Multislice computed tomographic findings of the anomalous origins of the right coronary artery: evaluation of possible causes of myocardial ischemia

Anomalous origin of the coronary artery: prevalence and coronary artery disease in adults undergoing coronary tomographic angiography

BACKGROUND

Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital coronary anomaly with the potential to cause adverse cardiac events. However, there is limited data on the association between AAOCA and coronary artery disease (CAD). Therefore, the aim of this study is to determine the prevalence and symptoms of patients with AAOCA, as well as investigate the correlation between AAOCA and CAD in a population referred for coronary computed tomographic angiography (CTA).

METHODS AND RESULTS

All consecutive patients who underwent CTA from 2010 to 2021 were included. Characteristics, symptoms, coronary related adverse events and CTA information were reviewed by medical records. Separate multivariable cumulative logistic regressions were performed, using the stenosis severity in each of the four coronaries as individual responses and as a combined patient clustered response. Finally, we identified 207 adult patients with AAOCA, the prevalence of AAOCA is 0.23% (207/90,501). Moreover, this study found no significant association between AAOCA and CAD. AAOCA did not contribute to higher rates of hospitalization or adverse cardiac events, including calcification.

CONCLUSION

AAOCA is a rare congenital disease that is not associated with increased presence of obstructive CAD in adults.

Coronary Artery Anomalies - State of the Art Review

Coronary artery anomalies (CAAs) comprise a wide spectrum of anatomic entities, with diverse clinical phenotypes. We present a case of an anomalous right coronary artery arising from the left aortic sinus with an interarterial course, a potentially fatal condition that can precipitate ischemia and sudden cardiac death. CAAs are increasingly detected in adults, mostly as incidental findings in the course of cardiac evaluation. This is due to the expanding use of invasive and noninvasive cardiac imaging, usually in the work-up for possible CAD. The prognostic implications of CAAs in this group of patients remain unclear. In AAOCA patients, appropriate work-up with anatomical and functional imaging should be performed for risk stratification. An individualized approach to management should be adopted, considering symptoms, age, sporting activities and the presence of high-risk anatomical features and physiologic consequences (such as ischemia, myocardial fibrosis, or cardiac arrhythmias) detected on multimodality imaging or other functional cardiac investigations. This comprehensive and up to date review seeks to crystallize current data in the recent literature, and proposes a clinical management algorithm for the clinician faced with the conundrum of managing such conditions.

Noninvasive Multimodality Imaging for the Assessment of Anomalous Coronary Artery

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.

Hemodynamic Relevance of Anomalous Coronary Arteries Originating From the Opposite Sinus of Valsalva-In Search of the Evidence

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.

Unusual origin for the right coronary artery: one center's observations on diagnosis and treatment

Right coronary arteries that originate from the left Sinus of Valsalva and course intramurally along the aortic wall in their proximal position are a variant of anomalous coronary arteries that can be associated with ischemic symptoms. Stenting of the proximal portion of these right coronary arteries along the intramural course can improve symptoms in those who clearly have anatomic distortion of the proximal artery. Long-term outcomes and durability of this approach when applied to symptomatic patients is unknown and future work with follow up IVUS is needed.

Percutaneous coronary intervention with anomalous origin of right coronary artery: case reports and literature review

Percutaneous coronary intervention (PCI) in an anomalous right coronary artery (RCA) can be technically difficult because selective cannulation of the vessel may not be easy. We thereby present two cases with unstable angina pectoris of anomalous originated RCA. The PCI were successfully performed in two patients with a special guiding wire manipulating skill which we called “gone with the flow” combined with balloon anchoring technology, providing excellent angiographic visualization and sound guide support for stent delivery throughout the procedure without severe cardiovascular adverse effects. Our primary data suggested that PCI for geriatric patients with an anomalous origin of RCA accompanied by severe atherosclerotic lesions might also be a safe, available, and feasible strategy.

Single coronary artery with anomalous rising of the right coronary artery: a rare coronary anomaly diagnosed by 256-multidetector computed tomography

Herein we report the diagnostic potential of cardiac computed tomography (cCT) to delineate the origin and course of an anomalous right coronary artery (RCA) originating from the midpart of the left anterior descended artery (LAD) in an adult with no other form of congenital heart disease. The patient was referred to our institution due to exertional dyspnea and suspected coronary artery disease. The patient underwent X-ray coronary angiography, and no high grade lesions were observed in the left coronary vessels. In the course of the mid-left-anterior-descending artery (LAD), an anomalous side branch coursing away from the left circumflex coronary artery (LCX) was observed, while a right coronary ostium could not be depicted. cCT confirmed the absence of a right coronary ostium, and the vessel originating from the mid LAD was identified as an anomalous RCA, which coursed anterior of the aorta and the pulmonary trunk.

Right coronary artery from the left sinus of valsalva: Multislice CT and transradial PCI

A 42-year-old-woman presented with de novo crescendo angina. Thallium-scintigraphy showed inferior ischemia. Coronary angiogram revealed a right coronary artery (RCA), originating from the left sinus of Valsalva with a severe proximal systolic compression. She underwent successful transradial percutaneous coronary intervention with stent implantation. Multislice-computed tomography (MSCT) is usually used to evaluate coronary artery anomalies and can effectively show the anomalous RCA and the inter-arterial trajectory between the aorta and pulmonary arteries. Anomalies of the origin of the coronary arteries are rare, but can produce specific clinicopathological entities that should be diagnosed with accuracy. This case report illustrates the role of MSCT in the detailed description of an abnormal coronary artery and the use of stenting for symptoms relief.

Anomalous right coronary artery originating from the left anterior descending artery: case report and review of the literature

The anomalous origin of the right coronary artery (RCA) as a branch of the left anterior descending (LAD) artery is a very rare variation of single coronary artery. At least 36 cases have been described previously in the literature. The vast majority of previous reports have described a single anomalous vessel with its origin after the first septal perforator of the LAD, which courses anterior to the right ventricular outflow tract to reach territory normally served by the right coronary artery. Of 35 cases in structurally normal hearts, 19 (54%) patients had >50% narrowing in one or more epicardial coronary arteries (54%), at least 14 (40%) of whom required revascularization. Thirteen cases (37%) did not have significant coronary artery disease, while the remaining 3 cases were unclear. The current report reviews previous reports of this anomaly and describes a patient with an anomalous RCA from the mid-LAD, in whom heart block, back pain and dyspnea was the initial manifestation of ischemia. On heart catheterization, there was significant coronary artery disease in the LAD proximal to the origin of the anomalous artery. The patient was successfully revascularized with a unique sequential left internal mammary artery bypass to the anomalous vessel and LAD.

Acute myocardial infarction in a patient with anomalous origin of the right coronary artery: Depiction at whole-heart coronary magnetic resonance angiography and delayed-enhanced imaging

A 71-year-old man was admitted to our hospital because of anterior chest pain. His electrocardiogram showed ST-segment depression and cardiac enzymes were normal. Non-ST-elevation acute myocardial infarction was suspected and whole-heart magnetic resonance imaging was performed. Whole-heart coronary magnetic resonance angiography (MRA) showed an anomalous origin of the right coronary artery from the left sinus of Valsalva and delayed-enhanced imaging showed transmural hyperenhancement of the inferior wall. Coronary angiography revealed the anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva and occlusion in the proximal portion of the RCA. Coronary revascularization was achieved by intracoronary thrombolysis followed by stent implantation. Whole-heart coronary MRA and delayed-enhanced imaging allows simultaneous assessment of coronary artery anomaly and extent of myocardial infarction.

Anomalous origin of the right coronary artery: Depiction at whole-heart coronary magnetic resonance angiography

Anomalous origin of the right coronary artery (RCA) is a rare congenital anomaly, which may cause myocardial ischemia and sudden death. Whole-heart coronary magnetic resonance angiography (MRA) was performed in a 61-year-old woman who had exercise-induced myocardial ischemia. MRA revealed that the RCA originated from the left sinus of Valsalva, separately from the left main coronary artery and it coursed between the ascending aorta and pulmonary artery. There was acute angle take-off of the RCA from the aorta. This is the first report describing whole-heart coronary MRA findings of the anomalous origin of the RCA.

Unusual cause of exercise-induced ventricular fibrillation in a well-trained adult endurance athlete: a case report

Introduction

The diseases responsible for sudden deaths in athletes differ considerably with regard to age. In young athletes, congenital malformations of the heart and/or vascular system cause the majority of deaths and can only be detected noninvasively by complex diagnostics. In contrast, in older athletes who die suddenly, atherosclerotic disease of the coronary arteries is mostly found. Reports of congenital coronary anomalies as a cause of sudden death in older athletes are rare.

Case presentation

A 48-year-old man who was a well-trained, long-distance runner collapsed at the finish of a half marathon because of a myocardial infarction with ventricular fibrillation. Coronary angiography showed an anomalous origin of the right coronary artery from the left sinus of Valsalva with minimal wall alterations. Multislice computed tomography of the coronary arteries confirmed these findings. Cardiomagnetic resonance imaging demonstrated a mild hypokinesia of the basal right- and left-ventricular posterior wall. An electrophysiological study showed an inducible temporary polymorphic ventricular tachycardia and an inducible ventricular fibrillation. The athlete was subsequently treated by acetylsalicylic acid 100 mg (0-1-0), bisoprolol 2.5 mg (1-0-0) and atorvastatin 10 mg (0-0-1) and was instructed to keep his training intensity under the 'individual anaerobic threshold'. Intense and long-lasting exercise under extreme environmental conditions, particularly heat, should also be avoided.

Conclusion

This case report presents a coronary anomaly as the most likely reason for an exercise-induced myocardial infarction with ventricular fibrillation in a well-trained 48-year-old endurance athlete. Therefore, coronary anomalies have also to be considered as a possible cause of cardiac problems in older athletes.