfilled the inclusion criteria. The median follow-up was 19 months [IQR 3;42]. The mean age at surgery was 41 ± 16 years, with six patients (55%) being male. Postoperatively, the angle between the proximal coronary artery and the aortic wall increased from 20 ± 5° to 28 ± 9° (p < 0.01) and ostial diameter in the transversal plane increased from 4.1 ± 2.5 mm to 6.2 ± 2.7 mm (p < 0.01). The median CTOA increased significantly from 1.6 mm2 [IQR 0.9;4.9] to 5.5 mm2 [IQR 3;11.8] (p < 0.005). During follow-up, in three patients a restenosis of the operated coronary artery was suspected. In these patients, the CTOA only showed a limited postoperative increase of ≤ 1.4 mm2. Conclusions: CTA can play an important role in the evaluation of the pre- and postoperative anatomy in AAOCA patients. CTOA may be of use in conjunction with the acute angle take-off and ostial diameter order to comprehensively evaluate the operated ostium after unroofing or patch angioplasty.
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Affiliation(s)
- Fleur M M Meijer
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden, Netherlands.,Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Philippine Kiès
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden, Netherlands.,Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Diederick B H Verheijen
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden, Netherlands.,Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Hubert W Vliegen
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden, Netherlands.,Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden, Netherlands.,Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands.,Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G Hazekamp
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden, Netherlands.,Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Anastasia D Egorova
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden, Netherlands.,Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
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14
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Courand PY, Bozio A, Ninet J, Boussel L, Bakloul M, Galoin-Bertail C, Metton O, Mitchell J, de Montclos TP, Walton C, Di Filippo S. Diagnosis and treatment of anomalous aortic origin of coronary artery: A twenty-year retrospective study of experience and decision-making in children and young adults. Int J Cardiol 2021; 337:54-61. [PMID: 33945804 DOI: 10.1016/j.ijcard.2021.04.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/24/2021] [Accepted: 04/29/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Anomalous aortic origin of a coronary artery, particularly in the presence of inter-arterial course between the great arteries, has been found to be associated with sudden death in young people. METHODS This study reports a single-center experience in the management of anomalous aortic origin of a coronary artery, with or without inter-arterial course, by focusing specifically on presentation, diagnosis, and patient outcome. RESULTS From March 1993 to February 2018, 100 patients (70 males) were diagnosed with anomalous aortic origin of a coronary artery, including 27 left coronary artery from the right sinus, 60 right coronary artery from the left sinus, and 13 other anomalies. Patients with inter-arterial course between the great arteries presented more frequently with syncope and/or sudden death compared to patients without (23.4% vs. 0%, p = 0.026). Diagnosis was reached using first-line transthoracic echocardiography in 65% of cases. Surgical repair was performed in 61 patients (61%). All operated patients (60 direct implantations, 1 unroofing) had been diagnosed with inter-arterial course between the great arteries, and were asymptomatic at a mean (±SD) postoperative follow-up of 4.9 ± 5.3 years. CONCLUSIONS An inter-arterial course of the anomalous right or left coronary arteries arising from the opposite sinus is associated with life-threatening events. Direct reimplantation of coronary artery is reliable, and should be discussed even in asymptomatic patients.
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Affiliation(s)
- Pierre-Yves Courand
- Fédération de cardiologie, Hôpital de la Croix-Rousse et Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France; Université de Lyon, CREATIS, CNRS UMR5220, INSERM U1044, INSA-Lyon, Université Claude Bernard Lyon 1, France
| | - Andre Bozio
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France
| | - Jean Ninet
- Service de chirurgie cardiaque, Hôpital Louis Pradel Hospices civils de Lyon, 69317 Lyon cedex 04, France
| | - Loic Boussel
- Service de radiologie, Hôpital de la Croix-Rousse, Hospices civils de Lyon, 69317 Lyon cedex 04, France
| | - Mohamed Bakloul
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France
| | - Claire Galoin-Bertail
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France
| | - Olivier Metton
- Service de chirurgie cardiaque, Hôpital Louis Pradel Hospices civils de Lyon, 69317 Lyon cedex 04, France
| | - Julia Mitchell
- Service de chirurgie cardiaque, Hôpital Louis Pradel Hospices civils de Lyon, 69317 Lyon cedex 04, France
| | - Thomas Perouse de Montclos
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France
| | - Camille Walton
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France
| | - Sylvie Di Filippo
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France.
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15
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Bigler MR, Huber AT, Räber L, Gräni C. A case report of a symptomatic right anomalous coronary artery with concomitant atherosclerotic disease: the benefit of a sequential comprehensive non-invasive and invasive diagnostic approach. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab081. [PMID: 33718769 PMCID: PMC7939695 DOI: 10.1093/ehjcr/ytab081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/04/2020] [Accepted: 02/04/2021] [Indexed: 11/13/2022]
Abstract
Background Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital disease associated with an increased risk of myocardial ischaemia, ventricular arrhythmias, and heart failure. Case summary A 75-year-old Caucasian man was referred for invasive coronary angiography (ICA) due to atypical chest pain. Invasive coronary angiography demonstrated non-significant atherosclerotic disease of the left coronary artery and an anomalous origin of the right coronary artery (RCA); without selective intubation. Coronary computed tomography angiography (CCTA) revealed a right-AAOCA with interarterial and intramural course, and a soft plaque in the distal RCA. Subsequent physical-stress single-photon emissions computed tomography (SPECT) showed exercise-induced inferoapical myocardial ischaemia, giving a Class IC level of evidence for surgical correction of the AAOCA. Repeated ICA with selective R-AAOCA intubation confirmed an 80% distal atherosclerotic stenosis, which was treated with direct stenting. Subsequent invasive physiologic evaluation under maximal dobutamine-volume challenge (gradually increasing dose of dobutamine max. 40 μg/kg per body weight/min, 3000 mL ringer lactate and 1 mg atropine was given until the patient reached a maximum of 145 b.p.m.), revealed a haemodynamically non-relevant anomalous segment with a fractional flow reserve (FFR) of 0.91. A follow-up SPECT was normal, and the patient was completely symptom-free at 1 month. Discussion We present the sequential diagnostic approach in a symptomatic patient with a right anomalous coronary artery and concomitant atherosclerotic disease. Using this approach, the patient could be deferred from guideline recommended open-heart surgery of the AAOCA, as direct invasive dobutamine/volume FFR revealed haemodynamic non-relevance of the anomalous segment after stenting the concomitant atherosclerotic stenosis in the distal segment within the same coronary artery.
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Affiliation(s)
- Marius Reto Bigler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Adrian Thomas Huber
- Department of Diagnostic, Interventional and Paediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
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16
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Bigler MR, Ashraf A, Seiler C, Praz F, Ueki Y, Windecker S, Kadner A, Räber L, Gräni C. Hemodynamic Relevance of Anomalous Coronary Arteries Originating From the Opposite Sinus of Valsalva-In Search of the Evidence. Front Cardiovasc Med 2021; 7:591326. [PMID: 33553251 PMCID: PMC7859106 DOI: 10.3389/fcvm.2020.591326] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/23/2020] [Indexed: 12/16/2022] Open
Abstract
Coronary artery anomalies (CAA) represent a heterogeneous group of congenital disorders of the arterial coronary circulation, defined by an anomalous origin of the coronary ostium and/or vessel course. Of particular interest are anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). The interarterial variants (with the anomalous vessel situated between the great arteries) are historically called "malignant," based on an anticipated higher risk for myocardial ischemia and sudden cardiac death (SCD), especially affecting young patients during strenuous physical activity. However, the interarterial course itself may not be the predominant cause of ischemia, but rather represents a surrogate for other ischemia-associated anatomical high-risk features. As the exact pathophysiology of ACAOS is not well-understood, there is a lack of evidence-based guidelines addressing optimal diagnostic work-up, downstream testing, sports counseling, and therapeutic options in patients with ACAOS. Therefore, treating physicians are often left with uncertainty regarding the clinical management of affected patients. This review focuses on the pathophysiologic consequences of ACAOS on myocardial ischemia and discusses the concept of the interplay between fixed and dynamic coronary stenosis. Further, we discuss the advantages and limitations of the different diagnostic modalities and give an outlook by highlighting the gaps of knowledge in the assessment of such anomalies.
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Affiliation(s)
- Marius Reto Bigler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Afreed Ashraf
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Seiler
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yasushi Ueki
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Kadner
- Department of Cardiovascular Surgery, Centre for Congenital Heart Disease, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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17
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Tso J, Turner CG, Kim JH. A Hidden Threat: Anomalous Aortic Origins of the Coronary Arteries in Athletes. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22. [PMID: 34177246 DOI: 10.1007/s11936-020-00859-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Purpose of Review Anomalous aortic origins of the coronary arteries (AAOCA) are a primary cause of sudden cardiac death in athletes. This review will detail the epidemiology, pathophysiology, and risk stratification of AAOCA, while also highlighting return-to-play considerations for athletes. Recent Findings Sport pre-participation cardiovascular screening methods lack sensitivity and specificity in the identification of AAOCA. For the symptomatic athlete, clinicians must maintain a heightened clinical suspicion for AAOCA in order to proceed with appropriate cardiac imaging and functional assessments. Anomalous origin of the left coronary artery with an interarterial course is considered high-risk and requires sport restriction until surgical correction. In contrast, risks associated with anomalous origin of the right coronary artery are controversial, thus management and sports eligibility decisions may incorporate principles of shared-decision making. Summary Management options for athletes with AAOCA are complex, requiring a comprehensive clinical evaluation. While advances in multimodality cardiovascular imaging and physiologic functional assessments have improved AAOCA risk stratification, best practice treatment strategies for some AAOCA subtypes remain uncertain. As such, clinical management and sport eligibility decisions require an individualized approach. Future prospective data will guide optimization of treatment strategies for athletes with AAOCA.
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Affiliation(s)
- Jason Tso
- Division of Cardiology, Emory Clinical Cardiology Research Institute, Atlanta, GA
| | - Casey G Turner
- Division of Cardiology, Emory Clinical Cardiology Research Institute, Atlanta, GA
| | - Jonathan H Kim
- Division of Cardiology, Emory Clinical Cardiology Research Institute, Atlanta, GA
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18
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Cavallo AU, Muscogiuri E, Forcina M, Colombo A, Fiore F, Sperandio M. Trans-septal course of anomalous left main coronary artery originating from single right coronary ostium presenting with atrial fibrillation in a severely obese patient: a case report. Egypt Heart J 2020; 72:61. [PMID: 32955624 PMCID: PMC7505909 DOI: 10.1186/s43044-020-00093-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/27/2020] [Indexed: 11/22/2022] Open
Abstract
Background To present a case of anomalous origin of the left coronary artery evaluated with invasive coronary angiography (ICA) and ECG-gated coronary computed tomography (CCT). Case presentation A patient (55 years old, male) with a past medical history of respiratory failure and atrial fibrillation underwent ICA to rule out coronary artery disease. Subsequently, the patient underwent ECG-gated CCT to evaluate a suspected anomalous aortic origin of the left coronary artery, since the interventional cardiologist was not able to properly identify the left coronary artery and its distal branches. CCT showed left coronary artery originating from the right coronary Valsalva sinus, coursing within the interventricular septum and emerging at the middle segment of the interventricular sulcus, where the left anterior descending and circumflex arteries originated. Conclusion The case we presented highlights the value of ECG-gated CCT in the evaluation of coronary anomaly anatomy and thus risk stratification derived by proper coronary anatomy assessment. Although ICA was not helpful in the diagnosis, it also has a pivotal role regarding the therapeutic management of this condition.
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Affiliation(s)
- Armando Ugo Cavallo
- Division of Radiology, San Carlo di Nancy Hospital, GVM Care and Research, Rome, Italy. .,Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Viale Oxford, 81, 00133, Rome, Italy.
| | - Emanuele Muscogiuri
- Division of Radiology, University Hospital Sant'Andrea, University of Rome "La Sapienza", Rome, Italy
| | - Marco Forcina
- Division of Radiology, San Carlo di Nancy Hospital, GVM Care and Research, Rome, Italy.,Division of Radiology, Policlinico Militare Celio, Rome, Italy
| | - Antonio Colombo
- Interventional Cardiology Unit, San Carlo di Nancy Hospital, GVM Care and Research, Rome, Italy.,Maria Cecilia Hospital, Cotignola, RA, Italy
| | - Flavio Fiore
- Intensive Care Unit, San Carlo di Nancy Hospital, GVM Care and Research, Rome, Italy
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19
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Ponsford MJ, Clark J, Mock J, Abinun M, Carne E, El-Shanawany T, Williams PE, Choudhury A, Freeman AF, Gennery AR, Jolles S. Hematopoietic Stem Cell Transplantation and Vasculopathy Associated With STAT3-Dominant-Negative Hyper-IgE Syndrome. Front Pediatr 2020; 8:575. [PMID: 33014947 PMCID: PMC7511721 DOI: 10.3389/fped.2020.00575] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/06/2020] [Indexed: 02/04/2023] Open
Abstract
Dominant negative mutations in the transcription-factor STAT3 underlie the rare primary immunodeficiency Job's syndrome. Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) has shown promise in correction of the underlying immunological defect, with one report suggesting HSCT can prevent development of wider connective tissue complications. Here, we report the case of a 26 year old male who developed an acute ST-elevation myocardial infarction due to coronary artery ectasia and thrombosis, occurring despite pediatric allogeneic HSCT for STAT3-HIES and a predicted 10-year conventional cardiovascular risk of 0.1%. Vasculopathy associated with STAT3-HIES may persist or arise following HSCT and can precipitate life-threatening complications. This has implications for counseling and vascular surveillance, and highlights the need for further studies to determine the risk, pathogenesis, and optimal management of the vasculopathy associated with STAT3-HIES.
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Affiliation(s)
- Mark J. Ponsford
- Immunodeficiency Centre for Wales, University Hospital for Wales, Cardiff, United Kingdom
- Division of Infection, Inflammation, and Immunity, School of Medicine, Tenovus Institute, Cardiff University, Cardiff, United Kingdom
| | - James Clark
- Department of Interventional Cardiology, University Hospital for Wales, Cardiff, United Kingdom
| | - Joel Mock
- Department of Interventional Cardiology, University Hospital for Wales, Cardiff, United Kingdom
| | - Mario Abinun
- Paediatric Haematopoietic Stem Cell Transplant Unit, Translational and Clinical Research Institute, Great North Children's Hospital, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Emily Carne
- Immunodeficiency Centre for Wales, University Hospital for Wales, Cardiff, United Kingdom
| | - Tariq El-Shanawany
- Immunodeficiency Centre for Wales, University Hospital for Wales, Cardiff, United Kingdom
| | - Paul E. Williams
- Immunodeficiency Centre for Wales, University Hospital for Wales, Cardiff, United Kingdom
| | - Anirban Choudhury
- Department of Interventional Cardiology, Morriston Hospital, Swansea Bay University Local Health Board, Swansea, United Kingdom
| | - Alexandra F. Freeman
- Laboratory of Clinical Immunology and Microbiology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Andrew R. Gennery
- Paediatric Haematopoietic Stem Cell Transplant Unit, Translational and Clinical Research Institute, Great North Children's Hospital, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Stephen Jolles
- Immunodeficiency Centre for Wales, University Hospital for Wales, Cardiff, United Kingdom
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20
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Molossi S, Agrawal H, Mery CM, Krishnamurthy R, Masand P, Sexson Tejtel SK, Noel CV, Qureshi AM, Jadhav SP, McKenzie ED, Fraser CD. Outcomes in Anomalous Aortic Origin of a Coronary Artery Following a Prospective Standardized Approach. Circ Cardiovasc Interv 2020; 13:e008445. [DOI: 10.1161/circinterventions.119.008445] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background:
Anomalous aortic origin of a coronary artery (CA) is the second leading cause of sudden cardiac death in young athletes. Management is controversial and longitudinal follow-up data are sparse. We aim to evaluate outcomes in a prospective study of anomalous aortic origin of CA patients following a standardized algorithm.
Methods:
Patients with anomalous aortic origin of a CA were followed prospectively from December 2012 to April 2017. All patients were evaluated following a standardized algorithm, and data were reviewed by a dedicated multidisciplinary team. Assessment of myocardial perfusion was performed using stress imaging. High-risk patients (high-risk anatomy—anomalous left CA from the opposite sinus, presence of intramurality, abnormal ostium—and symptoms or evidence of myocardial ischemia) were offered surgery or exercise restriction (if deemed high risk for surgical intervention). Univariate and multivariable analyses were used to determine predictors of high risk.
Results:
Of 201 patients evaluated, 163 met inclusion criteria: 116 anomalous right CA (71%), 25 anomalous left CA (15%), 17 single CA (10%), and 5 anomalous circumflex CA (3%). Patients presented as an incidental finding (n=80, 49%), with exertional (n=31, 21%) and nonexertional (n=32, 20%) symptoms and following sudden cardiac arrest/shock (n=5, 3%). Eighty-two patients (50.3%) were considered high risk. Predictors of high risk were older age at diagnosis, black race, intramural course, and exertional syncope. Most patients (82%) are allowed unrestrictive sports activities. Forty-seven patients had surgery (11 anomalous left CA and 36 anomalous right CA), 3 (6.4%) remained restricted from sports activities. All patients are alive at a median follow-up of 1.6 (interquartile range, 0.7–2.8) years.
Conclusions:
In this prospective cohort of patients with anomalous aortic origin of a CA, most have remained free of exercise restrictions. Development of a multidisciplinary team has allowed a consistent approach and may have implications in risk stratification and long-term prognosis.
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Affiliation(s)
- Silvana Molossi
- Coronary Anomalies Program, The Lillie Frank Abercrombie Section of Pediatric Cardiology (S.M., P.M., S.K.S.T., A.M.Q., S.P.J., E.D.M.), Texas Children’s Hospital, Baylor College of Medicine, Houston
| | - Hitesh Agrawal
- Invasive Cardiac Imaging and Interventional Catheterization Laboratory, Le Bonheur Children’s Hospital, The University of Tennessee Health Sciences Center, Memphis (H.A.)
| | - Carlos M. Mery
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children’s Medical Center, Austin (C.M.M., C.D.F.)
| | - Rajesh Krishnamurthy
- Division of Pediatric Radiology, Nationwide Children’s Hospital, Columbus, OH (R.K.)
| | - Prakash Masand
- Coronary Anomalies Program, The Lillie Frank Abercrombie Section of Pediatric Cardiology (S.M., P.M., S.K.S.T., A.M.Q., S.P.J., E.D.M.), Texas Children’s Hospital, Baylor College of Medicine, Houston
- Section of Pediatric Radiology (P.M., S.P.J.), Texas Children’s Hospital, Baylor College of Medicine, Houston
| | - S. Kristen Sexson Tejtel
- Coronary Anomalies Program, The Lillie Frank Abercrombie Section of Pediatric Cardiology (S.M., P.M., S.K.S.T., A.M.Q., S.P.J., E.D.M.), Texas Children’s Hospital, Baylor College of Medicine, Houston
| | - Cory V. Noel
- Seattle Children’s Pediatric Cardiology of Alaska, Seattle Children’s Hospital, Anchorage (C.V.N.)
| | - Athar M. Qureshi
- Coronary Anomalies Program, The Lillie Frank Abercrombie Section of Pediatric Cardiology (S.M., P.M., S.K.S.T., A.M.Q., S.P.J., E.D.M.), Texas Children’s Hospital, Baylor College of Medicine, Houston
| | - Siddharth P. Jadhav
- Coronary Anomalies Program, The Lillie Frank Abercrombie Section of Pediatric Cardiology (S.M., P.M., S.K.S.T., A.M.Q., S.P.J., E.D.M.), Texas Children’s Hospital, Baylor College of Medicine, Houston
- Section of Pediatric Radiology (P.M., S.P.J.), Texas Children’s Hospital, Baylor College of Medicine, Houston
| | - E. Dean McKenzie
- Coronary Anomalies Program, The Lillie Frank Abercrombie Section of Pediatric Cardiology (S.M., P.M., S.K.S.T., A.M.Q., S.P.J., E.D.M.), Texas Children’s Hospital, Baylor College of Medicine, Houston
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery (E.D.M.), Texas Children’s Hospital, Baylor College of Medicine, Houston
| | - Charles D. Fraser
- Texas Center for Pediatric and Congenital Heart Disease, University of Texas Dell Medical School/Dell Children’s Medical Center, Austin (C.M.M., C.D.F.)
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21
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22
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Harky A, Noshirwani A, Karadakhy O, Ang J. Comprehensive literature review of anomalies of the coronary arteries. J Card Surg 2019; 34:1328-1343. [DOI: 10.1111/jocs.14228] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Amer Harky
- Department of Cardiothoracic SurgeryLiverpool Heart and Chest HospitalLiverpool UK
| | - Arish Noshirwani
- Department of Cardiothoracic SurgeryLiverpool Heart and Chest HospitalLiverpool UK
| | | | - Juliana Ang
- School of MedicineUniversity of LiverpoolLiverpool UK
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24
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Abstract
Coronary anomalies occur in about 1% of the general population and in severe cases can lead to sudden cardiac death. Coronary computed tomography angiography and magnetic resonance imaging have been deemed appropriate for the evaluation of coronary anomalies by accurately allowing the noninvasive depiction of coronary artery anomalies of origin, course, and termination. The aim of this article is to describe and illustrate a comprehensive array for the classification of coronary artery anomalies.
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Bob-Manuel T, Jenkins JS, Morin DP. Non-arrhythmic causes of sudden death: A comprehensive review. Prog Cardiovasc Dis 2019; 62:265-271. [PMID: 31075277 DOI: 10.1016/j.pcad.2019.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 05/04/2019] [Indexed: 10/26/2022]
Abstract
Sudden cardiac death (SCD) is a major public health issue in the United States and worldwide. It is estimated to affect between 1 and 1.5 million patients worldwide annually, with the global burden expected to rise due to the concomitant rise in coronary artery disease in the developing world. Although arrhythmic causes of SCD such as ventricular tachycardia and ventricular fibrillation are common and well-studied, non-arrhythmic causes are also important, with diverse etiologies from ischemia-related structural heart disease to non-ischemic heart diseases, non-atherosclerotic coronary pathologies, and inflammatory states. Recent research has also found that risk factors and/or demographics predispose certain individuals to a higher risk of non-arrhythmia-related SCD. This review discusses the epidemiology, mechanisms, etiologies, and management of non-arrhythmic SCD.
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Affiliation(s)
| | - J Stephen Jenkins
- John Ochsner Heart and Vascular Center, New Orleans, LA, United States of America; University of Queensland Ochsner Clinical School, New Orleans, LA, United States of America
| | - Daniel P Morin
- John Ochsner Heart and Vascular Center, New Orleans, LA, United States of America; University of Queensland Ochsner Clinical School, New Orleans, LA, United States of America.
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Kastellanos S, Aznaouridis K, Vlachopoulos C, Tsiamis E, Oikonomou E, Tousoulis D. Overview of coronary artery variants, aberrations and anomalies. World J Cardiol 2018; 10:127-140. [PMID: 30386490 PMCID: PMC6205847 DOI: 10.4330/wjc.v10.i10.127] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/12/2018] [Accepted: 08/31/2018] [Indexed: 02/06/2023] Open
Abstract
Coronary artery anomalies and variants are relatively uncommon congenital disorders of the coronary artery anatomy and constitute the second most common cause of sudden cardiac death in young competitive athletes. The rapid advancement of imaging techniques, including computed tomography, magnetic resonance imaging, intravascular ultrasound and optical coherence tomography, have provided us with a wealth of new information on the subject. Anomalous origin of a coronary artery from the contralateral sinus is the anomaly most frequently associated with sudden cardiac death, in particular if the anomalous coronary artery has a course between the aorta and the pulmonary artery. However, other coronary anomalies, like anomalous origin of the left coronary artery from the pulmonary artery, atresia of the left main stem and coronary fistulae, have also been implicated in cases of sudden cardiac death. Patients are usually asymptomatic, and in most of the cases, coronary anomalies are discovered incidentally during coronary angiography or on autopsy following sudden cardiac death. However, in some cases, symptoms like angina, syncope, heart failure and myocardial infarction may occur. The aims of this article are to present a brief overview of the diverse coronary variants and anomalies, focusing especially on anatomical features, clinical manifestations, risk of sudden cardiac death and pathophysiologic mechanism of symptoms, as well as to provide valuable information regarding diagnostic workup, follow-up, therapeutic choices and timing of surgical treatment.
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Affiliation(s)
- Stylianos Kastellanos
- Cardiology Department, Castle Hill Hospital, Hull and East Yorkshire NHS Trust, Cottingham HU16 5JQ, United Kingdom
- Peripheral Vessels Unit and EKKAN (Unit for the athletes and for hereditary cardiovascular diseases), 1 Department of Cardiology, Hippokration Hospital, Medical School of National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Konstantinos Aznaouridis
- Cardiology Department, Castle Hill Hospital, Hull and East Yorkshire NHS Trust, Cottingham HU16 5JQ, United Kingdom
- Peripheral Vessels Unit and EKKAN (Unit for the athletes and for hereditary cardiovascular diseases), 1 Department of Cardiology, Hippokration Hospital, Medical School of National and Kapodistrian University of Athens, Athens 11527, Greece.
| | - Charalambos Vlachopoulos
- Peripheral Vessels Unit and EKKAN (Unit for the athletes and for hereditary cardiovascular diseases), 1 Department of Cardiology, Hippokration Hospital, Medical School of National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Eleftherios Tsiamis
- Peripheral Vessels Unit and EKKAN (Unit for the athletes and for hereditary cardiovascular diseases), 1 Department of Cardiology, Hippokration Hospital, Medical School of National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Evangelos Oikonomou
- Peripheral Vessels Unit and EKKAN (Unit for the athletes and for hereditary cardiovascular diseases), 1 Department of Cardiology, Hippokration Hospital, Medical School of National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Dimitris Tousoulis
- Peripheral Vessels Unit and EKKAN (Unit for the athletes and for hereditary cardiovascular diseases), 1 Department of Cardiology, Hippokration Hospital, Medical School of National and Kapodistrian University of Athens, Athens 11527, Greece
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Kloesel B, Richtsfeld M, Konia M, Bass JL. Management and Anesthetic Considerations for Patients With Anomalous Aortic Origin of a Coronary Artery. Semin Cardiothorac Vasc Anesth 2018; 22:383-394. [PMID: 30095030 DOI: 10.1177/1089253218793888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The term "coronary artery anomalies" encompasses a large and heterogeneous group of disorders that may affect origin, intrinsic anatomy, course, location, and termination of the coronary arteries. With these different anatomies, presentation, symptoms, and outcomes are heterogeneous as well. While significant efforts are directed toward improving diagnosis and risk-stratification, best evidence-guided practices remain in evolution. Data about anesthetic management of patients with coronary anomalies are lacking as well. This review aims to provide the anesthesiologist with a better understanding of an important subgroup of coronary artery anomalies: anomalous aortic origin of a coronary artery. We will discuss classification, pathophysiology, incidence, evaluation, management, and anesthetic implications of this potentially fatal disease group.
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Affiliation(s)
- Benjamin Kloesel
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - Martina Richtsfeld
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - Mojca Konia
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - John L Bass
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
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28
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McElhinney DB. Direct physiologic assessment of anomalous aortic origin of a coronary artery: Enhanced diagnostics or illusion of insight? Catheter Cardiovasc Interv 2018; 92:76-77. [DOI: 10.1002/ccd.27695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 11/06/2022]
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Agrawal H, Qureshi AM, Alam M, Mery CM, Molossi S. Anomalous aortic origin of a coronary artery with an intraseptal course: novel techniques in haemodynamic assessment. BMJ Case Rep 2018; 2018:bcr-2018-225707. [PMID: 29960972 DOI: 10.1136/bcr-2018-225707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Hitesh Agrawal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Athar M Qureshi
- Department of Cardiology, CHI St. Luke's Health, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Mahboob Alam
- Department of Cardiology, CHI St. Luke's Health, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Carlos M Mery
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Silvana Molossi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Houston, Texas, USA
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30
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Sachdeva S, Frommelt MA, Mitchell ME, Tweddell JS, Frommelt PC. Surgical unroofing of intramural anomalous aortic origin of a coronary artery in pediatric patients: Single-center perspective. J Thorac Cardiovasc Surg 2018; 155:1760-1768. [DOI: 10.1016/j.jtcvs.2017.11.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 10/18/2017] [Accepted: 11/01/2017] [Indexed: 01/15/2023]
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31
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Unzué L, García E, López-Melgar B, Agudo-Quilez P. Percutaneous treatment of an anomalous left main arising from the opposite sinus with subpulmonic course. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:632-637. [PMID: 29506965 DOI: 10.1016/j.carrev.2018.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/26/2017] [Accepted: 01/16/2018] [Indexed: 10/18/2022]
Abstract
Anomalous origin of a coronary artery from the opposite sinus of Valsalva (ACAOS) is a rare malformation traditionally considered "malignant" in cases of interarterial course. Recently, a protective effect of the low interarterial subtype (between the aorta and the right ventricle outflow tract) has been described. We present an IVUS-guided percutaneous intervention in a patient with anomalous origin of the left coronary artery from the right coronary sinus presenting with anterior ischemia. In patients with ACAOS, the integration of complementary image techniques is recommended, defining the anomalous course of the vessel and providing an accurate assessment of the individual risk for each patient. The use of IVUS may be advisable, emerging as a really useful tool to complete the study and guide the treatment.
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Affiliation(s)
- Leire Unzué
- Interventional Cardiology, Hospital Universitario Madrid Montepríncipe, Madrid, Spain.
| | - Eulogio García
- Interventional Cardiology, Hospital Universitario Madrid Montepríncipe, Madrid, Spain
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32
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Aubry P, Halna du Fretay X, Degrell P, Waldmann V, Karam N, Marijon E. [Sudden cardiac death and anomalous connections of the coronary arteries: What is known and what is unknown?]. Ann Cardiol Angeiol (Paris) 2017; 66:309-318. [PMID: 29050742 DOI: 10.1016/j.ancard.2017.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
Some anomalous connections of the coronary arteries may be associated with a risk of sudden cardiac death. In opposite with others cardiac diseases at risk of sudden cardiac death, the relationship between these congenital abnormalities and the risk of sudden cardiac death are not well understood. A correction of the anomaly is generally indicated after an aborted sudden cardiac death. Primary prevention strategy after the discovery of an anomaly at risk is debated. Even if the absolute risk of sudden death is very low, a pre-participation screening in young athletes may be discussed due to a non-rare incidence.
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Affiliation(s)
- P Aubry
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France; Service de cardiologie, centre hospitalier, 95500 Gonesse, France; Groupe ANOCOR : groupe de travail multidisciplinaire sur les anomalies congénitales des artères coronaires, groupe hospitalier Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France.
| | - X Halna du Fretay
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France; Groupe ANOCOR : groupe de travail multidisciplinaire sur les anomalies congénitales des artères coronaires, groupe hospitalier Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; Unité cardiologique de la Reine-Blanche, 45770 Saran, France
| | - P Degrell
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France
| | - V Waldmann
- Département de cardiologie, hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France; Inserm U970, Centre d'expertise Mort-Subite (CEMS), centre de recherche cardiovasculaire de Paris (PARCC), 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
| | - N Karam
- Département de cardiologie, hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France; Inserm U970, Centre d'expertise Mort-Subite (CEMS), centre de recherche cardiovasculaire de Paris (PARCC), 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
| | - E Marijon
- Département de cardiologie, hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France; Inserm U970, Centre d'expertise Mort-Subite (CEMS), centre de recherche cardiovasculaire de Paris (PARCC), 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
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Cheezum MK, Liberthson RR, Shah NR, Villines TC, O'Gara PT, Landzberg MJ, Blankstein R. Anomalous Aortic Origin of a Coronary Artery From the Inappropriate Sinus of Valsalva. J Am Coll Cardiol 2017; 69:1592-1608. [PMID: 28335843 DOI: 10.1016/j.jacc.2017.01.031] [Citation(s) in RCA: 219] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/05/2016] [Accepted: 01/03/2017] [Indexed: 02/07/2023]
Abstract
Anomalous aortic origin of a coronary artery (AAOCA) from the inappropriate sinus of Valsalva is increasingly recognized by cardiac imaging. Although most AAOCA subtypes are benign, autopsy studies report an associated risk of sudden death with interarterial anomalous left coronary artery (ALCA) and anomalous right coronary artery (ARCA). Despite efforts to identify high-risk ALCA and ARCA patients who may benefit from surgical repair, debate remains regarding their classification, prevalence, risk stratification, and management. We comprehensively reviewed 77 studies reporting the prevalence of AAOCA among >1 million patients, and 20 studies examining outcomes of interarterial ALCA/ARCA patients. Observational data suggests that interarterial ALCA is rare (weighted prevalence = 0.03%; 95% confidence interval [CI]: 0.01% to 0.04%) compared with interarterial ARCA (weighted prevalence = 0.23%; 95% CI: 0.17% to 0.31%). Recognizing the challenges in managing these patients, we review cardiac tests used to examine AAOCA and knowledge gaps in management.
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Affiliation(s)
- Michael K Cheezum
- Departments of Medicine and Radiology, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Cardiology Service, Fort Belvoir Community Hospital, Ft. Belvoir, Virginia.
| | - Richard R Liberthson
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nishant R Shah
- Lifespan Cardiovascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Brown University Alpert School of Medicine, Providence, Rhode Island
| | - Todd C Villines
- Department of Medicine, Cardiology Service, Walter Reed National Military Medical Center, Bethesda Maryland
| | - Patrick T O'Gara
- Departments of Medicine and Radiology, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Ron Blankstein
- Departments of Medicine and Radiology, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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34
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Agrawal H, Mery CM, Day PE, Sexson Tejtel SK, McKenzie ED, Fraser CD, Qureshi AM, Molossi S. Current practices are variable in the evaluation and management of patients with anomalous aortic origin of a coronary artery: Results of a survey. CONGENIT HEART DIS 2017; 12:610-614. [DOI: 10.1111/chd.12511] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/12/2017] [Accepted: 06/04/2017] [Indexed: 01/09/2023]
Affiliation(s)
- Hitesh Agrawal
- Coronary Anomalies Program; Texas Children's Hospital; Houston Texas
- The Lillie Frank Abercrombie Section of Cardiology; Baylor College of Medicine, Texas Children's Hospital; Houston Texas
| | - Carlos M. Mery
- Coronary Anomalies Program; Texas Children's Hospital; Houston Texas
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery; Texas Children's Hospital, Baylor College of Medicine; Houston Texas
| | - Patrick E. Day
- McGovern Medical School at The University of Texas Health Science Center at Houston; Houston Texas
| | - S. Kristen Sexson Tejtel
- Coronary Anomalies Program; Texas Children's Hospital; Houston Texas
- The Lillie Frank Abercrombie Section of Cardiology; Baylor College of Medicine, Texas Children's Hospital; Houston Texas
| | - E. Dean McKenzie
- Coronary Anomalies Program; Texas Children's Hospital; Houston Texas
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery; Texas Children's Hospital, Baylor College of Medicine; Houston Texas
- Division of Cardiothoracic Surgery; Children's Healthcare of Atlanta; Atlanta Georgia
| | - Charles D. Fraser
- Coronary Anomalies Program; Texas Children's Hospital; Houston Texas
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery; Texas Children's Hospital, Baylor College of Medicine; Houston Texas
| | - Athar M. Qureshi
- Coronary Anomalies Program; Texas Children's Hospital; Houston Texas
- The Lillie Frank Abercrombie Section of Cardiology; Baylor College of Medicine, Texas Children's Hospital; Houston Texas
| | - Silvana Molossi
- Coronary Anomalies Program; Texas Children's Hospital; Houston Texas
- The Lillie Frank Abercrombie Section of Cardiology; Baylor College of Medicine, Texas Children's Hospital; Houston Texas
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35
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Molossi S, Agrawal H. Clinical evaluation of anomalous aortic origin of a coronary artery (AAOCA). CONGENIT HEART DIS 2017. [DOI: 10.1111/chd.12505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Silvana Molossi
- Coronary Anomalies Program, Division of Pediatric Cardiology, Texas Children's Hospital, Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
| | - Hitesh Agrawal
- Coronary Anomalies Program, Division of Pediatric Cardiology, Texas Children's Hospital, Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
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Gräni C, Buechel RR, Kaufmann PA, Kwong RY. Multimodality Imaging in Individuals With Anomalous Coronary Arteries. JACC Cardiovasc Imaging 2017; 10:471-481. [DOI: 10.1016/j.jcmg.2017.02.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 02/08/2017] [Accepted: 02/15/2017] [Indexed: 01/02/2023]
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37
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Abudayyeh I, Tran BG, Tobis JM. Optimizing Coronary Angioplasty with FFR and Intravascular Imaging. CURRENT CARDIOVASCULAR RISK REPORTS 2017. [DOI: 10.1007/s12170-017-0534-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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38
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Aubry P, Halna du Fretay X, Dibon O, Dupouy P, Juliard JM. [Acute coronary syndromes with ST-segment elevation and anomalous connections of the coronary arteries]. Ann Cardiol Angeiol (Paris) 2015; 64:453-459. [PMID: 26482632 DOI: 10.1016/j.ancard.2015.09.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Acute coronary syndrome with ST-segment elevation associated with an anomalous connection of a coronary artery, when the latter is the culprit, may be problematic. Anatomic and radiologic knowledge of major congenital coronary abnormalities and some catheterization skills can help the operators not to delay a beneficial coronary reperfusion. The relationship between acute coronary syndromes with ST-segment elevation and anomalous connections of the coronary arteries needs to be analyzed with a large number of cases because the coronary artery disease frequency may vary with the type of coronary anomaly.
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Affiliation(s)
- P Aubry
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France; Service de cardiologie, centre hospitalier, 95500 Gonesse, France.
| | - X Halna du Fretay
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France; Service de cardiologie, centre hospitalier régional, 45000 Orléans, France
| | - O Dibon
- Service de cardiologie, centre hospitalier régional, 45000 Orléans, France
| | - P Dupouy
- Département de cardiologie interventionnelle et d'imagerie cardiovasculaire, hôpital privé d'Antony, 92160 Antony, France
| | - J-M Juliard
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France
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39
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Lee SE, Yu CW, Park K, Park KW, Suh JW, Cho YS, Youn TJ, Chae IH, Choi DJ, Jang HJ, Park JS, Na SH, Kim HS, Kim KB, Koo BK. Physiological and clinical relevance of anomalous right coronary artery originating from left sinus of Valsalva in adults. Heart 2015; 102:114-9. [DOI: 10.1136/heartjnl-2015-308488] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/14/2015] [Indexed: 11/03/2022] Open
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40
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Angelini P, Uribe C, Monge J, Tobis JM, Elayda MA, Willerson JT. Origin of the right coronary artery from the opposite sinus of Valsalva in adults: characterization by intravascular ultrasonography at baseline and after stent angioplasty. Catheter Cardiovasc Interv 2015; 86:199-208. [PMID: 26178792 PMCID: PMC4657462 DOI: 10.1002/ccd.26069] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 05/21/2015] [Indexed: 01/27/2023]
Abstract
OBJECTIVES We attempted to characterize the anatomy, function, clinical consequences, and treatment of right-sided anomalous coronary artery origin from the opposite side (R-ACAOS). BACKGROUND Anomalous aortic origin of a coronary artery is a source of great uncertainty in cardiology. A recent study by our group found that ACAOS had a high prevalence (0.48%) in a general population of adolescents. METHODS Sixty-seven consecutive patients were diagnosed with R-ACAOS according to a new definition: ectopic right coronary artery (RCA) with an intramural proximal course. We used intravascular ultrasonograms of the RCA to quantify congenital stenosis (in patients with potentially serious clinical presentations), and we correlated these measurements with clinical manifestations. RESULTS All patients had some proximal intramural stenosis (mean 50%, range 16-83% of the cross-sectional area). Forty-two patients (62%) underwent stent-percutaneous coronary intervention (PCI) of R-ACAOS because of significant symptoms, positive stress tests, and/or significant stenosis. Stent-PCI was successful in all cases and correlated with improved symptoms at >1-year follow-up in 30 patients (71%) who were available for clinical follow-up. No ACAOS-related deaths occurred. The instent restenosis rate was 4/30 (13%) at a mean follow-up time of 5.0 years. CONCLUSIONS This preliminary, but large and unprecedented observational study shows that cases angiographically identified as R-ACAOS universally feature an intramural aortic course but only occasionally severe stenosis on resting IVUS imaging. Our data suggest that stent-PCI with IVUS monitoring ameliorates patients' presenting symptoms.
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Affiliation(s)
- Paolo Angelini
- Department of Cardiology, Texas Heart Institute, Houston, Texas.,Center for Coronary Artery Anomalies, Texas Heart Institute, Houston, Texas
| | - Carlo Uribe
- Center for Coronary Artery Anomalies, Texas Heart Institute, Houston, Texas
| | - Jorge Monge
- Center for Coronary Artery Anomalies, Texas Heart Institute, Houston, Texas
| | - Jonathan M Tobis
- Department of Cardiology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California
| | - MacArthur A Elayda
- Department of Biostatistics and Epidemiology, Texas Heart Institute, Houston, Texas
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41
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Angelini P. ACAOS is better revealed by intravascular ultrasonography than by computed tomographic angiography. Tex Heart Inst J 2015; 42:246-7. [PMID: 26175639 DOI: 10.14503/thij-15-5010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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42
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Anomalía coronaria congénita, un enemigo silencioso del ejercicio físico. Rev Clin Esp 2015; 215:297-9. [DOI: 10.1016/j.rce.2015.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 02/17/2015] [Accepted: 02/17/2015] [Indexed: 11/22/2022]
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43
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Sénior JM, Tamayo N, Fernández A, Rodríguez AE. Anomalías de las arterias coronarias. IATREIA 2015. [DOI: 10.17533/udea.iatreia.v29n1a09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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44
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Cheong BYC, Angelini P. Magnetic Resonance Imaging of the Myocardium, Coronary Arteries, and Anomalous Origin of Coronary Arteries. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Aubry P, Honton B, Leurent G, Halna du Fretay X, Dupouy P, Ou P, Juliard JM. [Ectopic connection of the left coronary artery with the contralateral sinus with or without intramural pathway: how and why differentiating them?]. Ann Cardiol Angeiol (Paris) 2014; 63:410-416. [PMID: 25450989 DOI: 10.1016/j.ancard.2014.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Among the wide spectrum of congenital abnormalities of coronary arteries, a left coronary artery connected with the contralateral sinus is considered as an anatomical high-risk while associated with a proximal preaortic course. The ectopic connection may be associated with or without intramural pathway regarding the aortic wall. An intramural pathway is a characteristic to be considered because it is able to be involved in myocardial ischemia-related adverse events of which the sudden death. Therefore, making an identification of an intramural pathway is essential for the ectopic connections of the left coronary artery associated with a preaortic course.
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Affiliation(s)
- P Aubry
- Service de cardiologie, groupe hospitalier Bichat-Claude-Bernard, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France; Service de cardiologie, centre hospitalier, 95500 Gonesse, France.
| | - B Honton
- Service de cardiologie, clinique Pasteur, 31000 Toulouse, France
| | - G Leurent
- Service de cardiologie et maladies vasculaires, CHU, 35000 Rennes, France
| | - X Halna du Fretay
- Service de cardiologie, groupe hospitalier Bichat-Claude-Bernard, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France; Service de cardiologie, hôpital Foch, 92150 Suresnes, France
| | - P Dupouy
- Département de cardiologie interventionnelle et d'imagerie cardiovasculaire, hôpital privé d'Antony, 92160 Antony, France
| | - P Ou
- Service de radiologie, groupe hospitalier Bichat-Claude-Bernard, AP-HP, 75018 Paris, France
| | - J-M Juliard
- Service de cardiologie, groupe hospitalier Bichat-Claude-Bernard, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France
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Abstract
Anomalous origin of a coronary artery from the aorta is a potentially serious anomaly that occurs in about 0.1-0.2% of the population. This percentage is small; however, it translates into about 4000 annual births with these anomalies. The clinical presentation of these anomalies is rare, and hence most are and will remain asymptomatic. The various anatomic anomalies are described, with anomalous origin of the left coronary artery that then passes between the aorta and pulmonary artery being the most serious of these anomalies. The pathophysiology resulting from these anomalies is described, as are methods for identifying those who require treatment; however, we still do not know the best methods of determining which patients need treatment.
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Surgical Unroofing of Anomalous Aortic Origin of a Coronary Artery: A Single-Center Experience. Ann Thorac Surg 2014; 98:941-5. [DOI: 10.1016/j.athoracsur.2014.04.114] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 04/21/2014] [Accepted: 04/23/2014] [Indexed: 11/19/2022]
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Angelini P. Novel Imaging of Coronary Artery Anomalies to Assess Their Prevalence, the Causes of Clinical Symptoms, and the Risk of Sudden Cardiac Death. Circ Cardiovasc Imaging 2014; 7:747-54. [DOI: 10.1161/circimaging.113.000278] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Paolo Angelini
- From the Center for Coronary Artery Anomalies, Texas Heart Institute, Houston, TX
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Joggerst S, Monge J, Uribe C, Sherron S, Angelini P. Sudden cardiac arrest at the finish line: in coronary ectopia, the cause of ischemia is from intramural course, not ostial location. Tex Heart Inst J 2014; 41:212-6. [PMID: 24808787 DOI: 10.14503/thij-12-2867] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 26-year-old woman, a well-trained runner, had a sudden cardiac arrest just before crossing the finish line of a marathon. She was rapidly resuscitated and was later found to have an ectopic origin of the left coronary artery. This anomaly was surgically repaired by translocating the ostium from the right to the left sinus of Valsalva. Her difficult postoperative course prompted further coronary evaluation, which revealed severe stenosis of the neoostium. The patient underwent a second operation: this time, the stenosis was bypassed via a left internal mammary artery-to-left anterior descending coronary artery (LAD) graft. Hypoplasia of the LAD and spasm during manipulation caused the graft to fail, necessitating double-stent angioplasty of the left main ostium and the LAD 2 months later. At the patient's 6-month follow-up examination, she had no further evidence of functional ischemia, and she resumed jogging. Because the mode and mechanism of the patient's condition and events were documented in unusual detail, this case furthers our understanding of sudden cardiac arrest in athletes who have rare coronary anomalies. We conclude that ectopia of a coronary artery does not itself cause potentially fatal ischemia. Rather, these events are due to the ectopic artery's intramural proximal course within the aortic media, which might result in critical stenosis by means of hypoplasia or lateral compression of the artery.
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Affiliation(s)
- Steven Joggerst
- Department of Cardiology, Texas Heart Institute, Houston, Texas 77030
| | - Jorge Monge
- Department of Cardiology, Texas Heart Institute, Houston, Texas 77030
| | - Carlo Uribe
- Department of Cardiology, Texas Heart Institute, Houston, Texas 77030
| | - Scott Sherron
- Department of Cardiology, Texas Heart Institute, Houston, Texas 77030
| | - Paolo Angelini
- Department of Cardiology, Texas Heart Institute, Houston, Texas 77030
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