Coronary Artery Anomalies: When You Need to Worry

Clinical Outcomes in Adult Patients With an Anomalous Right Coronary Artery from the Left Sinus of Valsalva

An anomalous origin of the right coronary artery from the opposite sinus of Valsalva with an intramural course (R-ACAOS-IM) may cause sudden cardiac death in children and adolescents. However, the natural history and management of patients in whom this anomaly is detected later during adulthood remains uncertain. The goals of this study were to assess the impact of an R-ACAOS-IM on the clinical outcomes in an adult population and to determine if adult patients with this anomaly who do not have significant coronary artery disease (CAD) can be managed safely without surgical intervention. A database review identified patients aged >35 years with anomalous coronary arteries diagnosed by cardiac catheterization or coronary computed tomography angiography. The outcomes of patients with R-ACAOS-IM were compared with patients with anomalous left circumflex coronary arteries with retroaortic course (LCx-RA) (an anomaly not associated with ischemic events). The primary outcome was all-cause mortality. The study population consisted of 185 patients aged 59 ± 12 years. Clinical characteristics were similar in the R-ACAOS-IM (n = 88) and LCx-RA (n = 97) groups. At a follow-up of 6.6 ± 4.5 years, there was no difference in mortality (hazard ratio 0.64, 95% confidence interval 0.32 to 1.28, p = 0.20) when adjusted for gender, age, and CAD. A subgroup analysis of 88 patients with no obstructive CAD managed nonoperatively found no difference between the LCx and R-ACAOS-IM groups in mortality (hazard ratio 2.45, 95% confidence interval 0.45 to 13.40, p = 0.30). There was no significant difference between the 2 groups in the composite outcome of death, nonfatal myocardial infarction, or survived cardiac arrest. The outcome of adult patients who have anomalous R-ACAOS-IM are similar to patients who have anomalous LCx-RA with a known benign course. In conclusion, these results suggest that most patients who survive this anomaly into adulthood may be managed conservatively without intervention.

Coronary Artery Fistulae in Adult: Two Decades of Experience in Clinical Presentation, Angiographic Feature, and Management

Coronary artery fistula (CAF) in adults is a rare but significant coronary artery anomaly. Main data on that rare disease were mostly obtained from case reports and small studies. In presented study, we share our two-decade experience on the clinical and angiographic characteristics of CAF. The data were collected retrospectively by analyzing the angiographic data between January 1, 2000 and December 31, 2019. Demographic data, clinical data, laboratory, and cardiac catheterization reports were reviewed. CAFs were found in 40 patients (0.06%). There were 22 male (55%) patients. The mean age was 61.2 years. Twenty-nine patients (72.5%) had small, 4 patients (10%) had medium, and 7 patients (17.5%) had large CAFs. The majority of study population had solitary CAF ( n  = 31, 77.5%). The pulmonary artery is the major side of fistula drainage ( n  = 20, 50%). The study population was divided into two groups as follow: group 1-small CAFs 29 (72.5%), group 2-medium and large CAF (MLCAF) 11 (27.5%). Patients with MLCAFs had more atrial fibrillation, abnormal coronary morphology, and multiple fistulae. In patients with hemodynamically significant CAFs, 7 (17.5%) patients had surgical ligation and 3 (7.5%) patients had transcutaneous closure. Three patients died during mean follow-up period of 5 years. The incidence and the pattern of CAFs in our study were similar to previous studies. Clinical course of small fistulae was benign. Symptomatic MLCAFs need to be treated by transcatheter or surgical way and should be individualized per patient.

Coronary Anomalies in 11,267 Southwest Chinese Patients Determined by Angiography

Background

The prevalence of coronary artery anomalies (CAAs) is rare and varies among different countries or areas. More importantly, the symptoms exhibited by some CAAs make the diagnosis of coronary artery disease (CAD) difficult and hamper the physician from making the right intervention for CAD patients.

Objective

To investigate the prevalence of CAAs in 11,267 patients from three hospitals in Southwest China.

Methods

11,267 patients who have undergone coronary angiography from three Southwest China hospitals were investigated retrospectively. Dominance patterns, prevalence, and the location of each CAA were recorded and analyzed.

Results

The presence of a dominant right coronary artery (RCA) was found in 60.58% of patients. CAAs were found in 11.12% (1258) patients, and 87.66% anomalies were located in the left anterior descending (LAD) artery and its branches. Most of CAAs were found to be myocardial bridges (MBs, 1060 cases, 9.41%). Other CAAs included anomalous coronary origin (43 cases, 0.38%), coronary artery fistulas (CAFs, 36 cases, 0.32%), and coronary artery aneurysm or ectasia (119 cases, 1.06%). It also noted that most anomalies were found with RCA originating from the left coronary sinus (79.07%), most CAFs were located in the LAD and its branches (58.33%), and most coronary artery ectasias were located in the RCA (43.25%).

Conclusions

CAAs in patients from Southwest China were unique compared to other studies. Recognition of these CAAs is important for accurate diagnosis and treatment choice of patients with chest pain.

Successful transcatheter closure of coronary artery fistula in a patient with anomalous aortic origin of the left main coronary artery from the right aortic sinus

Transcatheter closure is an established method to treat coronary artery fistula (CAF). We present transcatheter closure in a 6-year-old girl with CAF and anomalous aortic origin of the left main coronary artery from the right aortic sinus. The CAF originated from the left coronary artery (LCA), coursed through the interventricular septum (intraseptal course) with prominent dilation, and drained into the right ventricular outflow tract. She underwent transcatheter closure and was in a stable condition at the 3-year follow-up with regression of the dilated portion of the intraseptal-type LCA. Hence, transcatheter closure of CAF is feasible in patients with anomalous origins of coronary arteries. <Learning objective: This report describes the feasibility and safeness of transcatheter closure of a coronary artery fistula in a patient with an anomalous origin of a coronary artery. This is the first report to visualize the regression of the markedly dilated left coronary artery with an intraseptal course.>.

Postmortem imaging as a complementary tool for the investigation of cardiac death

In the past 2 decades, modern radiological methods, such as multiple detector computed tomography (MDCT), MDCT-angiography, and cardiac magnetic resonance imaging (MRI) were introduced into postmortem practice for investigation of sudden death (SD), including cases of sudden cardiac death (SCD). In forensic cases, the underlying cause of SD is most frequently cardiovascular with coronary atherosclerotic disease as the leading cause. There are many controversies about the role of postmortem imaging in establishing the cause of death and especially the value of minimally invasive autopsy techniques. This paper discusses the state of the art for postmortem radiological evaluation of the heart compared to classical postmortem examination, especially in cases of SCD. In SCD cases, postmortem CT is helpful to estimate the heart size and to visualize haemopericardium and calcified plaques and valves, as well as to identify and locate cardiovascular devices. Angiographic methods are useful to provide a detailed view of the coronary arteries and to analyse them, especially regarding the extent and location of stenosis and obstruction. In postsurgical cases, it allows verification and documentation of the patency of stents and bypass grafts before opening the body. Postmortem MRI is used to investigate soft tissues such as the myocardium, but images are susceptible to postmortem changes and further work is necessary to increase the understanding of these radiological aspects, especially of the ischemic myocardium. In postsurgery cases, the value of postmortem imaging of the heart is reportedly for the diagnostic and documentation purposes. The implementation of new imaging methods into routine postmortem practice is challenging, as it requires not only an investment in equipment but, more importantly, investment in the expertise of interpreting the images. Once those requirements are implemented, however, they bring great advantages in investigating cases of SCD, as they allow documentation of the body, orientation of sampling for further analyses and gathering of other information that cannot be obtained by conventional autopsy such as a complete visualization of the vascular system using postmortem angiography.Key pointsThere are no established guidelines for the interpretation of postmortem imaging examination of the heartAt present, postmortem imaging methods are considered as less accurate than the autopsy for cardiac deathsPostmortem imaging is useful as a complementary tool for cardiac deathsThere is still a need to validate postmortem imaging in cardiac deaths by comparing with autopsy findings.