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Ramponi F, Lattouf O, Jin A, Puskas JD. Surgical Management of Anomalous Right Coronary Artery in the Adult: Technique and Case Series. Heart Lung Circ 2024; 33:510-517. [PMID: 38403570 DOI: 10.1016/j.hlc.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/11/2023] [Accepted: 01/26/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND The management of adult patients with anomalous aortic origin of the right coronary artery (ARCA) from the left aortic sinus poses important challenges. The presence of symptoms or documented ischaemia, the anatomical characteristics of the ostium, and the course of the coronary determine decision-making. METHODS A retrospective review was performed of all cases of surgical management of ARCA at a single centre. The primary endpoints were mortality and myocardial infarction at 30 days. Secondary endpoints included recurrence of symptoms, freedom from re-intervention, and mortality during long-term follow-up. RESULTS From October 2019 to August 2023, 15 adult patients underwent surgery for ARCA; 13 patients were included in this study (mean age 53.9±11.1 years; 10 female). A slit-like orifice, a long intramural segment, and an interarterial course were found in all patients. Twelve (12) patients (92.3%) were symptomatic: nine with angina, combined with dyspnoea on exertion in seven. One (1) patient had history of pre-syncope. One (1) patient presented with out-of-hospital cardiac arrest. All patients underwent formal unroofing of the orifice and intramural portion of the ARCA; five patients had a concomitant procedure. No 30-day mortality nor myocardial infarction was recorded. At a mean follow-up of 20.1±12.8 months, all patients were alive. One (1) patient (7.6%) developed recurrent dyspnoea; investigations showed no ischaemia. No repeated interventions were required. CONCLUSIONS Surgical unroofing of anomalous coronary artery in the adult is safe and effective; correction of both the slit-like orifice and intramural portion of the anomaly provides a durable result in patients with ARCA.
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Affiliation(s)
- Fabio Ramponi
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Omar Lattouf
- Emory University School of Medicine, Atlanta, GA, USA
| | - Amber Jin
- Department of Cardiothoracic Surgery, Mount Sinai Morningside, New York, NY, USA
| | - John D Puskas
- Emory University School of Medicine, Atlanta, GA, USA
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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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Angelini P, Uribe C. Critical update and discussion of the prevalence, nature, mechanisms of action, and treatment options in potentially serious coronary anomalies. Trends Cardiovasc Med 2023; 33:518-528. [PMID: 35643274 DOI: 10.1016/j.tcm.2022.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 05/19/2022] [Accepted: 05/22/2022] [Indexed: 11/29/2022]
Abstract
As widely discussed in recent literature, coronary artery anomalies only occasionally lead to potentially serious myocardial ischemic events. The most important group of coronary anomalies has been called anomalous coronary artery origin from an abnormal sinus or a site in the ascending aorta (ACAOS). Only some cases of right- or left-sided intramural-course ACAOS (R-ACAOS-IM or L-ACAOS-IM) can potentially cause significant symptoms or sudden cardiac death, typically during exertion in athletes. After an ACAOS-IM case is qualitatively identified, it is necessary to establish the severity of associated stenosis (which is always present to some degree in ACAOS-IM). The 3 stages of a comprehensive diagnostic process are: 1. initial screening of high-risk populations (young elite athletes, optimally by use of magnetic resonance imaging [MRI]) to identify the prevalence of similar cases in large populations (the denominator of any risk calculation); 2. evaluating symptoms (chest pain, syncope, or sudden death) and performing stress testing; 3. in patients found to carry ACAOS-IM, evaluating the severity of coronary obstruction by intravascular ultrasonography, which is an objective, definitive, and quantifying imaging modality for this condition, essential in selected carriers of such anomalies. The possible treatment alternatives are discussed and updated.
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Affiliation(s)
- Paolo Angelini
- The Center for Coronary Artery Anomalies, Texas Heart Institute, Houston, Texas, United States.
| | - Carlo Uribe
- The Center for Coronary Artery Anomalies, Texas Heart Institute, Houston, Texas, United States
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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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Zeppilli P, Bianco M, Gervasi SF, Cammarano M, Monti R, Sollazzo F, Modica G, Morra L, Nifosì FM, Palmieri V. Congenital coronary artery anomalies in sports medicine. Why to know them. Clin Cardiol 2023; 46:1038-1048. [PMID: 37432696 PMCID: PMC10540032 DOI: 10.1002/clc.24084] [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: 04/11/2023] [Revised: 06/15/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023] Open
Abstract
The anomalous origin of a coronary artery (AOCA) is a challenging topic, due to its rarity, the complexity of the pathophysiological aspects, the clinical presentation (often silent), the difficulty of diagnosis, and the potential risk of causing acute cardiovascular events up to sudden cardiac death, particularly when triggered by heavy physical exercise or sport practice. Increasing interest in sport medical literature is being given to this topic. This paper reviews current knowledge of AOCAs in the specific context of the athletic setting addressing epidemiological and pathophysiological aspects, diagnostic work-up, sports participation, individual risk assessment, therapeutic options, and return to play decision after surgery.
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Affiliation(s)
- Paolo Zeppilli
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Massimiliano Bianco
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Salvatore F. Gervasi
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Michela Cammarano
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Riccardo Monti
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Fabrizio Sollazzo
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Gloria Modica
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Lorenzo Morra
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Francesco M. Nifosì
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
| | - Vincenzo Palmieri
- Sports Medicine Unit, Fondazione Policlinico Universitario A. Gemelli IRCCSCatholic UniversityRomeItaly
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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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Razavi A, Sachdeva S, Frommelt PC, LaDisa JF. Computational Assessment of Hemodynamic Significance in Patients With Intramural Anomalous Aortic Origin of the Coronary Artery Using Virtually Derived Fractional Flow Reserve and Downstream Microvascular Resistance. J Biomech Eng 2022; 144:1119460. [PMID: 34505124 DOI: 10.1115/1.4052368] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Indexed: 11/08/2022]
Abstract
Anomalous aortic origin of a coronary artery (AAOCA) is the second most common cause of sudden cardiac death in young athletes. One of the hypothesized mechanisms of ischemia in these patients is the lateral compression of the anomalous artery with an intramural or interarterial course. The presence of a narrowing in the anomalous artery will cause physiologic changes in downstream resistance that should be included for computational assessment of possible clinical ramifications. In this study, we created different compression levels, i.e., proximal narrowing, in the intramural course of a representative patient model and calculated hyperemic stenosis resistance (HSR) as well as virtual fractional flow reserve (vFFR). Models also included the effect of the distal hyperemic microvascular resistance (HMR) on vFFR. Our results agreed with similar FFR studies indicating that FFR is increased with increasing HMR and that different compression levels could have similar FFR depending on the HMR. For example, vFFR at HSR: 1.0-1.3 and HMR: 2.30 mmHg/cm/s is 0.68 and close to vFFR at HSR: 0.6-0.7 and HMR: 1.6 mmHg/cm/s, which is 0.7. The current findings suggest that functional assessment of anomalous coronary arteries through FFR should consider the vascular resistance distal to the narrowing in addition to the impact of a proximal narrowing and provides computational approaches for implementation of these important considerations.
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Affiliation(s)
- Atefeh Razavi
- Department of Biomedical Engineering, Marquette University, Milwaukee, WI 53233; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332
| | - Shagun Sachdeva
- Pediatric Cardiology, Baylor College of Medicine, Houston, TX 77030
| | - Peter C Frommelt
- Department of Pediatrics, Division of Pediatric Cardiology, Medical College of Wisconsin Children's Wisconsin, Milwaukee, WI 53226
| | - John F LaDisa
- Department of Biomedical Engineering, Marquette University, Milwaukee, WI 53233; Departments of Pediatrics, Cardiovascular Medicine and Physiology, Medical College of Wisconsin, Wauwatosa, WI 53226
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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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Tang CX, Lu MJ, Schoepf JU, Tesche C, Bauer M, Nance J, Griffith P, Lu GM, Zhang LJ. Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve in Patients with Anomalous Origin of the Right Coronary Artery from the Left Coronary Sinus. Korean J Radiol 2020; 21:192-202. [PMID: 31997594 PMCID: PMC6992438 DOI: 10.3348/kjr.2019.0230] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 09/25/2019] [Indexed: 12/15/2022] Open
Abstract
Objective To examine the fractional flow reserve derived from computed tomographic angiography (CT-FFR) in patients with anomalous origin of the right coronary artery from the left coronary sinus (R-ACAOS) with an interarterial course, assess the relationship of CT-FFR with the anatomical features of interarterial R-ACAOS on coronary computed tomographic angiography (CCTA), and determine its clinical relevance. Materials and Methods Ninety-four patients with interarterial R-ACAOS undergoing CCTA were retrospectively included. Anatomic features (proximal vessel morphology [oval or slit-like], take-off angle, take-off level [below or above the pulmonary valve], take-off type, intramural course, % proximal narrowing area, length of narrowing, minimum luminal area [MLA] at systole and diastole, and vessel compression index) on CCTA associated with CT-FFR ≤ 0.80 were analyzed. Receiver operating characteristic analysis was performed to describe the diagnostic performance of CT-FFR ≤ 0.80 in detecting interarterial R-ACAOS. Results Significant differences were found in proximal vessel morphology, take-off level, intramural course, % proximal narrowing area, and MLA at diastole (all p < 0.05) between the normal and abnormal CT-FFR groups. Take-off level, intramural course, and slit-like ostium (all p < 0.05) predicted hemodynamic abnormality (CT-FFR ≤ 0.80) with accuracies of 0.69, 0.71, and 0.81, respectively. Patients with CT-FFR ≤ 0.80 had a higher prevalence of typical angina (29.4% vs. 7.8%, p = 0.025) and atypical angina (29.4% vs. 6.5%, p = 0.016). Conclusion Take-off level, intramural course, and slit-like ostium were the main predictors of abnormal CT-FFR values. Importantly, patients with abnormal CT-FFR values showed a higher prevalence of typical angina and atypical angina, indicating that CT-FFR is a potential tool to gauge the clinical relevance in patients with interarterial R-ACAOS.
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Affiliation(s)
- Chun Xiang Tang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Meng Jie Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Joseph Uwe Schoepf
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Christian Tesche
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Maximilian Bauer
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - John Nance
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Parkwood Griffith
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC, USA
| | - Guang Ming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Long Jiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.
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Anomalous Aortic Origin of the Coronary Arteries: A Novel Unroofing Technique in an Adult Cohort. Ann Thorac Surg 2018; 107:823-828. [PMID: 30312617 DOI: 10.1016/j.athoracsur.2018.08.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 08/01/2018] [Accepted: 08/13/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Anomalous aortic origin of the coronary arteries (AAOCA) is associated with sudden cardiac death and frequently treated with unroofing of an intramural segment. Most reports on AAOCA are of patients less than 30 years of age. We have reviewed our "older" patients who have undergone surgical repair and report a novel unroofing technique. METHODS A retrospective review was conducted of 40 adult patients who underwent surgery for AAOCA from June 2005 to June 2016. Our surgical approach changed from traditional sharp excision to electrical fulguration of the shared intramural wall segment. We assessed our population for symptom relief, resolution of ischemia, and reintervention. More than 6 months of follow-up was available for 34 patients. RESULTS Mean age was 47.1 ± 11.6 years (range, 19 to 67); 17 patients were female. The coronary anomaly was right from left in 35 patients, left from right 4, and left coronary from noncoronary sinus in 1 patient. Thirty-nine of 40 patients were symptomatic, with two prior sudden cardiac arrests. Preoperatively, 22 of 31 patients tested positive for ischemia, including the asymptomatic. The operation was unroofing in 37 of 40 patients, 17 by sharp excision and 20 by electrical fulguration. There were no 30-day deaths or complications and no reinterventions. Isolated unroofing by fulguration required shorter cardiopulmonary bypass and cross-clamp times than excision: 39 versus 62 minutes (p = 0.02) and 28 versus 42 minutes (p = 0.02), respectively. At an average follow-up of 5.0 years, 28 of 34 patients reported symptomatic improvement. There were two unrelated late deaths. CONCLUSIONS Unroofing by sharp excision and by electrical fulguration were equally safe in the short term. Fulguration is technically easier and faster while still equally effective.
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Anomalous origin of coronary arteries from the "wrong" sinus in athletes: Diagnosis and management strategies. Int J Cardiol 2017; 252:13-20. [PMID: 29146296 DOI: 10.1016/j.ijcard.2017.10.117] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/28/2017] [Accepted: 10/31/2017] [Indexed: 12/22/2022]
Abstract
AIMS Although anomalous origin of left (AOLCA) and right coronary artery (AORCA) from the wrong sinus may cause sudden death (SD) in athletes, early diagnosis and management of these anomalies are still challenging. We analysed clinical/instrumental profiles of athletes identified with AOLCA/AORCA focusing our attention on diagnosis, management and follow-up. METHODS AND RESULTS We report 23 athletes (17 males, mean age 27±17yrs.), 6 with AOLCA and 17 with AORCA. Diagnosis was made by trans-thoracic echocardiography (TTE) in 21/23(91%). Symptoms were present only in 10(41%). Only 3 had an abnormal rest-ECG and 9(39%) an abnormal stress test ECG (3 ST-depression, 4 ventricular arrhythmias, 1 supraventricular arrhythmias, 1 rate-dependent left-bundle-branch-block). Anatomy of the anomalous coronary artery showed no significant correlation with clinical presentation, except for a tendency to higher occurrence of proximal hypoplasia in symptomatic athletes (83% vs 40%, p=0.09). All athletes were disqualified from competitive-sports and advised to avoid strenuous effort. Surgery was recommended to all athletes with AOLCA and 6 with AORCA, but only 6 underwent surgery. No major cardiac events or ischemic symptoms/signs occurred during a mean follow-up of 65±70months. CONCLUSIONS Early diagnosis of AOLCA/AORCA in athletes is feasible by TTE. Typical symptoms/signs of myocardial ischemia are present only in one third of cases thus underlying the need of a high index of clinical suspicion to achieve the diagnosis. After exercise restriction, none had major cardiac events or ischemia symptoms/signs recurrence. There was no correlation between anatomical characteristics and clinical presentation with the possible exception of coronary hypoplasia.
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