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Stephens EH, Jegatheeswaran A, Brothers JA, Ghobrial J, Karamlou T, Francois CJ, Krishnamurthy R, Dearani JA, Binsalamah Z, Molossi S, Mery CM. Anomalous Aortic Origin of a Coronary Artery. Ann Thorac Surg 2024; 117:1074-1086. [PMID: 38302054 DOI: 10.1016/j.athoracsur.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/09/2023] [Accepted: 01/03/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Although anomalous aortic origin of a coronary artery (AAOCA) is associated with risk of sudden cardiac arrest (SCA), there is a spectrum of disease, with the appropriate management for many remaining unclear. Increasing data warrant review for an updated perspective on management. METHODS A panel of congenital cardiac surgeons, cardiologists, and imaging practitioners reviewed the current literature related to AAOCA and its management. Survey of relevant publications from 2010 to the present in PubMed was performed. RESULTS The prevalence of AAOCA is 0.4% to 0.8%. Anomalous left coronary artery is 3 to 8 times less common than anomalous right coronary, but carries a much higher risk of SCA. Nevertheless, anomalous right coronary is not completely benign; 10% demonstrate ischemia, and it remains an important cause of SCA. Decision-making regarding which patients should be recommended for surgical intervention includes determining anatomic features associated with ischemia, evidence of ischemia on provocative testing, and concerning cardiovascular symptoms. Ischemia testing continues to prove challenging with low sensitivity and specificity, but the utility of new modalities is an active area of research. Surgical interventions focus on creating an unobstructed path for blood flow and choosing the appropriate surgical technique given the anatomy to accomplish this. Nontrivial morbidity has been reported with surgery, including new-onset ischemia. CONCLUSIONS A proportion of patients with AAOCA demonstrate features and ischemia that warrant surgical intervention. Continued work remains to improve the ability to detect inducible ischemia, to risk stratify these patients, and to provide guidance in terms of which patients warrant surgical intervention.
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Affiliation(s)
| | - Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, United Kingdom; Department of Children's Cardiovascular Disease, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Julie A Brothers
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Tara Karamlou
- Division of Pediatric and Congenital Cardiac Surgery, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Rajesh Krishnamurthy
- Division of Cardiovascular Imaging, Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ziyad Binsalamah
- Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Silvana Molossi
- Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Carlos M Mery
- Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Dell Children's Medical Center, Austin, Texas
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2
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Gaddameedi SR, Thapa M, Arty F, Atreya S, Ravilla J, Panchal P, Du D. Case Report and Literature Review of an Anomalous Course of the Left Main Coronary Artery (LMCA) Arising From the Right Sinus of Valsalva (RSV) Presenting as Takotsubo Cardiomyopathy. Cureus 2024; 16:e63028. [PMID: 38919862 PMCID: PMC11197674 DOI: 10.7759/cureus.63028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2024] [Indexed: 06/27/2024] Open
Abstract
Takotsubo cardiomyopathy (TC) mimics myocardial infarction with symptoms like chest pain, electrocardiogram (EKG) changes, and elevated troponin levels, although it typically features normal coronary arteries upon angiography. While often asymptomatic, coronary artery anomalies (CAAs) can cause intermittent vasospasm and endothelial dysfunction, potentially inducing TC. We report the case of a 74-year-old female with a history of hypertension, hyperlipidemia, and peripheral artery disease, who presented with sudden onset chest pain. Initial EKG and elevated troponin suggested myocardial infarction. However, coronary angiography revealed an anomalous left main coronary artery (LMCA) originating from the right coronary artery (RCA), with no significant stenosis. Subsequent transthoracic echocardiography indicated TC, with the left ventricular ejection fraction improving from 35-40% to 60-65% within days. Cardiac computed tomography angiography (CCTA) revealed that the anomalous LMCA originated from the common trunk at the right sinus of Valsalva (RSV), which further continued as a large, dominant RCA. The LMCA branched into a small to moderate left anterior descending artery (LAD) and a non-dominant left circumflex artery (LCx). The LMCA followed a prepulmonic/anterior course, while the LCx took an interarterial course between the aorta and pulmonary artery. The patient was referred for further surgical evaluation. We conclude that the CAA was an incidental finding and was not related to underlying TC. Although rare, this case suggests a possible correlation between CAAs and a predisposition to stress-induced cardiomyopathy, warranting further investigation.
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Affiliation(s)
| | - Milan Thapa
- Internal Medicine, Rutgers Health/Monmouth Medical Center, Long Branch, USA
| | - Fnu Arty
- Internal Medicine, Rutgers Health/Monmouth Medical Center, Long Branch, USA
| | - Suryansh Atreya
- Internal Medicine, Rutgers Health/Monmouth Medical Center, Long Branch, USA
| | - Jayasree Ravilla
- Internal Medicine, Rutgers Health/Monmouth Medical Center, Long Branch, USA
| | - Pratik Panchal
- Cardiology, Rutgers Health/Monmouth Medical Center, Long Branch, USA
| | - Doantrang Du
- Internal Medicine, Rutgers Health/Monmouth Medical Center, Long Branch, USA
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3
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Gaudino M, Di Franco A, Arbustini E, Bacha E, Bates ER, Cameron DE, Cao D, David TE, De Paulis R, El-Hamamsy I, Farooqi KM, Girardi LN, Gräni C, Kochav JD, Molossi S, Puskas JD, Rao SV, Sandner S, Tatoulis J, Truong QA, Weinsaft JW, Zimpfer D, Mery CM. Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review. Ann Thorac Surg 2023; 116:1124-1141. [PMID: 37855783 DOI: 10.1016/j.athoracsur.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 10/20/2023]
Abstract
As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York.
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Eloisa Arbustini
- Transplant Research Area and Centre for Inherited Cardiovascular Diseases, Scientific Department, IRCCS and Polyclinic San Matteo Foundation, Pavia, Italy
| | - Emile Bacha
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Eric R Bates
- Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Duke E Cameron
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Tirone E David
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ruggero De Paulis
- Department of Cardiac Surgery, European Hospital, Rome, Italy; UniCamillus University, Rome, Italy
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kanwal M Farooqi
- Division of Pediatric Cardiology, New York-Presbyterian, Columbia University Irving Medical Center, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan D Kochav
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Silvana Molossi
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sunil V Rao
- Division of Interventional Cardiology, NYU Langone Health, New York, New York
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Quynh A Truong
- Department of Radiology, New York Presbyterian, Weill Cornell Medicine, New York, New York
| | - Jonathan W Weinsaft
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Daniel Zimpfer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, Dell Medical School at The University of Texas at Austin/Dell Children's Medical Center, Austin, Texas
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4
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Gaudino M, Di Franco A, Arbustini E, Bacha E, Bates ER, Cameron DE, Cao D, David TE, De Paulis R, El-Hamamsy I, Farooqi KM, Girardi LN, Gräni C, Kochav JD, Molossi S, Puskas JD, Rao SV, Sandner S, Tatoulis J, Truong QA, Weinsaft JW, Zimpfer D, Mery CM. Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review. J Am Coll Cardiol 2023; 82:2034-2053. [PMID: 37855757 DOI: 10.1016/j.jacc.2023.08.012] [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: 05/15/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 10/20/2023]
Abstract
As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Eloisa Arbustini
- Transplant Research Area and Centre for Inherited Cardiovascular Diseases, Scientific Department, IRCCS and Polyclinic San Matteo Foundation, Pavia, Italy
| | - Emile Bacha
- Division of Cardiac, Thoracic, and Vascular Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York, USA
| | - Eric R Bates
- Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Duke E Cameron
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Tirone E David
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ruggero De Paulis
- Department of Cardiac Surgery, European Hospital, Rome, Italy; UniCamillus University, Rome, Italy
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Kanwal M Farooqi
- Division of Pediatric Cardiology, New York-Presbyterian, Columbia University Irving Medical Center, New York, New York, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan D Kochav
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Silvana Molossi
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - John D Puskas
- Department of Cardiovascular Surgery, Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sunil V Rao
- Division of Interventional Cardiology, NYU Langone Health, New York, New York, USA
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - James Tatoulis
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Quynh A Truong
- Department of Radiology, New York Presbyterian, Weill Cornell Medicine, New York, New York, USA
| | - Jonathan W Weinsaft
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Daniel Zimpfer
- Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, Dell Medical School at The University of Texas at Austin/Dell Children's Medical Center, Austin, Texas, USA
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5
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Angelini P, Uribe C, Corno AF. Pathophysiology and Treatment of Intraseptal-Course Left Coronary Anomaly: Surgery for All? Pediatr Cardiol 2023:10.1007/s00246-023-03328-1. [PMID: 37943349 DOI: 10.1007/s00246-023-03328-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
Intraseptal-course, ectopic coronary anomalies are not well characterized as to anatomy, function, prognosis, and treatment. Recently, a revolutionary but unsupported new theory is claiming that most patients with a Left Anomalous Coronary Artery originating from the Opposite Sinus with anomalous Intra-Septal course (L-ACAOS-IS)-even small children-have significant stenoses and require open-heart surgery to prevent acute myocardial infarction and death. This surprising view has spurred ongoing discussions among adult and pediatric cardiologists and cardiac surgeons, compelling us (the conservative party in the discussion) to offer an in-depth and comprehensive review of this anomaly, based on objective but opposite data. We and other adult cardiologists have followed numerous L-ACAOS-IS patients for many years and have observed none of the claimed catastrophes. Rather, we have consistently found that L-ACAOS-IS generally has a benign clinical prognosis. We present the general principle of coronary artery dysfunction in anatomical congenital anomalies (that only significant luminal coronary stenosis can have clinical repercussions). We then review anatomical and functional details of L-ACAOS-IS related to prognosis and treatment indications, which could explain many of the clinical presentations recently mentioned. Finally, we encourage our more liberal colleagues to recognize that, compared with normal coronary arteries, those with anomalies of origin and course are associated with frequent coronary spasm. In particular, we underscore that some of the ischemic manifestations and other results might actually be caused by pressure wire-induced artifacts (rigid wires tend to cause coronary spasm when advanced into tortuous coronary arteries).
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Affiliation(s)
- Paolo Angelini
- The Texas Heart Institute Center for Cardiovascular Care, Houston, TX, USA
| | - Carlo Uribe
- The Texas Heart Institute Center for Cardiovascular Care, Houston, TX, USA
| | - Antonio F Corno
- School of Engineering, University of Leicester, University Road, Leicester, LE1 7RH, UK.
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6
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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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7
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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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8
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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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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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10
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Angelini P, Uribe C. Stent Angioplasty in Coronary Artery Anomalies With Intramural Course: When, Why, How, With What Results? JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100595. [PMID: 39130716 PMCID: PMC11307458 DOI: 10.1016/j.jscai.2023.100595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 08/13/2024]
Abstract
Although coronary artery anomalies include multiple disorders, few are likely to require intervention, given that the risk for critical sequelae (ie, sudden cardiac arrest and sudden cardiac death) is generally low. This article addresses which coronary artery anomaly carriers may need intervention and which interventions may be required. The recent introduction of stent angioplasty is discussed in particular, along with general reviews of nomenclature, various anatomical and functional presentations, quantitative diagnosis methods, and indications for surgical versus percutaneous intervention. Novel criteria for defining severe stenosis also are proposed. Optimal risk quantification depends on precise imaging that only intravascular ultrasonography or optical coherence tomography can reliably obtain. Accordingly, the technique of intravascular ultrasonography-monitored stent angioplasty is described in detail. Initial results from our group's study of 100 patients with right or left anomalous origin of a coronary artery from an opposite sinus of Valsalva with intramural course are reported. Future efforts should prospectively evaluate stent angioplasty in multicenter studies based on precise, consistent techniques and follow-up protocols, such as those initiated by our group. Comparisons with surgical results should be part of the program, with the understanding that detailed and complete results from those techniques will require long-term (5- to 10-year) studies.
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Affiliation(s)
- Paolo Angelini
- The Texas Heart Institute Center for Cardiovascular Care, Houston, Texas
| | - Carlo Uribe
- The Texas Heart Institute Center for Cardiovascular Care, Houston, Texas
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11
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AlQubbany A, Alqurashi Y, Zagzoog A, Almehmadi F, Al-Husayni F, Ahmad A, Albugami S. Anomalous Coronary Arteries: A Cause for Malignant Arrhythmias. Cureus 2023; 15:e39658. [PMID: 37388603 PMCID: PMC10306351 DOI: 10.7759/cureus.39658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/01/2023] Open
Abstract
Anomalous aortic origin of a coronary artery (AAOCA) is a congenital condition that can lead to sudden cardiac death (SCD), particularly among young individuals. The cause of SCD is thought to be ischemia, primarily related to the course of the anomalous coronary artery. Surgical intervention, such as unroofing or coronary revascularization, is the preferred management modality for patients with evidence of ischemia or concomitant fixed obstruction. Herein, we presented a case of a 24-year-old male admitted to the emergency department with a history of palpitations, dyspnea, diaphoresis, and syncope. The patient had no prior medical diseases and was eventually diagnosed with an anomalous right coronary artery (ARCA) originating from the left coronary sinus. The patient underwent surgical unroofing of the ARCA to prevent further episodes of ischemia and ventricular arrhythmias. The case highlights that coronary artery anomalies can be life-threatening and lead to SCD, especially in young individuals with no risk factors. Investigating coronary anomalies in medically free patients presenting with cardiac symptoms and arrhythmias is crucial.
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Affiliation(s)
- Atif AlQubbany
- Department of Cardiac Sciences, King Faisal Cardiac Center, National Guard Hospital, King Abdulaziz Medical City, Jeddah, SAU
- Department of Cardiac Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, SAU
- Department of Cardiac Sciences, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Jeddah, SAU
| | - Yazeed Alqurashi
- Department of Internal Medicine, King Faisal Cardiac Center, National Guard Hospital, King Abdulaziz Medical City, Jeddah, SAU
| | - Amin Zagzoog
- Department of Cardiac Sciences, King Faisal Cardiac Center, National Guard Hospital, King Abdulaziz Medical City, Jeddah, SAU
- Department of Cardiac Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, SAU
- Department of Cardiac Sciences, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Jeddah, SAU
| | - Fahad Almehmadi
- Department of Cardiac Sciences, King Faisal Cardiac Center, National Guard Hospital, King Abdulaziz Medical City, Jeddah, SAU
- Department of Cardiac Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, SAU
- Department of Cardiac Sciences, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Jeddah, SAU
| | - Faisal Al-Husayni
- Department of Cardiac Sciences, King Faisal Cardiac Center, National Guard Hospital, King Abdulaziz Medical City, Jeddah, SAU
- Department of Cardiac Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, SAU
| | - Akram Ahmad
- Department of Cardiology, Dr. Samir Abbas Hospital, Jeddah, SAU
| | - Saad Albugami
- Department of Cardiac Sciences, King Faisal Cardiac Center, National Guard Hospital, King Abdulaziz Medical City, Jeddah, SAU
- Department of Cardiac Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, SAU
- Department of Cardiac Sciences, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Jeddah, SAU
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12
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Amioka N, Nakamura K, Matsuo N, Watanabe A, Kotani Y, Kasahara S, Ito H. Repeated Syncope During Exercise as a Result of Anomalous Origin of Left Coronary Artery With Intramural Aortic Course in a Teenage Boy. Tex Heart Inst J 2022; 49:489427. [PMID: 36538599 PMCID: PMC9809068 DOI: 10.14503/thij-21-7677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Anomalous origin of the left coronary artery from the opposite sinus of Valsalva with an intramural aortic course (L-ACAOS-IM) can cause syncope, sometimes as a prodrome of lethal events, including sudden cardiac death, in young athletes. The detailed mechanism of syncope in patients with L-ACAOS-IM is still unclear. This case report describes a 17-year-old boy who presented to the hospital because of syncope following chest pain with increasing frequency during exercise, such as playing soccer and running. In a treadmill exercise test, a decrease in blood pressure was seen (from 99/56 mm Hg to 68/38 mm Hg); chest pain and faintness accompanied by ST-segment elevation in lead aVR and ST-segment depression at other leads on electrocardiography were noted. These findings and symptoms disappeared spontaneously within a few minutes while clinicians prepared for emergency medications. Coronary computed tomography angiography (CCTA) showed that the origin of the left coronary artery (LCA) was the opposite sinus of Valsalva, and the course of the LCA was through the aortic wall toward the left coronary sinus. He was diagnosed with L-ACAOS-IM. After surgical treatment by unroofing the intramural part of the LCA and reconstructing a neo-ostium, he no longer experienced syncope during exercise. This case suggests that low cardiac output caused by myocardial ischemia, not life-threatening arrythmia, is a main mechanism of syncope in patients with L-ACAOS-IM. Consideration should be given to performing CCTA before an exercise stress test for young patients with syncope and chest pain to avoid the risk of severe myocardial ischemia.
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Affiliation(s)
- Naofumi Amioka
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Naoaki Matsuo
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
, Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
, Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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13
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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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14
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Roberto Schetz Alves M, Momoli J, Lindsey Pilato E, Lenci Marques G. Origin, Course, and Angulation of Coronary Artery Anomaly - A Case Report. Cureus 2022; 14:e28669. [PMID: 36199653 PMCID: PMC9526454 DOI: 10.7759/cureus.28669] [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] [Accepted: 09/01/2022] [Indexed: 11/24/2022] Open
Abstract
Congenital coronary artery anomalies are a rare diagnosis that can be silent when the patient is asymptomatic. Although these abnormalities may, in most cases, not present clinical alterations, in some cases, they prove to be a cause of myocardial ischemia and sudden death. We report the case of a 20-year-old asymptomatic patient, seen in a routine cardiology consultation, evidenced in an ergometric test ST-segment depression. In this case, follow-up was carried out with coronary angiotomography and scintigraphy to understand the reason for this finding. After the angiotomography has evidenced the diagnosis of anomalous origin and course of the right coronary artery and the trunk of the left coronary artery, in addition to anomalous angulation of the right coronary vessel.
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15
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Saitto G, Lio A, Polizzi V, Russo M, Nicolò F, Ranocchi F, Musumeci F. Surgical Management of Acute Myocardial Infarction Caused by Intramural Anomalous Left Coronary Artery in a Young Female Athlete. Tex Heart Inst J 2022; 49:486469. [PMID: 36149934 DOI: 10.14503/thij-20-7425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In the complex spectrum of coronary anomalies, the origin of the left coronary artery from the right sinus of Valsalva with intramural course could represent a catastrophic life-threatening condition leading to extensive myocardial infarction and sudden cardiac death, especially in young athletes. We report the case of a young female athlete with anomalous left coronary artery from the opposite sinus who survived a major non-ST-elevation myocardial infarction during the eighth kilometer of a running race. It was successfully treated by creating a neo-ostium of the left coronary artery in the left sinus at the point at which the artery left the aortic wall.
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Affiliation(s)
- Guglielmo Saitto
- Cardiac Surgery and Heart Transplantation Unit, San Camillo Hospital, Rome, Italy
| | - Antonio Lio
- Cardiac Surgery and Heart Transplantation Unit, San Camillo Hospital, Rome, Italy
| | - Vincenzo Polizzi
- Cardiac Surgery and Heart Transplantation Unit, San Camillo Hospital, Rome, Italy
| | - Marco Russo
- Cardiac Surgery and Heart Transplantation Unit, San Camillo Hospital, Rome, Italy
| | - Francesca Nicolò
- Cardiac Surgery and Heart Transplantation Unit, San Camillo Hospital, Rome, Italy
| | - Federico Ranocchi
- Cardiac Surgery and Heart Transplantation Unit, San Camillo Hospital, Rome, Italy
| | - Francesco Musumeci
- Cardiac Surgery and Heart Transplantation Unit, San Camillo Hospital, Rome, Italy
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16
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Can we talk? The residual, urgent questions about surgery for coronary artery anomalies. JTCVS OPEN 2022; 11:127-128. [PMID: 36172437 PMCID: PMC9510787 DOI: 10.1016/j.xjon.2022.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Can ectopic right coronary from the left sinus have a different course than intramural? A case of ectopic right with retroaortic course. Cardiol Young 2022; 32:1338-1340. [PMID: 35144710 DOI: 10.1017/s1047951121004947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Retrocardiac course of an ectopic right coronary artery is newly described. The alternative (usual) course of an anomalous right coronary from the left sinus of Valsalva is pre-aortic and intramural, with stenosis. In the present exceptional case, there was no stenosis.
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18
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Hu F, Wang X, Wan J, Li Y, Wang T, Zhou K, Shi X, Liu Z, Fang J, Hua Y. An Atypical Anomalous Aortic Origin of the Left Coronary Artery With Intra-Arterial Wall Course Pretending a Normal Migration on Imaging Screening: A Case Report. Front Cardiovasc Med 2022; 9:918832. [PMID: 35757337 PMCID: PMC9222707 DOI: 10.3389/fcvm.2022.918832] [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: 04/12/2022] [Accepted: 05/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background An anomalous aortic origin of a coronary artery (AAOCA) has been considered as a dominant cause of sudden cardiac death (SCD) among young age children. Therefore, it is critical to identify AAOCA timely to avoid lethal events. Recently, accumulating cases of right or left coronary arteries originating from inappropriate locations at the sinus of Valsalva have been identified. Here, we report a rare case of AAOCA with an intra-arterial wall course pretending normal migration on imaging screening in a patient who suffered from syncope. Case summary A 7-year-old male without a previous history of cardiovascular and cerebrovascular diseases suddenly suffered from sharp chest pain and syncope after intensive exercise. The electrocardiogram showed that the ST segment of multiple leads was depressed by more than 0.05 mV, and biomarkers indicated severe myocardial injuries. The left ventricular ejection fraction (LVEF) decreased dramatically to 23%. Fulminant myocarditis and cardiomyopathy were therefore excluded. However, a relatively normal coronary artery origin, which arose from the left coronary sinus, presented on echocardiography and cardiac CT angiography (CTA). It is difficult to draw an association between severe clinical manifestations and slight malformations on echocardiography and CTA. Furthermore, selective coronary angiography revealed that an anomalous left coronary artery arose from the superior margin of the inappropriate sinus, developed an intramural wall course and finally exits the left sinus of Valsalva and migrated between the aorta and the pulmonary artery, which induced severe myocardial infarction during exercise. Then, the patient received surgical correction with a modified unroofing procedure. After 2 months of intensive treatment, the patient was discharged and remained asymptomatic through 18 months of follow-up. Conclusion AAOCA, especially anomalous left coronary artery (ALCA), represents a major potential risk of SCD. We reported an atypical manifestation of ALCA arising from the inappropriate sinus of Valsalva and merging into the intra-arterial wall to develop a strange course and then sprout between the aorta and the pulmonary artery. The diversity of AAOCA might present as a relatively normal course under non-invasive radiological imaging scanning.
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19
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Caniato F, Ristalli F, Mattesini A, Di Mario C, Secco GG. Optimal Angiographic Views for Coronary Angioplasty. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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20
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Can we talk? The residual questions about surgery for coronary artery anomalies. JTCVS OPEN 2022; 10:354-355. [PMID: 36004232 PMCID: PMC9390255 DOI: 10.1016/j.xjon.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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21
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Liu X, Chen X, Li X, Ma C. Takotsubo syndrome following radiofrequency ablation of atrial fibrillation in a patient with coronary artery anomaly: a case report. Eur Heart J Case Rep 2022; 6:ytac147. [PMID: 35497387 PMCID: PMC9048891 DOI: 10.1093/ehjcr/ytac147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/04/2021] [Accepted: 04/01/2022] [Indexed: 11/19/2022]
Abstract
Background Takotsubo syndrome (TTS) is an acute heart failure syndrome usually induced by emotional or physical stress. The prevalence of TTS seems to be higher than previously anticipated. Radiofrequency catheter ablation could be a rare trigger of TTS. The pathophysiology is not fully understood. Sympathetic stimulation plays an important role on the development of TTS. Case summary A 62-year-old woman was referred for RFCA because of drug-refractory symptomatic paroxysmal atrial fibrillation. No other chronic diseases were stated except for a hypertension history. Three hours after the AF ablation, the patient complained of chest pain. New electrocardiographic abnormalities were presented including progressive T-wave inversion and significant QT prolongation. Multimodality imaging, including echocardiography, coronary angiography, left ventriculography, and computed tomography was conducted in establishing the TTS diagnosis. The congenital coronary artery anomaly was confirmed at the same time. Both transthoracic echocardiography and left ventriculography showed typical TTS changes. Elevation of the brain natriuretic peptide and Troponin I was observed during the acute phase. Angiotensin-converting enzyme inhibitor and β-blocker were administrated during hospitalization and after discharge. Two weeks later, echocardiography and cardiovascular magnetic resonance revealed a total recovery of left ventricular function and apex kinesis. Discussion Sometimes, it is hard to distinguish TTS from acute coronary syndrome because of similar manifestations. Multimodality imaging is helpful to confirm the diagnosis. Radiofrequency catheter ablation could be a rare trigger of TTS, and its incidence may increase in patients with coronary artery anomaly. Coronary spasm and increased cardiac sympathetic activity induced by the ablation might be the mechanism involved.
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Affiliation(s)
- Xiaoxia Liu
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing,PR Zip 100029, China
| | - Xuan Chen
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing,PR Zip 100029, China
| | - Xu Li
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing,PR Zip 100029, China
| | - Changsheng Ma
- Department of Cardiology, Beijing An Zhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Chaoyang District, Beijing,PR Zip 100029, China
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22
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Rigatelli G, Chiastra C, Pennati G, Dubini G, Migliavacca F, Zuin M. Applications of computational fluid dynamics to congenital heart diseases: a practical review for cardiovascular professionals. Expert Rev Cardiovasc Ther 2021; 19:907-916. [PMID: 34704881 DOI: 10.1080/14779072.2021.1999229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The increased survival rate of patients with congenital heart disease (CHD) has made it likely that 70%-95% of infants with CHDs surviving into adulthood often require careful follow-up and (repeat) interventions. Patients with CHDs often have abnormal blood flow patterns, due to both primary cardiac defect and the consequent surgical or endovascular repair. AREA COVERED Computational fluid dynamics (CFD) alone or coupled with advanced imaging tools can assess blood flow patterns of CHDs to both understand their pathophysiology and anticipate the results of surgical or interventional repair. EXPERT OPINION CFD is a mathematical technique that quantifies and describes the characteristics of fluid flow using the laws of physics. Through dedicated software based on virtual reconstruction and simulation and patients' real data coming from computed tomography, magnetic resonance imaging, and 3/4 D-ultrasound, reconstruction of models of circulation of most CHD can be accomplished. CFD can provide insights about the pathophysiology of coronary artery anomalies, interatrial shunts, coarctation of the aorta and aortic bicuspid valve, tetralogy of Fallot and univentricular heart, with the capability in some cases of simulating different types of surgical or interventional repair and tailoring the treatment on the basis of these findings.
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Affiliation(s)
- Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy
| | - Claudio Chiastra
- PoliToBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Giancarlo Pennati
- Laboratory of Biological Structure Mechanics (Labs), Department of Chemistry, Materials and Chemical Engineering Giulio Natta, Politecnico di Milano, Milan, Italy
| | - Gabriele Dubini
- Laboratory of Biological Structure Mechanics (Labs), Department of Chemistry, Materials and Chemical Engineering Giulio Natta, Politecnico di Milano, Milan, Italy
| | - Francesco Migliavacca
- Laboratory of Biological Structure Mechanics (Labs), Department of Chemistry, Materials and Chemical Engineering Giulio Natta, Politecnico di Milano, Milan, Italy
| | - Marco Zuin
- Section of Internal and Cardiopulmonary Medicine, University of Ferrara, Ferrara, Italy
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23
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Abstract
Coronary artery anomalies (CAAs) are a group of congenital conditions characterized by abnormal origin or course of any of the 3 main epicardial coronary arteries. Although CAAs have been identified as a common underlying condition in young athletes with sudden cardiac death, the widespread use of invasive and noninvasive coronary imaging has led to increased recognition of CAAs among adults. CAAS are often discovered as an incidental finding during the diagnostic workup for ischemic heart disease. The clinical correlates and prognostic implication of CAAs remain poorly understood in this context, and guideline-recommended therapeutic choices are supported by a low level of scientific evidence. Several studies have examined whether assessment of CAA-related myocardial ischemia can improve risk stratification in these patients, suggesting that multimodality imaging and functional tests may be key in the management of CAAs. The aim of this review is to outline definitions, classification, and epidemiology of the most relevant CAAs, highlighting recent advances and the potential impact of multimodality evaluation, and to discuss current therapeutic opportunities.
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Affiliation(s)
- Francesco Gentile
- Cardiology Division, Pisa University Hospital, Italy (F.G., V.C., R.D.C.)
| | | | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Italy (F.G., V.C., R.D.C.).,Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy (R.D.C.)
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24
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Angelini P. Screening, preventing, treating coronary disease in young versus adult athletes: a complex discussion. Trends Cardiovasc Med 2021; 32:438-439. [PMID: 34534649 DOI: 10.1016/j.tcm.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Paolo Angelini
- From the Department of Cardiology, Texas Heart Institute, 6624 Fannin Street, Suite 2780, Houston, Texas 77030, United States.
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25
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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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26
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Where's the beef in anomalous coronary artery origin from an opposite aortic sinus? Int J Cardiol 2021; 339:45-46. [PMID: 34216711 DOI: 10.1016/j.ijcard.2021.06.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 11/22/2022]
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27
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Angelini P, Muthupillai R, Lopez A, Cheong B, Uribe C, Hernandez E, Coulter S, Perin E, Molossi S, Gentile F, Flamm S, Lorenz G, D'Ascenzi F, Tobis J, Sarnari R, Corno A, Furgerson J, Chiribiri A, Villa ADM, Orzan F, Brugada P, Jefferies J, Aubry P, Towbin J, Thiene G, Tomanek R. Young athletes: Preventing sudden death by adopting a modern screening approach? A critical review and the opening of a debate. IJC HEART & VASCULATURE 2021; 34:100790. [PMID: 34124338 PMCID: PMC8175289 DOI: 10.1016/j.ijcha.2021.100790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/07/2021] [Accepted: 04/23/2021] [Indexed: 10/29/2022]
Abstract
Preventing sudden cardiac death (SCD) in athletes is a primary duty of sports cardiologists. Current recommendations for detecting high-risk cardiovascular conditions (hr-CVCs) are history and physical examination (H&P)-based. We discuss the effectiveness of H&P-based screening versus more-modern and accurate methods. In this position paper, we review current authoritative statements and suggest a novel alternative: screening MRI (s-MRI), supported by evidence from a preliminary population-based study (completed in 2018), and a prospective, controlled study in military recruits (in development). We present: 1. Literature-Based Comparisons (for diagnosing hr-CVCs): Two recent studies using traditional methods to identify hr-CVCs in >3,000 young athletes are compared with our s-MRI-based study of 5,169 adolescents. 2. Critical Review of Previous Results: The reported incidence of SCD in athletes is presently based on retrospective, observational, and incomplete studies. H&P's screening value seems minimal for structural heart disease, versus echocardiography (which improves diagnosis for high-risk cardiomyopathies) and s-MRI (which also identifies high-risk coronary artery anomalies). Electrocardiography is valuable in screening for potentially high-risk electrophysiological anomalies. 3. Proposed Project : We propose a prospective, controlled study (2 comparable large cohorts: one historical, one prospective) to compare: (1) diagnostic accuracy and resulting mortality-prevention performance of traditional screening methods versus questionnaire/electrocardiography/s-MRI, during 2-month periods of intense, structured exercise (in military recruits, in advanced state of preparation); (2) global costs and cost/efficiency between these two methods. This study should contribute significantly toward a comprehensive understanding of the incidence and causes of exercise-related mortality (including establishing a definition of hr-CVCs) while aiming to reduce mortality.
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Affiliation(s)
- Paolo Angelini
- Department of Cardiology, Texas Heart Institute, Houston, TX, USA
| | - Raja Muthupillai
- Department of Radiology, University of Houston, Houston, TX, USA
| | - Alberto Lopez
- Electrophysiology Laboratory, Department of Cardiology, Texas Heart Institute, Houston, TX, USA
| | - Benjamin Cheong
- Department of Radiology, Texas Heart Institute, Houston, TX, USA
| | - Carlo Uribe
- Department of Cardiology, Texas Heart Institute, Houston, TX, USA
| | | | | | - Emerson Perin
- Department of Cardiology, Texas Heart Institute, Houston, TX, USA
| | - Silvana Molossi
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, United States
| | | | - Scott Flamm
- Department of Radiology, Cleveland Clinic, Cleveland, OH, USA
| | - Giovanni Lorenz
- Department of Radiology, Wilford Hall Ambulatory Center, San Antonio Military Health System, Joint Base San Antonio, San Antonio, TX, USA
| | | | - Jonathan Tobis
- Department of Cardiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Roberto Sarnari
- Department of Radiology, Northwestern University, Chicago, IL, USA
| | - Antonio Corno
- Department of Congenital Cardiac Surgery, Children's Memorial Hermann Hospital, UTHealth, Houston, TX, USA
| | - James Furgerson
- Department of Cardio-Radiology, US Air Force Lackland Hospital, San Antonio, TX, USA
| | - Amedeo Chiribiri
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom
| | - Adriana D M Villa
- Department of Radiology, St. Thomas Hospital, King's College London, United Kingdom
| | - Fulvio Orzan
- Division of Cardiology, Department of Medical Sciences, University of Turin, Italy
| | - Pedro Brugada
- Cardiovascular Division, Free University of Brussels (UZ Brussel) VUB, Brussels, Belgium
| | - John Jefferies
- The Cardiac Institute, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Pierre Aubry
- Department of Cardiology, Bichat Hospital, Paris, France
| | - Jeffrey Towbin
- Division of Adult Cardiovascular Diseases, Methodist University of Tennessee Cardiovascular Institute and Department of Preventive Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Gaetano Thiene
- Department of Pathologic Anatomy, University of Padua, Italy
| | - Robert Tomanek
- Department of Anatomy and Cell Biology, University of Iowa, Iowa City, IA, USA
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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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29
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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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Rigatelli G, Zuin M. Computed Tomography-based Patient-specific Biomechanical and Fluid Dynamic Study of Anomalous Coronary Arteries with Origin from the Opposite Sinus and Intramural Course. Heart Int 2020; 14:105-111. [PMID: 36276502 PMCID: PMC9524708 DOI: 10.17925/hi.2020.14.2.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 12/04/2020] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND The anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) constitutes one of the most clinically relevant coronary artery anomalies in adults. Exact pathophysiology and the impact of intramural (IM) course segment stenting in ACAOS with IM course (ACAOS-IM) has not been clarified. We aimed to elucidate the pathophysiology and impact of stenting applying biomechanical and computational fluid dynamics to computed tomography (CT) in patient-specific coronary vessel reconstruction. METHODS We separated coronary artery (left or L-, right or R-) ACAOS-IM into segments (proximal, mid and distal), based on coronary angiography and coronary CT angiography features, in a series of patients at Rovigo General Hospital, Italy, between 1 January 2003 and 1 January 2018. Blood pressure gradient across the coronary circulation, calculated blood flow, vorticity magnitude, wall shear stress (WSS) and IM segment deformation were analysed by simulating exercise, before and after virtual stent implantation. RESULTS In 21 symptomatic patients (13 males, mean age 46.1 ± 8.1 years, L-ACAOS-IM in 9 and R-ACAOS-IM in 12 patients), computational fluid dynamic analysis in both L- and R-ACAOS demonstrated higher basal WSS values in the IM course (9.5 ± 0.2 and 8.6 ± 0.2 Pa for R- and L-ACAOS, respectively), than in the rest of the vessels. These values decreased after stenting. Vorticity magnitude significantly decreased after stenting as well, compared with baseline. Biomechanical deformation analysis revealed not only compression, but also a twisting of the IM segment with a mean distal pressure drop of 32% and 35% in R- and L-ACAOS, respectively, which was corrected by stent implantation. CONCLUSIONS In both L- and R-ACAOS subtypes, the IM segment appeared to be phasically compressed and deformed with a degree of twisting that causes resting and exercise cross-sectional deformation and a drop in distal pressure. Stenting of the IM segment results in normalisation of the flow profile, correction of the IM segment deformation and reverses the drop in pressure, for both variants of ACAOS.
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Affiliation(s)
- Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy
| | - Marco Zuin
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy
- Section of Internal and Cardiopulmonary Medicine, University of Ferrara, Ferrara, Italy
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31
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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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32
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Angelini P. How to Work Up a Case of Sudden Cardiac Arrest in a Young Sportsman. JACC Case Rep 2020; 2:2124-2127. [PMID: 34317121 PMCID: PMC8299764 DOI: 10.1016/j.jaccas.2020.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Paolo Angelini
- Center for Coronary Artery Anomalies, Texas Heart Institute, Houston, Texas
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Farjat Pasos JI, Ibarra JP, Angelini P, Arias EA. Left main-like bifurcation primary percutaneous coronary intervention case report: anomalous right coronary artery ostium from the left anterior descending. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 33426457 PMCID: PMC7780483 DOI: 10.1093/ehjcr/ytaa313] [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: 05/05/2020] [Revised: 06/04/2020] [Accepted: 08/04/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND A single coronary artery ostium (SCAO) is estimated to be present in 0.066% of the general population. The proximal coronary course and the relationship with surrounding structures are related to malignant vs. benign prognoses. We present a case of SCAO with the right coronary artery (RCA) arising from the mid-left anterior descending (LAD), complicated by anterior and inferior STEMI because of acute thrombotic occlusion at the bifurcation and its percutaneous management. CASE SUMMARY A 56-year-old male was admitted with sudden onset of resting chest pain. His ECG showed an anterior, inferior, and right ventricular STEMI. Via trans-radial access, coronary angiography showed significant stenoses at the left main and the circumflex but also a thrombotic occlusion at the proximal segment of the LAD while no RCA was seen. After crossing the LAD occlusion, the dominant RCA appeared from the mid-LAD. A provisional stent technique was performed achieving good results. Coronary computed tomography angiography showed an SCAO congenital anomaly with a patent stent in the bifurcation accompanied by diffuse coronary artery disease causing mild stenosis of the left main, proximal, and distal circumflex. DISCUSSION The RCA arising from the mid-LAD with pre-pulmonic course has been described in only 37 cases. One reported an LAD/RCA bifurcation treatment with two stents technique in a stable scenario. The present is the first case reported of an acute thrombotic occlusion of an LAD/RCA bifurcation clinically resulting in a left main equivalent STEMI treated successfully with primary percutaneous coronary intervention using a bifurcation technique.
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Affiliation(s)
- Julio I Farjat Pasos
- Interventional Cardiology Department, "Ignacio Chavez" National Institute of Cardiology. Juan Badiano 1. Tlalpan, Mexico City 14080, Mexico
| | - Jorge Padilla Ibarra
- Interventional Cardiology Department, "Ignacio Chavez" National Institute of Cardiology. Juan Badiano 1. Tlalpan, Mexico City 14080, Mexico
| | - Paolo Angelini
- Interventional Cardiology Department, Texas Heart Institute, 6770 Bertner Ave, Houston, TX 77030, USA
| | - Eduardo A Arias
- Interventional Cardiology Department, "Ignacio Chavez" National Institute of Cardiology. Juan Badiano 1. Tlalpan, Mexico City 14080, Mexico
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34
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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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Lo Rito M, Romarowski RM, Rosato A, Pica S, Secchi F, Giamberti A, Auricchio F, Frigiola A, Conti M. Anomalous aortic origin of coronary artery biomechanical modeling: Toward clinical application. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)32430-2. [PMID: 32950237 DOI: 10.1016/j.jtcvs.2020.06.150] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 05/30/2020] [Accepted: 06/05/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Anomalous aortic origin of the coronary artery can be associated with sudden cardiac death and ischemic events. Anatomic static characteristics mainly dictated surgical indications, although adverse events are usually related to dynamic physical effort. We developed a computational model able to simulate anomalous coronary behavior, and we aimed to assess its clinical applicability and to investigate coronary characteristics at increasing loading stress conditions. METHODS We selected 5 patients with anomalous aortic origin of the coronary artery and 5 control subjects. For each of them, we construct a 3-dimensional model resembling the aortic root and coronary arteries based on 25 parameters obtained from computed tomography. Structural finite element analysis simulations were run to simulate pressure increasing in the aortic root during exercise (+40 mm Hg, +100 mm Hg with respect baseline condition, assumed at 80 mm Hg) and investigate coronary lumen characteristics. RESULTS The 25 parameters were obtainable in all subjects with a consistent interobserver agreement. In control subjects, the right coronary artery had a more significant lumen expansion at loading conditions compared with anomalous aortic origin of coronary artery (6%-19.2% vs 1.8%-8.1%, P = .008), which also showed an inability to expand within the intramural segment. CONCLUSIONS The proposed anomalous aortic origin of coronary artery model is able to represent the pathogenic disease mechanism after being populated with patient-specific data. It can assess the impaired expansion of anomalous right coronary at loading conditions, a process that cannot be quantified in any clinical set-up. This first clinical application showed promising results on quantifying pathological behavior, potentially helping in patient-specific risk stratification.
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Affiliation(s)
- Mauro Lo Rito
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
| | | | - Antonio Rosato
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Silvia Pica
- Multimodality Cardiac Imaging Section, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Francesco Secchi
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alessandro Giamberti
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Ferdinando Auricchio
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
| | - Alessandro Frigiola
- Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Michele Conti
- Department of Civil Engineering and Architecture, University of Pavia, Pavia, Italy
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Abstract
PURPOSE OF REVIEW The most pertinent clinical question in post-coronary computed tomography angiography (CCTA) patients is the assessment of the physiological significance of an anatomically identified stenosis. The clinical application of radionuclide MPI using single-photon emission computed tomography (SPECT) versus positron emission tomography (PET) in the evaluation and management of patients with an inconclusive CCTA is reviewed using a case-based approach. RECENT FINDINGS Recent evidence suggests that CCTA is the most sensitive non-invasive test to exclude angiographic CAD and may be an effective first-line test especially among symptomatic low-intermediate risk patients. However, in the presence of angiographic atherosclerosis, its specificity and positive predictive value for identifying flow-limiting stenosis are modest. Radionuclide myocardial perfusion imaging offers accurate quantitative assessment of myocardial ischemia, which helps with risk stratification and patient management especially the potential need for revascularization. Routine accurate quantifications of myocardial blood flow and flow reserve are major advantages of PET MPI, which are especially useful when used in patients at intermediate-high clinical risk.
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Affiliation(s)
- Vasvi Singh
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Brigham and Women's Hospital, 75 Francis St, ASB-L1 037C, Boston, MA, 02115, USA.
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Angelini P, Muthupillai R, Cheong B, Paisley R. We Have Plenty of Reasons to Propose New, Updated Policies for Preventing Sudden Cardiac Death in Young Athletes. J Am Heart Assoc 2020; 9:e014368. [PMID: 32306825 PMCID: PMC7428543 DOI: 10.1161/jaha.119.014368] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Paolo Angelini
- Departments of Cardiology and Cardiovascular Radiology Texas Heart Institute Houston TX
| | - Raja Muthupillai
- Departments of Cardiology and Cardiovascular Radiology Texas Heart Institute Houston TX
| | - Benjamin Cheong
- Departments of Cardiology and Cardiovascular Radiology Texas Heart Institute Houston TX
| | - Robert Paisley
- Departments of Cardiology and Cardiovascular Radiology Texas Heart Institute Houston TX
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Garcia-Arribas D, Olmos C, Higueras J, Marcos-Alberca P, de la Pedraja I, Garcia-Bouza M. Anomalous Origin of Left Coronary Artery with Intramural Aortic Course Causing Symptoms in a Teenaged Athlete. Tex Heart Inst J 2020; 47:165-167. [PMID: 32603454 DOI: 10.14503/thij-16-5771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Anomalous origin of the left coronary artery from the opposite sinus of Valsalva with an intramural aortic course is a rare congenital anomaly with a poor prognosis. We report the case of a 14-year-old soccer player who briefly lost consciousness while sprinting. He had exertional chest pain, syncope, ischemic changes on his electrocardiogram, and elevated cardiac troponin levels. Computed tomographic angiograms showed an anomalous origin of the left coronary artery from the right sinus of Valsalva and a course through the aortic wall toward the left coronary sinus. A surgically created neo-ostium in the left coronary sinus relieved the patient's ischemia, and he resumed playing soccer after cardiac rehabilitation.
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Affiliation(s)
- Daniel Garcia-Arribas
- Cardiovascular Institute, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos, 28040 Madrid, Spain
| | - Carmen Olmos
- Cardiovascular Institute, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos, 28040 Madrid, Spain
| | - Javier Higueras
- Cardiovascular Institute, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos, 28040 Madrid, Spain
| | - Pedro Marcos-Alberca
- Cardiovascular Institute, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos, 28040 Madrid, Spain
| | - Iñigo de la Pedraja
- Department of Radiology, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos, 28040 Madrid, Spain
| | - Monica Garcia-Bouza
- Cardiovascular Institute, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos, 28040 Madrid, Spain
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Angelini P. In Syncope or Sudden Death from Coronary Artery Anomalies, Hypotension and Bradycardia are More Frequent than Ventricular Fibrillation. Tex Heart Inst J 2020; 47:168-169. [PMID: 32603462 PMCID: PMC7328092 DOI: 10.14503/thij-19-7105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Paolo Angelini
- Department of Cardiology, Texas Heart Institute, Houston, Texas 77030
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40
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Doan TT, Zea-Vera R, Agrawal H, Mery CM, Masand P, Reaves-O’Neal DL, Noel CV, Qureshi AM, Sexson-Tejtel SK, Fraser CD, Molossi S. Myocardial Ischemia in Children With Anomalous Aortic Origin of a Coronary Artery With Intraseptal Course. Circ Cardiovasc Interv 2020; 13:e008375. [DOI: 10.1161/circinterventions.119.008375] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Intraseptal anomalous aortic origin of a coronary artery is considered a benign condition. However, there have been case reports of patients with myocardial ischemia, arrhythmia, and sudden cardiac death. The purpose of this study was to determine the clinical presentation, myocardial perfusion on provocative stress testing, and management of children with anomalous aortic origin of a coronary artery with an intraseptal course in a prospective cohort.
Methods:
Patients with anomalous aortic origin of a coronary artery and intraseptal course were prospectively enrolled from December 2012 to May 2019, evaluated, and managed following a standardized algorithm. Myocardial perfusion was assessed using stress imaging. Fractional flow reserve was performed in patients with myocardial hypoperfusion on noninvasive testing. Exercise restriction, β-blockers, and surgical intervention were discussed with the families.
Results:
Eighteen patients (female 6, 33.3%), who presented with no symptoms (10, 55.6%), nonexertional (4, 22.2%), and exertional symptoms (4, 22.2%), were enrolled at a median age of 12.4 years (0.3–15.9). Perfusion imaging was performed in 14/18 (77.8%) and was abnormal in 7/14 (50%); fractional flow reserve was positive in 5/8 (62.5%). All 4 patients with exertional symptoms and 3/10 (30%) with no or nonexertional symptoms had myocardial hypoperfusion. Coronary artery bypass grafting was performed in a 4-year-old patient; β-blocker and exercise restriction were recommended in 4 patients not suitable for surgery. One patient had nonexertional chest pain and 17 were symptom-free at median follow-up of 2.5 years (0.2–7.1).
Conclusions:
Up to 50% of patients with intraseptal anomalous aortic origin of a coronary artery had inducible myocardial hypoperfusion during noninvasive provocative testing. Long-term follow-up is necessary to understand the natural history of this rare anomaly.
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Affiliation(s)
- Tam T. Doan
- Coronary Anomalies Program (T.T.D., P.M., D.L.R.-O., C.V.N., A.M.Q., S.K.S.-T., S.M.), Baylor College of Medicine, Houston
| | - Rodrigo Zea-Vera
- Texas Children’s Hospital and General Surgery Residency Program (R.Z.V.), Baylor College of Medicine, Houston
| | - Hitesh Agrawal
- Le Bonheur Children’s Hospital, University of Tennessee Health Science 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, The University of Texas at Austin (C.M.M., C.D.F.)
| | - Prakash Masand
- Coronary Anomalies Program (T.T.D., P.M., D.L.R.-O., C.V.N., A.M.Q., S.K.S.-T., S.M.), Baylor College of Medicine, Houston
- Section of Pediatric Radiology (P.M.), Baylor College of Medicine, Houston
| | - Dana L. Reaves-O’Neal
- Coronary Anomalies Program (T.T.D., P.M., D.L.R.-O., C.V.N., A.M.Q., S.K.S.-T., S.M.), Baylor College of Medicine, Houston
| | - Cory V. Noel
- Coronary Anomalies Program (T.T.D., P.M., D.L.R.-O., C.V.N., A.M.Q., S.K.S.-T., S.M.), Baylor College of Medicine, Houston
| | - Athar M. Qureshi
- Coronary Anomalies Program (T.T.D., P.M., D.L.R.-O., C.V.N., A.M.Q., S.K.S.-T., S.M.), Baylor College of Medicine, Houston
| | - S. Kristen Sexson-Tejtel
- Coronary Anomalies Program (T.T.D., P.M., D.L.R.-O., C.V.N., A.M.Q., S.K.S.-T., S.M.), 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, The University of Texas at Austin (C.M.M., C.D.F.)
| | - Silvana Molossi
- Coronary Anomalies Program (T.T.D., P.M., D.L.R.-O., C.V.N., A.M.Q., S.K.S.-T., S.M.), Baylor College of Medicine, Houston
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41
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Gräni C, Grunwald C, Windecker S, Siontis GCM. Coronary Artery Anomaly in Takotsubo Cardiomyopathy: Cause or Innocent Bystander? Tex Heart Inst J 2020; 47:44-46. [PMID: 32148454 DOI: 10.14503/thij-18-6809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Coronary artery anomalies can provoke intermittent vasospasm and endothelial dysfunction, which can cause takotsubo cardiomyopathy. However, in takotsubo cardiomyopathy, apical myocardial regions are typically affected, and these do not correlate with a specific epicardial coronary distribution territory. We report the case of a 74-year-old woman who presented with acute respiratory failure and suspected myocardial infarction. She had a left coronary artery anomaly, dominant right coronary artery supply, takotsubo cardiomyopathy, depressed left ventricular ejection fraction, and no atherosclerotic disease. In the absence of exercise ischemia, we considered the anomalous artery to be an incidental finding. After 6 weeks of medical therapy, the patient's ejection fraction was normal; one year later, she remained asymptomatic. The anomalous left coronary artery in the presence of dominant right coronary supply did not explain the diffuse apical regional wall-motion abnormalities in our patient. To our knowledge, this is the first report of coexisting takotsubo cardiomyopathy and anomalous coronary artery in a patient presenting with acute dyspnea.
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Incidental Anomalous Left Coronary Artery in a Transplanted Heart. Case Rep Cardiol 2020; 2019:2715896. [PMID: 31949953 PMCID: PMC6948275 DOI: 10.1155/2019/2715896] [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: 10/10/2019] [Accepted: 12/09/2019] [Indexed: 11/17/2022] Open
Abstract
Anomalous coronary artery is an uncommon congenital cardiac anomaly that is often detected incidentally on coronary angiography. It has rarely been reported in the donor heart of patients who have undergone cardiac transplantation. Here, we report a case of a 72-year-old patient who received a second heart transplant and has been identified to have an anomalous left main coronary artery originating from the right coronary sinus on postoperative coronary angiography.
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Almeida I, Santos H, Miranda H, Santos M, Almeida S, Chin J. Cardiac arrest due to an anomalous aortic origin of a coronary artery: are older patients really safe? Rev Bras Ter Intensiva 2020; 32:606-610. [PMID: 33470363 PMCID: PMC7853687 DOI: 10.5935/0103-507x.20200099] [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: 11/19/2019] [Accepted: 04/19/2020] [Indexed: 11/28/2022] Open
Abstract
The authors report a rare case of successful Advanced Life Support in the context of cardiac arrest due to the presence of an anomalous aortic origin of the right coronary artery in a 49-year-old patient. The patient was admitted due to chest pain and dyspnea, with rapid evolution of pulseless ventricular tachycardia and cardiopulmonary arrest. Acute myocardial infarction was considered, and in the absence of a hemodynamic laboratory in the hospital, thrombolysis was performed. Subsequently, coronary angiography revealed no angiographic lesions in the coronary arteries and an anomalous right coronary artery originating from the opposite sinus of Valsalva. Coronary computed tomography angiography confirmed this finding and determined the course between the pulmonary artery and the aorta. The patient underwent cardiac surgery with a bypass graft to the right coronary artery, with no recurrent episodes of arrythmia.
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Affiliation(s)
- Inês Almeida
- Centro Hospitalar Barreiro Montijo EPE - Barreiro, Portugal
| | - Helder Santos
- Centro Hospitalar Barreiro Montijo EPE - Barreiro, Portugal
| | - Hugo Miranda
- Centro Hospitalar Barreiro Montijo EPE - Barreiro, Portugal
| | - Mariana Santos
- Centro Hospitalar Barreiro Montijo EPE - Barreiro, Portugal
| | - Samuel Almeida
- Centro Hospitalar Barreiro Montijo EPE - Barreiro, Portugal
| | - Joana Chin
- Centro Hospitalar Barreiro Montijo EPE - Barreiro, Portugal
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45
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Angelini P. Coronary artery anomalies: Why should we diagnose them in young athletes, by what means, and for what aims? Eur J Prev Cardiol 2019; 26:985-987. [DOI: 10.1177/2047487319840894] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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46
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Gräni C, Kaufmann PA, Windecker S, Buechel RR. Diagnosis and Management of Anomalous Coronary Arteries with a Malignant Course. ACTA ACUST UNITED AC 2019; 14:83-88. [PMID: 31178934 PMCID: PMC6545977 DOI: 10.15420/icr.2019.1.1] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/11/2019] [Indexed: 12/26/2022]
Abstract
Although the prevalence of anomalous coronary artery from the opposite sinus (ACAOS) in the general population is low, more frequent use of invasive and non-invasive imaging to rule out coronary artery disease has seen an increase in absolute numbers of ACAOS. ACAOS are traditionally classified as malignant (with an interarterial course) and benign variants. Malignant variants have been recognised in autopsy studies to be an underlying cause of sudden cardiac death in young athletes. Conversely, it seems that older people with ACAOS are less predisposed to adverse cardiac events. Non-invasive anatomic imaging is complementary to invasive imaging and helps to further identify high-risk anatomic features. Using functional non-invasive perfusion imaging can assess potential ischaemia induced by dynamic compression of malignant ACAOS. Information gained from clinical imaging guides the management of these patients.
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Affiliation(s)
- Christoph Gräni
- Department of Cardiology, Bern University Hospital Bern, Switzerland.,Department of Nuclear Medicine, University Hospital Zurich Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, University Hospital Zurich Zurich, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital Bern, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, University Hospital Zurich Zurich, Switzerland
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47
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Rigatelli G, Zuin M, Galasso P, Carraro M, D'Elia K, Daniela L, Roncon L, Truyen TTTT, Nguyen T. Mechanisms of Myocardial Ischemia Inducing Sudden Cardiac Death in Athletes with Anomalous Coronary Origin from the Opposite Sinus: Insights from a computational fluid dynamic study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:1112-1116. [PMID: 30808598 DOI: 10.1016/j.carrev.2019.01.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/19/2019] [Accepted: 01/28/2019] [Indexed: 12/26/2022]
Abstract
AIMS The left coronary anomalous origin from the opposite sinus (L- ACAOS) constitutes the most clinically relevant arterial abnormality among the wide spectrum of coronary artery anomalies. We investigated the physiology of L-ACAOS with and without intramural course (IM) in athletes, using the computational fluid dynamic (CFD) analysis. METHODS AND RESULTS The coronary artery circulation with L-ACAOS with and without IM has been segmented and then reconstructed, after reviewing both the angiographic and computed tomography findings of 13 consecutive athletes (10 males, mean age 45.1 ± 8.2 years) with L-ACAOS collected in our institution between 1st January 2003 and 1st January 2018. Vorticity magnitude, static pressure and wall shear stress (WSS) have been analysed in a model of L-ACAOS with no IM course and in L-ACAOS-IM at rest and during exercise. The mean vorticity magnitude and WSS significantly increased from rest to exercise in both models, in right coronary artery, left anterior descending and left circumflex coronary arteries. The mean static pressure significantly increased with exercise in IM (1.118e + 004 vs 1.164e + 004 Pa, p < 0.001) as well as the mean vorticity magnitude and the mean WSS (7012.78 1/s vs 9019.56 1/s, p < 0.001, Δ = 2006.78 1/s and 3.02 Pa vs 2.11 Pa, p < 0.001, Δ = 0.91 Pa). This net increment was transmitted to the entire left coronary system in L-ACAOS-IM but not in L-ACAOS with no IM. CONCLUSIONS In L-ACAOS, different hemodynamic parameters observed in the intramural segment seem to confirm that IM is compressed during exercise. These rheological properties might propagated along the left coronary system, potentially predisposing, if confirmed in vivo, distal coronary segments to a higher risk of spasm and thrombosis in athletes.
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Affiliation(s)
- Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy.
| | - Marco Zuin
- Section of Internal and Cardiopulmonary Medicine, University of Ferrara, Ferrara, Italy; Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Paola Galasso
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Mauro Carraro
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Katia D'Elia
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Lanza Daniela
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Loris Roncon
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | | | - Thach Nguyen
- Tan Tao University, School of Medicine, Long An, Viet Nam; Cardiovascular Research, Methodist Hospital, Merrillville, IN, USA
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Angelini P, Uribe C. Symptomatic right coronary anomaly with dynamic systolic intramural obliteration and isolated right ventricular ischemia. Catheter Cardiovasc Interv 2018; 93:445-447. [PMID: 30585420 DOI: 10.1002/ccd.28028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/01/2018] [Indexed: 11/06/2022]
Abstract
A 52-year-old man was referred for an anomalous right coronary artery (RCA) originating from the left sinus of Valsalva with an intramural course (R-ACAOS-IM), accompanied by progressive angina and dyspnea. He had been initially advised to have surgical treatment. Computerized axial tomographic angiography showed he had an ectopic origin from the left sinus of a small RCA, with a course between the aorta and pulmonary artery. His negative treadmill nuclear stress test was prematurely terminated because of angina and dyspnea. At our institution, intravascular ultrasound imaging indicated an intramural course and critically severe phasically changing proximal stenosis (80%-100%). The stenosis was resolved with stent-angioplasty of the intramural segment. He had no complications and returned quickly to an asymptomatic state with unrestricted physical activity.
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Affiliation(s)
- Paolo Angelini
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Carlo Uribe
- Department of Cardiology, Texas Heart Institute, Houston, Texas
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Angelini P, Cheong BY, Lenge De Rosen VV, Lopez A, Uribe C, Masso AH, Ali SW, Davis BR, Muthupillai R, Willerson JT. High-Risk Cardiovascular Conditions in Sports-Related Sudden Death: Prevalence in 5,169 Schoolchildren Screened via Cardiac Magnetic Resonance. Tex Heart Inst J 2018; 45:205-213. [PMID: 30374227 DOI: 10.14503/thij-18-6645] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Improving preparticipation screening of candidates for sports necessitates establishing the prevalence of high-risk cardiovascular conditions (hr-CVC) that predispose young people to sudden cardiac death (SCD). Our accurate, novel protocol chiefly involved the use of cardiac magnetic resonance (CMR) to estimate this prevalence. Middle and high school students from a general United States population were screened by means of questionnaires, resting electrocardiograms, and CMR to determine the prevalence of 3 types of hr-CVC: electrocardiographic abnormalities, cardiomyopathies, and anomalous coronary artery origin from the opposite sinus with intramural coronary course (ACAOS-IM). We examined the range of normal left ventricular size and function in the main study cohort (schoolchildren 11-14 yr old). We defined diagnostic criteria for hr-CVC and compared the cardiac measurements of these younger participants with those of older children whom we examined (age, 15-18 yr). From 5,169 completed diagnostic studies (mean participant age, 13.06 ± 1.78 yr), CMR results revealed 76 previously undiagnosed cases of hr-CVC (1.47% of the total cohort): 11 of dilated cardiomyopathy (14.5%), 3 of nonobstructive hypertrophic cardiomyopathy (3.9%), 23 ACAOS-IM cases (30.3%; 6 left-ACAOS and 17 right-ACAOS), 4 Wolff-Parkinson-White patterns (5.3%), 34 prolonged QT intervals (44.7%), and 1 Brugada pattern (1.3%). Cardiomyopathies were significantly more prevalent in the older children. Of note, we identified 959 cases (18.5%) of left ventricular noncompaction. If our estimate is accurate, only 1.47% of school-age sports participants will need focused secondary evaluations; the rest can probably be reassured about their cardiac health after one 30-minute screening study.
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