Anomalous origin of the coronary artery from the wrong coronary sinus evaluated with computed tomography: “High-risk” anatomy and its clinical relevance

Clinical analysis of sixty-nine children with anomalous aortic origin of the coronary artery

We aimed to analyse the clinical characteristics of children with different types of anomalous aortic origin of the coronary artery (AAOCA) at different ages, and to discuss the factors related to myocardial ischaemia. In this retrospective study, we included 69 children diagnosed with AAOCA using CT coronary angiography; we classified the participants based on the type of AAOCA, age, and high-risk anatomy. The clinical characteristics of the different AAOCA types and age groups were compared, and the correlation between manifestations and high-risk anatomy was analysed. Anomalous origin of the left coronary artery from the right coronary artery sinus, anomalous origin of the right coronary artery from the left coronary artery sinus, and a coronary artery origin without coronary sinuses was found in 10 (14.5%), 57 (82.6%), 2 (2.9%) patients, respectively. There were no significant differences in sex, clinical manifestations, percentage of positive myocardial injury markers, electrocardiogram, transthoracic echocardiography, or proportion of high-risk anatomy among the groups with different AAOCA types. According to age group, the proportion of asymptomatic infants and pre-schoolers was the highest (p < 0.001). Forty-three patients (62.3%) had high-risk anatomy and were more likely to present with severe symptoms and cardiac syncope (p < 0.05).   Conclusion: There were no significant differences in the proportions of high-risk anatomy and clinical characteristics among children with different AAOCA types. We found a relation between the severity of AAOCA clinical symptoms and anatomical risk. What is Known: • Clinical symptoms in children with AAOCA are varied and the results of routine cardiological examinations lack specificity. • High-risk anatomical features, exercise, cardiac symptoms, and ALCA are risk factors for the occurrence of SCD in patients with AAOCA. What is New: • Compared the clinical characteristics of different types of AAOCA and ages. • Analysed the correlation between symptoms and high-risk anatomical features.

Anomalous origin of left circumflex artery from the right sinus of Valsalva: Clinical outcomes in a consecutive series of master athletes

BACKGROUND

Aim of the study was to collect and describe a case series of consecutive master athletes in whom an anomalous origin of left circumflex artery (LCx) from the right sinus of Valsalva (ALCx) was detected at a clinically indicated coronary computed tomography angiography CCTA) to establish a focused clinical management and counseling about sport activity in those subjects.

METHODS

We analyzed a prospective registry of subjects referred to a clinically indicated CCTA. Information about the clinical status was obtained by previous clinical records and clinical evaluation at time of image acquisition; follow-up allowed to record symptoms, outcomes and downstream testing.

RESULTS

The study population consisted in 14 subjects, of which one competitive athlete and 13 recreational master athletes. Mean age was of 67.2 ± 10.6 years (71% of male); follow-up lasted 6.4 ± 2.6 years. The major high-risk anatomy features (inter-arterial course, intramural segment, high take-off and slit-like ostium) were absent. None had abnormal ostial morphology and all had full retroaortic course; three subjects (21%) presented an acute take-off angle. Coronary artery disease (CAD) was present in 10 patients (71%). Major outcomes (cardiac hospitalization, death for all causes) recorded were not related to the anomalous LCx. Symptoms were most related to atherosclerotic CAD in different vessels whereas two subjects without CAD exhibited cardiac symptoms, without hospitalization.

CONCLUSIONS

Our study suggests that the diagnosis of ALCx, being usually associated to low-risk anatomical characteristics, could be considered a benign finding, with scarce or no implications for physically active individuals neither for recreational athletes.

Long-term patency of rescue stenting of an anomalous left circumflex coronary artery after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) in the setting of an anomalous left circumflex coronary artery (LCX) has had a variety of outcomes. Most commonly an anomalous LCX originates as a separate ostium arising from the right coronary sinus or is found branching off of the proximal right coronary artery. The artery courses around the aortic annulus before taking the course seen in typical anatomy. Given this deviation from typical anatomy and increased aortic annulus pressure by the replacement valve, there is an increased risk of a complication such as acute coronary artery occlusion. Special consideration and preparation are needed to prevent adverse outcomes, including death. We report a case in which intraprocedural anomalous LCX rescue stenting proved to be effective for treatment of acute coronary occlusion. Follow-up angiography provided an opportunity to demonstrate long-term patency in rescue stenting during TAVR.

Evaluation of the Ostium in Anomalous Origin of the Right Coronary Artery with an Interarterial Course Using Dynamic Cardiac CT and Implications of Ostial Findings

OBJECTIVE

We aimed to evaluate the ostium of right coronary artery of anomalous origin from the left coronary sinus (AORL) with an interarterial course throughout the cardiac cycle on CT and analyze the clinical significance of the ostial findings.

MATERIALS AND METHODS

From January 2011 to December 2015, 68 patients (41 male, 57.3 ± 12.1 years) with AORL with an interarterial course and retrospective cardiac CT data were included. AORL was classified as high or low ostial location based on the pulmonary annulus in the diastolic and systolic phases on cardiac CT. In addition, the height, width, height/width ratio, area, and angle of the ostium were measured in both cardiac phases. After cardiac CT, patients were followed until December 31, 2020 for major adverse cardiac events (MACE). Clinical and CT characteristics associated with MACE were explored using Cox regression analysis.

RESULTS

During a median follow-up period of 2071 days (interquartile range, 1180.5-2747.3 days), 13 patients experienced MACE (19.1%, 13/68). Seven (10.3%, 7/68) had the ostial location change from high in the diastolic phase to low in the systolic phase. In the univariable analysis, younger age (hazard ratio [HR] = 0.918, p < 0.001), high ostial location (HR = 4.008, p = 0.036), larger height/width ratio (HR = 5.621, p = 0.049), and smaller ostial angle (HR = 0.846, p = 0.048) in the systolic phase were significant predictors of MACE. In multivariable cox regression analysis, younger age (adjusted HR = 0.917, p = 0.002) and high ostial location in the systolic phase (adjusted HR = 4.345, p = 0.026) were independent predictors of MACE.

CONCLUSION

The ostial location of AORL with an interarterial course can change during the cardiac cycle, and high ostial location in the systolic phase was an independent predictor of MACE.

Interarterial course of anomalous right coronary artery: role of symptoms and surgical outcomes

Anomalous origin of right coronary artery with interarterial course (ARCA-IA) is a risk factor for sudden death and other cardiac complications. Surgical correction remains its gold standard treatment. We describe clinical characteristics, workup, surgical techniques and outcomes of ARCA-IA at our center. A retrospective analysis of cardiovascular database was performed. From March 2005 through January 2011, 11 patients with mean age of 53 ± 18 years were diagnosed with ARCA-IA. Reported symptoms included chest pain (64%), arrhythmia [27%; i.e. atrial flutter (9%), recurrent supraventricular tachycardia (9%), ventricular tachycardia (9%)], syncope (18%), dyspnea (9%) and aborted sudden cardiac death (9%). Chest pain (n = 7) was episodic and lasted longer than 6 months before diagnosis. Initial diagnosis was made at coronary computed tomography in two patients and at cardiac catheterization in nine patients. Four patients had positive stress test and were subsequently found to have ARCA-IA at cardiac catheterization. There was no operative mortality. Surgery (bypass with ligation of native vessel or translocation and reimplantation) was performed in seven patients. Three patients refused surgery, and in one patient, surgery was not considered due to comorbidities. Symptom relief was noted in all surgical patients. At mean follow-up of 36 months, two patients had noncardiac-related deaths whereas nine were asymptomatic. There were no deaths reported in patients treated surgically. Definitive surgery is indicated in symptomatic ARCA-IA and is associated with excellent long-term outcome. RCA dominance in ARCA-IA is an adverse marker with increased symptoms; this hypothesis should be tested in larger studies.

Anomalous Coronary Arteries: When to Follow-up, Risk Stratify, and Plan Intervention

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.

Diagnosis and prognostic significance of anomalous origin of coronary artery from the opposite sinus of Valsalva assess by dual-source coronary computed tomography angiography

Background

Clinically recognized coronary anomalies in adults are infrequent and characteristically establish on autopsy. The clinical importance coronary arteries consist of those with anomalous origin of the coronary artery from the opposite sinus of Valsalva (ACAOS) with an inter-arterial course (IAC). We have endeavored to attribute variable risk based on morphological appearances of the ACAOS by dual-source coronary computed tomography angiography (DSCTA).

Material and methods

ACAOS patients who undergoing DSCTA over a 5-year period were identified and assess morphologic characteristics. Medical records were reviewed for major adverse cardiovascular events (MACEs).

Results

A total of 1126 patients who undergoing DSCTA were evaluated. Twenty-four patients with ACAOS with IAC were recognized with a prevalence of 2.1% of study population. Twenty patients had anomalous origin of right coronary artery from left sinus of Valsalva (RCA-LSV) and 4 patients had anomalous origin of left coronary from right sinus of Valsalva (LCA-RSV). A significant increased prevalence of MACEs in were observed in intramural, slit-like and high inter-arterial course morphology group. Median follow-up time was 13 months (IQR 3-18  months). During follow-up 2 died, 4 had PCI, 13 had myocardial infarction and 7 had surgical treatment.

Conclusions

Intramural, slit-like and high type inter-arterial course morphology of ACAOS with IAC are high risk features for MACEs which can be identified by DSCTA.

Automatic Detection of the Aortic Annular Plane and Coronary Ostia from Multidetector Computed Tomography

Anatomic landmark detection is crucial during preoperative planning of transcatheter aortic valve implantation (TAVI) to select the proper device size and assess the risk of complications. The detection is currently a time-consuming manual process influenced by the image quality and subject to operator variability. In this work, we propose a novel automatic method to detect the relevant aortic landmarks from MDCT images using deep learning techniques. We trained three convolutional neural networks (CNNs) with 344 multidetector computed tomography (MDCT) acquisitions to detect five anatomical landmarks relevant for TAVI planning: the three basal attachment points of the aortic valve leaflets and the left and right coronary ostia. The detection strategy used these three CNN models to analyse a single MDCT image and yield three segmentation volumes as output. These segmentation volumes were averaged into one final segmentation volume, and the final predicted landmarks were obtained during a postprocessing step. Finally, we constructed the aortic annular plane, defined by the three predicted hinge points, and measured the distances from this plane to the predicted coronary ostia (i.e., coronary height). The methodology was validated on 100 patients. The automatic landmark detection was able to detect all the landmarks and showed high accuracy as the median distance between the ground truth and predictions is lower than the interobserver variations (1.5 mm [1.1–2.1], 2.0 mm [1.3–2.8] with a paired difference −0.5 ± 1.3 mm and p value <0.001). Furthermore, a high correlation is observed between predicted and manually measured coronary heights (for both R² = 0.8). The image analysis time per patient was below one second. The proposed method is accurate, fast, and reproducible. Embedding this tool based on deep learning in the preoperative planning routine may have an impact in the TAVI environments by reducing the time and cost and improving accuracy.

Prognostic value of dual-source computed tomography (DSCT) angiography characteristics in anomalous coronary artery from the opposite sinus (ACAOS) patients: a large-scale retrospective study

Background

Most reported cases of right anomalous coronary artery from the opposite sinus (R-ACAOS) have benign clinical outcomes. However, patients with left ACAOS (L-ACAOS) and some of the patients with R-ACAOS are more at risk for arrhythmias and sudden cardiac death, which remains a major concern. Here we report the prevalence and anatomical features of ACAOS patients. Moreover, we explore the high-risk morphological signs and evaluate their mid-term prognostic value in R-ACAOS patients without surgical intervention.

Methods

Data from coronary computed tomography angiography (CTA) of 30,593 patients, pertaining to a single center over 5 consecutive years, were retrospectively analyzed. The image analysis included stenosis severity ranking and high-risk anatomy evaluation, based on the commercially available image post-processing software OsirX. Patients with R-ACAOS and without evidence of coronary atherosclerosis (CAD) were followed-up, with recording of the cardiovascular clinical events. Cox regression analysis was performed to identify the potential anatomical risk factors of cardiovascular clinical events for non-CAD R-ACAOS patients, using R project.

Results

The prevalence of ACAOS in the study population was 0.69% (211/30593). Significant differences were found between patients with mild (< 50%) and severe (> 50%) stenosis, in terms of height-to-weight ratio (HW ratio), take-off angle, and proximal stenosis length. A total of 54 cardiovascular clinical events were observed among 108 non-CAD R-ACAOS patients and an average follow-up of 27.8 ± 18.7 months. Among those patients’ anatomical features, stenosis severity was the main risk factor for cardiovascular clinical events during the mid-term follow-up, with a risk ratio of 4.14 (95% CI: 1.78 to 9.63, P < 0.001).

Conclusions

Among patients referred to coronary CTA, the overall incidence of ACAOS was 0.69%. For patients with R-ACAOS, severe stenosis was the independent risk factor of adverse clinical events in the mid-term follow-up, and positive clinical intervention might be needed to help them avoid the malignant clinical events.

Significant incidental cardiac disease on thoracic CT: what the general radiologist needs to know

Objective

Incidental cardiac findings are often found on chest CT studies, some of which may be clinically significant. The objective of this pictorial review is to illustrate and describe the appearances and management of the most frequently encountered significant cardiac findings on non-electrocardiographically gated thoracic CT. Most radiologists will interpret multidetector chest CT and should be aware of the imaging appearances, significance, and the appropriate next management steps, when incidental significant cardiac disease is encountered on thoracic CT.

Conclusion

This article reviews significant incidental cardiac findings which may be encountered on chest CT studies. After completing this review, the reader should not only be familiar with recognizing clinically significant cardiac findings seen on thoracic CT examinations but also have the confidence to direct their further management.

Anatomical variants and coronary anomalies detected by dual-source coronary computed tomography angiography in North-eastern Thailand

Purpose

Congenital coronary anomalies are uncommon, with an incidence ranging from 0.17% in autopsy cases to 1.2% in angiographically evaluated cases. The recent development of dual-source coronary computed tomography angiography (coronary CTA) allows accurate and noninvasive depiction of coronary artery anomalies.

Material and methods

A retrospective study included a total of 924 patients who underwent coronary CTA because of known or suspected coronary artery disease. In each study, coronary artery anomalies (CAs) were investigated.

Results

A total of 924 patients (mean age 51.2 ± 12.8 years), who underwent dual-source coronary CTA, were studied. The overall prevalence of CAs in our study was 3.7%, with the following distribution: four single coronary artery, 14 anomalous origin from opposite sinus of Valsalva, three absent left main, four high take-off coronary artery, three anomalous left coronary artery from pulmonary artery, and eight coronary artery fistulas.

Conclusions

The present study supports the use of coronary CTA as a reliable noninvasive tool for defining anomalous coronary arteries in an appropriate clinical setting and provides detailed three-dimensional anatomic information that may be difficult to obtain with invasive coronary angiography.

Aortic expansion induces lumen narrrowing in anomalous coronary arteries: a parametric structural finite element analysis

Anomalous aortic origin of coronary arteries (AAOCA) is a congenital disease that can lead to cardiac ischemia during intense physical activity. Although AAOCA is responsible for sudden cardiac death (SCD) among young athletes and soldiers, the mechanisms underlying the coronary occlusion during physical effort still have to be clarified. The present study investigates the correlation between geometric features of the anomaly and coronary lumen narrowing under aortic root dilatations. Idealized parametric computer-aided designed (CAD) models of the aortic root with anomalous and normal coronary are created and static finite element (FE) simulations of increasing aortic root expansions are carried out. Different coronary take-off angles and intramural penetrations are investigated to assess their role on coronary lumen narrowing. Results show that increasing aortic and coronary pressures lead to lumen expansions in normal coronaries, particularly in the proximal tract, while the expansion of anomalous coronary is impaired especially at the ostium. Concerning the geometric features of the anomaly, acute take-off angles cause elongated coronary ostia, with an eccentricity increasing with aortic expansion; the impact of intramural penetration of coronary on its luminal narrowing is limited. The present study provides a proof of concept of the biomechanical reasons underlying the lumen narrowing in AAOCA during aortic expansion, promoting the role of computational simulations as a tool to assess the mechanisms of this pathology.

Anomalous Aortic Origin of a Coronary Artery: Symptoms Do Not Correlate With Intramural Length or Ostial Diameter

Background:

Anomalous aortic origin of a coronary artery (AAOCA) is a known cause of sudden death. Our hypothesis was that longer intramural length and smaller ostial diameter correlate with preoperative symptoms. If true, this would assist in the decision for surgical indications. We also assessed the accuracy of preoperative imaging to predict intramural length.

Methods:

Retrospective analysis of patients who underwent AAOCA unroofing from 2006 to 2014. Patients had preoperative computed tomography angiography (CTA) or magnetic resonance imaging (MRI). Intramural length was measured. Intramural lengths and ostial diameters were also measured intraoperatively (operating room [OR]). Symptoms were noted. Intramural lengths and ostial diameters were compared between patients with and without preoperative symptoms. The accuracy of intramural length measured by CTA/MRI versus the length measured in the OR was assessed using a Bland-Altman analysis.

Results:

Sixty-six patients underwent surgical repair of AAOCA. Fifty-two (79%) patients were symptomatic and 14 (21%) were asymptomatic. Mean age was 12.4 ± 4.0 years. There was no mortality. There was strong agreement between intramural length measured by CTA/MRI and measured in the OR. There was no significant difference in AAOCA intramural length in the symptomatic (8.6 ± 3.5 mm) and asymptomatic (8.9 ± 2.8 mm, P = .77) patients, which were measured both by CTA/MRI and intraoperatively (symptomatic 7.3 ± 2.5 mm, asymptomatic 6.9 ± 2.8 mm; P = .62). There was also no significant difference in AAOCA ostial diameters between groups (symptomatic = 1.9 ± 0.5 mm, asymptomatic = 1.6 ± 0.5 mm; P = .09).

Conclusion:

Preoperative CTA/MRI was very accurate in predicting the length of surgical unroofing. There was no demonstrable correlation between preoperative symptoms and intramural AAOCA length or AAOCA ostial diameter.

Anomalous origin of the coronary artery arising from the opposite sinus: prevalence and outcomes in patients undergoing coronary CTA

AIMS

The impact of coronary computed tomographic angiography (CTA) on management of anomalous origin of the coronary artery arising from the opposite sinus (ACAOS) remains uncertain. We examined the prevalence, anatomical characterization, and outcomes of ACAOS patients undergoing CTA.

METHODS AND RESULTS

Among 5991 patients referred for CTA at two tertiary hospitals between January 2004 and June 2014, we identified 103 patients (1.7% prevalence) with 110 ACAOS vessels. Mean age was 52 years (range 5-83, 63% male), with 55% previously known ACAOS and 45% discovered on CTA. ACAOS subtypes included: 39% interarterial (n = 40 anomalous right coronary artery, n = 3 anomalous left coronary artery), 38% retroaortic, 15% subpulmonic, 5% prepulmonic, and 2% other. ACAOS patients were assessed for symptoms, ischaemic test results, revascularization, all-cause or cardiovascular (CV) death, and myocardial infarction. CTAs were reviewed for ACAOS course, take-off height and angle, length and severity of proximal narrowing, intramural course, and obstructive coronary artery disease (CAD). In follow-up (median 5.8 years), there were 20 surgical revascularizations and 3 CV deaths. After adjusting for obstructive CAD (n = 21/103, 20%), variables associated with ACAOS revascularization included the following: CV symptoms, proximal vessel narrowing ≥50%, length of narrowing >5.4 mm, and an interarterial course.

CONCLUSION

The prevalence of ACAOS on CTA was 1.7%, including 45% of cases discovered incidentally. CTA provided excellent characterization of ACAOS features associated with coronary revascularization, including the length and severity of proximal vessel narrowing.

[Drowning versus cardiac ischemia: Cardiac arrest of an 11-year-old boy at a swimming lake]

This report describes a case of sudden cardiac arrest and subsequent attempted cardiopulmonary resuscitation of an 11-year-old child on the shores of a swimming lake. Reports of eyewitnesses excluded the obviously suspected diagnosis of a drowning accident. The result of the autopsy was sudden cardiac death due to a congenital coronary anomaly (abnormal left coronary artery, ALCA). Favored by vigorous physical activity, this anomaly can lead to malignant arrhythmias because the ectopic coronary artery with its intramural course through the aortic wall is compressed during every systole. This pathology was not known to the boy or his family; in fact he liked sports but had suffered of a syncope once which was not followed up. Without a strong suspicion it is difficult to diagnose a coronary artery anomaly and it is often missed even in college athletes. Tragically, sudden cardiac arrest may be the first symptom of an undiagnosed abnormal coronary artery. Following syncope or chest pain during exercise with a normal electrocardiogram (ECG) cardiac imaging, such as computed tomography (CT) or angiography should be initiated in order to enable surgical repair of an abnormal coronary artery.

Anomalous origin of the right coronary artery with an interarterial course and intramural part

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Exercise-induced angina and dyspnea caused by anomalous origin of the RCA from the left sinus.

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Possible mechanisms are discussed.

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The patient successfully underwent surgery with complete remission of all symptoms.

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Unique images of the RCAs entire course demonstrating its vulnerability.

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Different symptoms and surgical approaches from key case series

Introduction

An anomalous origin and course of the right coronary artery (RCA)1 is a very rare congenital anomaly that can be fatal if it remains undiscovered.

Presentation of case

In this case report, we present a patient with a one-year history of exercise-induced angina and dyspnea caused by anomalous origin of the RCA from the left sinus, and anomalous course between the aorta and the pulmonary artery.

Discussion

Possible mechanisms of this disease’s symptomatology are compression of the RCA between the aorta and the pulmonary artery in its anomalous inter-arterial course, and squeezing of the RCA in the proximal intramural part.

Conclusion

In this report, we present some unique images of the RCAs course, which contribute to the understanding of this disease’s symptomatology. The patient successfully underwent surgery with Right Internal Mammary Artery to RCA (RIMA–RCA)2 bypass with complete remission of all symptoms.