Anatomic characteristics and outcome of adults with coronary arteries arising from an anomalous location detected with coronary computed tomography angiography

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.

Unusual intramural course in an anomalous left coronary artery from the opposite coronary sinus

We report a case of a patient with an anomalous left coronary artery originating from the opposite coronary sinus with evidence of intramural course at the level of the septal commissure and no slit-like deformation of the coronary ostium, acute take-off, or proximal vessel narrowing. According to previous publications, patients with anomalous coronary artery and intramural segments identified at surgery had coronary CT findings of acute take-off angle or proximal vessel narrowing; slit-like orifice; and elliptical cross-sectional shape. Although further investigation is required, we suggest that the intramural course may not be ruled out based on the absence of slit-like ostium, acute take-off, or proximal vessel narrowing.

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.

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.

Computed Tomography Derived Coronary Triangulated Orifice Area-Deduction of a New Parameter for Follow-up After Surgical Correction of Anomalous Aortic Origin of Coronary Arteries and Call for Validation

Introduction: Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus of Valsalva is a rare congenital abnormality. Computed tomography angiography (CTA) is primarily used as a diagnostic tool to evaluate the anatomy and identify potentially malignant AAOCA variants. Limited data is available on the role of CTA during postoperative follow-up. We aimed to develop an objective CTA derived parameter for diagnostic evaluation and follow-up after surgical correction of AAOCA and correlate the anatomical features to the postoperative outcome.

Methods: All consecutive patients who underwent surgical repair of AAOCA from 2001 to 2018 and had pre and postoperative CTA imaging available were included. A retrospective analysis of the pre- and postoperative CTA and the outcomes was performed. The origin and course of the anomalous coronary artery and the ostial dimensions were evaluated and correlated with restenosis of operated coronary artery. To allow an accurate evaluation of the effective orifice area at diagnosis and after surgical repair we deduce and propose a new parameter—the coronary triangulated orifice area (CTOA).

Results: Out of the 54 patients who underwent surgical treatment for AAOCA, 11 fulfilled the inclusion criteria. The median follow-up was 19 months [IQR 3;42]. The mean age at surgery was 41 ± 16 years, with six patients (55%) being male. Postoperatively, the angle between the proximal coronary artery and the aortic wall increased from 20 ± 5° to 28 ± 9° (p < 0.01) and ostial diameter in the transversal plane increased from 4.1 ± 2.5 mm to 6.2 ± 2.7 mm (p < 0.01). The median CTOA increased significantly from 1.6 mm² [IQR 0.9;4.9] to 5.5 mm² [IQR 3;11.8] (p < 0.005). During follow-up, in three patients a restenosis of the operated coronary artery was suspected. In these patients, the CTOA only showed a limited postoperative increase of ≤ 1.4 mm².

Conclusions: CTA can play an important role in the evaluation of the pre- and postoperative anatomy in AAOCA patients. CTOA may be of use in conjunction with the acute angle take-off and ostial diameter order to comprehensively evaluate the operated ostium after unroofing or patch angioplasty.

Transient numerical simulation of the right coronary artery originating from the left sinus and the effect of its acute take-off angle on hemodynamics

Background

An anomalous origin of the right coronary artery from the left coronary artery sinus is usually characterized by an acute take-off angle. Most affected patients have no clinical symptoms; however, some patients have decreased blood flow into the right coronary artery during exercise, which can lead to symptoms such as myocardial ischemia. Most researchers who have studied an anomalous origin of the right coronary artery from the left coronary artery sinus have done so through clinical cases. In this study, we used numerical simulation to evaluate the hemodynamics of this condition and the effect of an acute take-off angle on hemodynamic parameters. We expect that the results of this study will help in further understanding the clinical symptoms of this anomaly and the hemodynamic impact of an acute take-off angle.

Methods

Three-dimensional models were reconstructed based on the computed tomography images from 16 patients with a normal right coronary artery and 26 patients with an anomalous origin of the right coronary artery from the left coronary artery sinus. A numerical simulation of a two-way fluid-structure interaction was executed with ANSYS Workbench software. The blood was assumed to be an incompressible Newtonian fluid, and the vessel was assumed to be an isotropic, linear elastic material. Hemodynamic parameters and the effect of an acute take-off angle were statistically analyzed.

Results

During the systolic period, the wall pressure in the right coronary artery was significantly reduced in patients with an anomalous origin of the right coronary artery (t =1.32 s, P=0.0001; t =1.34-1.46 s, P<0.0001). The wall shear stress in the abnormal group was higher at the beginning of the systolic period (t =1.24 s, P=0.0473; t =1.26 s, P=0.0193; t =1.28 s, P=0.0441). The acute take-off angle was smaller in patients with clinical symptoms (27.81°±4.406°) than in patients without clinical symptoms (31.86°±2.789°; P=0.017). In the symptomatic group, pressure was negatively correlated with the acute take-off angle (P=0.0185-0.0341, r=-0.459 to -0.4167).

Conclusions

This study shows that an anomalous origin of the right coronary artery from the left coronary artery sinus causes changes in hemodynamic parameters, and that an acute take-off angle in patients with this anomaly is associated with terminal ischemia of the right coronary artery.

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.

Coronary Computed Tomography Angiography-Derived Fractional Flow Reserve in Patients with Anomalous Origin of the Right Coronary Artery from the Left Coronary Sinus

Objective

To examine the fractional flow reserve derived from computed tomographic angiography (CT-FFR) in patients with anomalous origin of the right coronary artery from the left coronary sinus (R-ACAOS) with an interarterial course, assess the relationship of CT-FFR with the anatomical features of interarterial R-ACAOS on coronary computed tomographic angiography (CCTA), and determine its clinical relevance.

Materials and Methods

Ninety-four patients with interarterial R-ACAOS undergoing CCTA were retrospectively included. Anatomic features (proximal vessel morphology [oval or slit-like], take-off angle, take-off level [below or above the pulmonary valve], take-off type, intramural course, % proximal narrowing area, length of narrowing, minimum luminal area [MLA] at systole and diastole, and vessel compression index) on CCTA associated with CT-FFR ≤ 0.80 were analyzed. Receiver operating characteristic analysis was performed to describe the diagnostic performance of CT-FFR ≤ 0.80 in detecting interarterial R-ACAOS.

Results

Significant differences were found in proximal vessel morphology, take-off level, intramural course, % proximal narrowing area, and MLA at diastole (all p < 0.05) between the normal and abnormal CT-FFR groups. Take-off level, intramural course, and slit-like ostium (all p < 0.05) predicted hemodynamic abnormality (CT-FFR ≤ 0.80) with accuracies of 0.69, 0.71, and 0.81, respectively. Patients with CT-FFR ≤ 0.80 had a higher prevalence of typical angina (29.4% vs. 7.8%, p = 0.025) and atypical angina (29.4% vs. 6.5%, p = 0.016).

Conclusion

Take-off level, intramural course, and slit-like ostium were the main predictors of abnormal CT-FFR values. Importantly, patients with abnormal CT-FFR values showed a higher prevalence of typical angina and atypical angina, indicating that CT-FFR is a potential tool to gauge the clinical relevance in patients with interarterial R-ACAOS.

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.

Coronary anatomy in children with bicuspid aortic valves and associated congenital heart disease

Objective

In patients with bicuspid aortic valve (BAV), coronary anatomy is variable. High take-off coronary arteries have been described, but data are scarce, especially when associated with complex congenital heart disease (CHD). The purpose of this study was to describe coronary patterns in these patients.

Methods

In 84 postmortem heart specimens with BAV and associated CHD, position and height of the coronary ostia were studied and related to BAV morphology.

Results

High take-off right (RCA) and left coronary arteries (LCA) were observed in 23% and 37% of hearts, respectively, most frequently in hearts with hypoplastic left ventricle (HLV) and outflow tract anomalies. In HLV, high take-off was observed in 18/40 (45%) more frequently of LCA (n=14) than RCA (n=6). In hearts with aortic hypoplasia, 8/13 (62%) had high take-off LCA and 6/13 (46%) high take-off RCA. High take-off was seen 19 times in 22 specimens with perimembranous ventricular septal defect (RCA 8, LCA 11). High take-off was associated with type 1A BAV (raphe between right and left coronary leaflets), more outspoken for the RCA. Separate ostia of left anterior descending coronary artery and left circumflex coronary artery were seen in four hearts (5%), not related to specific BAV morphology.

Conclusion

High take-off coronary arteries, especially the LCA, occur more frequently in BAV with associated CHD than reported in normal hearts and isolated BAV. Outflow tract defects and HLV are associated with type 1A BAV and high take-off coronary arteries. Although it is unclear whether these findings in infants with detrimental outcome can be related to surviving adults, clinical awareness of variations in coronary anatomy is warranted.

Anomalous Aortic Origin of a Coronary Artery From the Inappropriate Sinus of Valsalva

Anomalous aortic origin of a coronary artery (AAOCA) from the inappropriate sinus of Valsalva is increasingly recognized by cardiac imaging. Although most AAOCA subtypes are benign, autopsy studies report an associated risk of sudden death with interarterial anomalous left coronary artery (ALCA) and anomalous right coronary artery (ARCA). Despite efforts to identify high-risk ALCA and ARCA patients who may benefit from surgical repair, debate remains regarding their classification, prevalence, risk stratification, and management. We comprehensively reviewed 77 studies reporting the prevalence of AAOCA among >1 million patients, and 20 studies examining outcomes of interarterial ALCA/ARCA patients. Observational data suggests that interarterial ALCA is rare (weighted prevalence = 0.03%; 95% confidence interval [CI]: 0.01% to 0.04%) compared with interarterial ARCA (weighted prevalence = 0.23%; 95% CI: 0.17% to 0.31%). Recognizing the challenges in managing these patients, we review cardiac tests used to examine AAOCA and knowledge gaps in management.

Hybrid CCTA/SPECT myocardial perfusion imaging findings in patients with anomalous origin of coronary arteries from the opposite sinus and suspected concomitant coronary artery disease

BACKGROUND

Anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) are associated with adverse cardiac events. Discrimination between ACAOS and coronary artery disease (CAD)-related perfusion defects may be difficult. The aim of the present study was to investigate the value of hybrid coronary computed tomography angiography (CCTA)/SPECT-MPI in patients with ACAOS and possible concomitant CAD.

METHODS

We retrospectively identified 46 patients (mean age 56 ± 12 years) with ACAOS revealed by CCTA who underwent additional SPECT-MPI. ACAOS with an interarterial course were classified as malignant, whereas all other variants were considered benign. CCTA/SPECT-MPI hybrid imaging findings (ischemia or scar) were analyzed according to the territory subtended by an anomalous vessel or a stenotic coronary artery.

RESULTS

Twenty-six (57%) patients presented with malignant ACAOS. Myocardial ischemia or scar was found only in patients who had concomitant obstructive CAD in the vessel matching the perfusion defect as evidenced by hybrid CCTA/SPECT imaging.

CONCLUSION

Hybrid CCTA/SPECT-MPI represents a valuable non-invasive tool to discriminate the impact of ACAOS from concomitant CAD on myocardial ischemia. Our results suggest that in a middle-aged population myocardial ischemia due to ACAOS per se may be exceedingly rare and is more likely attributable to concomitant CAD.

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.

Incidental finding of single coronary artery in a patient with alcoholic cardiomyopathy presenting as acute heart failure

Single coronary artery is a rare clinical finding. Diagnosis is typically made incidentally after the patient presents with symptoms and undergoes coronary angiography, coronary computed tomography angiography (CTA), or post-mortem during autopsy. Several high-risk features of anomalous coronary arteries have been described in the literature. Our paper describes a case of dilated alcoholic cardiomyopathy presenting as heart failure with diagnostic workup incidentally revealing single coronary artery.