Congenital anomalous aortic origins of the coronary arteries in adults: A Tunisian coronary arteriography study

A Survey on the Management of Anomalous Aortic Origins of the Coronary Arteries

The management of patients with an anomalous aortic origin of a coronary artery (AAOCA) remains controversial despite the publication of the 2017 American Association for Thoracic Surgery (AATS) expert guidelines. We surveyed the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery and the Pediheart.net online community regarding their care of patients with anomalous origins of the right or left coronary from the opposite cusp with inter-arterial courses and compared them to the AATS guidelines. We received 111 complete responses. Four notable variations from the AATS recommendations were identified. Respondents were more likely to use ECG exercise testing than the stress imaging recommended in the AATS guidelines. For a 16-year-old with AAOCA, recommendations for surgery generally followed the AATS guidelines. However, for asymptomatic left AAOCA without signs of ischemia on stress imaging, only 69.4% felt surgery was appropriate or somewhat appropriate. In the setting of a 16-year-old with right AAOCA free from signs or symptoms of ischemia, respondents were more likely to recommend surgery if the patient was a competitive athlete, a topic not directly addressed in the AATS guidelines. After surgical treatment of AAOCA, only 24% of respondents recommended lifelong antiplatelet therapy despite recommendations for this in the AATS guidelines. Respondents recommendations were generally consistent with the 2017 AATS guidelines but with important variations in the use of stress imaging, indications for surgery in asymptomatic left AAOCA, the impact of identification as a competitive athlete and duration of postoperative antiplatelet therapy.

Abnormal blood supply to a normal lung: left circumflex artery branch supplying the right lung

A middle-aged woman with hypertension presented with atypical chest pain of 1 month duration and had a positive exercise stress test. She underwent diagnostic coronary angiography which demonstrated an anomalous branch arising from the proximal part of the left circumflex artery supplying the right lung. She had atherosclerotic plaques in the right coronary artery and left anterior descending artery. Stress myocardial perfusion imaging did not reveal any inducible ischaemia in the left circumflex artery territory. She was started on medical therapy for coronary artery disease and is doing well on follow-up.

Gender Differences in Types, Frequency, Clinical Manifestations and Atherosclerotic Burden of Coronary Artery Anomalies

BACKGROUND

Although not well established; gender may play a role in the incidence, clinical manifestations, and atherosclerotic burden of Coronary Artery Anomalies (CAAS). Our aim is to investigate the impact of gender on coronary artery anomalies.

METHODS

All coronary angiograms performed at the University Heart Center Zurich, Switzerland, between January 2000 and December 2016 were investigated. Those of anomalous origin, course and termination (fistula) were included in the analysis with the exclusion of coronary artery aneurysms and myocardial bridges.

RESULTS

Out of the original 39577 angiographic studies that included 28550 males and 11026 females, Coronary Artery Anomalies (CAAS) were documented in 130 (0.32%) patients of whom 69.2% (n=90) and 30.8%(n=40) were males and females respectively. However, the overall prevalence of coronary anomalies amongst both genders did not differ (0.32% vs 0.36%, P = 1) and so were the basic characteristics except for hypertension, which was more prevalent in females (P = 0.03644). The most prevalent anomaly overall was (left circumflex artery from right coronary artery/sinus), which was present in (n=47, 36.2%). No impact of gender on the incidence of individual anomalies except for Right Coronary Artery (RCA) originating from Left Circumflex Artery (LCX), which was only documented in men (P = 0.0000116). On the other hand malignant CAAS presented equally with a proportion of 10% for both genders (P = 1). Although males outnumbered females in terms of atherosclerotic burden in CAAS this was statistically not significant (P = 0.331).

CONCLUSION

Both genders have a similar impact on the overall prevalence, clinical manifestations and atherosclerotic burden of CAAs. Anomaly of RCA originating from LCX occurred more frequently in males than females.

Unusual trifurcation of a single left coronary artery

Congenital coronary artery anomalies are rare and usually an incidental finding during coronary angiography. Most of the anomalies are benign in nature; however, some are malignant and may result in sudden cardiac death. A 46-year-old woman with diabetes and hypertension underwent coronary angiography for evaluation of exertional angina, which revealed an unusual trifurcation of a single left coronary artery with an anomalous origin of the right coronary artery from the left anterior descending artery but no significant coronary narrowing. The patient was managed conservatively.

Anomalous Aortic Origin of a Coronary Artery Is Not Always a Surgical Disease

Anomalous aortic origin of the coronary artery (AAOCA) from the opposite sinus of Valsalva with an interarterial course has become a high-profile lesion as a result of its association with sudden cardiac death in otherwise young and healthy individuals. Despite our incomplete knowledge of its pathophysiology and natural history, surgical intervention is often recommended. Evidence now shows AAOCA to be relatively common, with lower than previously suspected rates of sudden cardiac death. Analysis of this information reveals that AAOCA is not always a surgical disease. Future multi-institutional studies will continue to define those subgroups best served by observation or surgery.

Anomalous right coronary artery in a middle-aged patient: A case report and review of the literature

BACKGROUND

An anomalous right coronary artery originating from the left sinus of Valsalva is a rare, but often incidental, finding in middle-aged to elderly people. Prevalence is difficult to define, as well as determining potential harmful hemodynamic consequences. Moreover, the optimal treatment remains debatable.

CASE SUMMARY

The authors present a case of a middle-aged patient diagnosed with an anomalous right coronary artery causing ischemia, who was treated surgically.

CONCLUSION

By reviewing literature, the authors conclude that choice of treatment depends on age, symptoms, and certain anatomic features of this anomaly. However, there are no randomized trials available in this field.

Abnormal origins of the coronary arteries from the aortic root

Anomalous origin of a coronary artery from the aorta is a potentially serious anomaly that occurs in about 0.1-0.2% of the population. This percentage is small; however, it translates into about 4000 annual births with these anomalies. The clinical presentation of these anomalies is rare, and hence most are and will remain asymptomatic. The various anatomic anomalies are described, with anomalous origin of the left coronary artery that then passes between the aorta and pulmonary artery being the most serious of these anomalies. The pathophysiology resulting from these anomalies is described, as are methods for identifying those who require treatment; however, we still do not know the best methods of determining which patients need treatment.

[Single coronary ostium: single coronary artery and ectopic coronary artery connected with the contralateral artery. How and why differentiating them?]

Among the wide spectrum of congenital abnormalities of coronary arteries, a single coronary artery is often confused with an ectopic coronary artery connected with the contralateral coronary artery. Both abnormalities are characterized by a single coronary ostium, but they differ by the lack or not of an initial ectopic course. The prognosis of anomalous connections of coronary arteries depends mainly on the type of the initial course in relation to other cardiac structures. Therefore, the distinction between a single coronary artery and an ectopic coronary artery connected with the contralateral artery is of importance.

The incidence and pattern of coronary artery anomalies in the north-west of iran: a coronary arteriographic study

Background and Objectives

Coronary artery anomalies are found in approximately 1% of patients undergoing diagnostic coronary angiography (CAG). Angiographic recognition of these vessels is important because of their clinical significance and importance in patients undergoing coronary angioplasty or cardiac surgery. There are fairly enough reports concerning the incidence of coronary anomalies in different geographic areas, but this is the first study among the Iranian population.

Subjects and Methods

We reviewed the database of the Catheterization Laboratory of Imam Reza and Shahid Madani Hospitals, Tabriz University of Medical Sciences, Iran. Our inquiry included all patients who referred for CAG from other hospitals, between February 2007 and April 2009. Patients with congenital heart diseases, high "take off" of coronary arteries and separate origin of the conus artery from the right coronary sinus (RCS) were excluded. In total, 6065 films were reviewed.

Results

Seventy nine (1.30%) patients were found to have coronary anomalies. Seventy five (1.24%) patients had anomalies of origin and distribution, while four (0.06%) had coronary artery fistulae. Most common anomaly was separate ostia of the left anterior descending artery and left circumflex artery, which was found in 42 patients (53.16%) with angiographic incidence of 0.69%. The next most common anomalies were anomalous circumflex artery from RCS/right coronary artery (RCA) {n=17 (21.51%)}, and anomalous RCA arising from left coronary sinus {n=6 (7.59%)}.

Conclusion

In general, the incidence and pattern of coronary anomalies in our study was similar to earlier reports from different parts of the world.

Anomalous aortic origin of coronary arteries from the opposite sinus: a critical appraisal of risk

Background

Anomalous aortic origin of the coronary artery (AAOCA) from the opposite sinus of Valsalva with an interarterial course has received much attention due to its association with sudden death in otherwise healthy individuals. AAOCA is relatively common and may have significant public health implications. While our knowledge of its pathophysiology and natural history remains incomplete, an emphasis has been placed on surgical correction.

Discussion

In 2005 we published a review examining the rates of sudden death with AAOCA, as well as complications of surgical management. Evidence now points even more strongly to lower rates of sudden death, while surgical outcomes data now better documents associated risks.

Summary

Armed with this updated information, we agree with the need for a national registry to better track patients with AAOCA. We submit that the risks of surgical management outweigh any benefits in the asymptomatic patient with anomalous right coronary artery, and expectant management should also be strongly considered even in asymptomatic patients with anomalous left coronary artery.

An exceptional combination of congenital coronary anomalies

We present a case of congenital coronary artery anomalies combining the absence of the circumflex artery, ectopic origins of left anterior descending and diagonal arteries and abnormal courses of these vessels. These rare anomalies were detected during an elective coronary angiography in a patient with stable angina that was related to significant stenosis of the posterolateral and middle right coronary artery. A computed tomography scanner with three-dimensional reconstructions confirmed the anatomy.

Anomalous origination of a coronary artery from the opposite sinus

Anomalous origination of a coronary artery from the opposite sinus (ACAOS) is estimated to be present in 0.2-2.0% of the population. In the majority of individuals, ACAOS has no hemodynamic or prognostic implications, but in a minority of cases, typically where the anomalous coronary artery takes an interarterial course to reach its correct myocardial territory, it can precipitate ischemia and sudden cardiac death (SCD). With the growing use of CT coronary angiography (CTCA) in the investigation of ischemic heart disease, we can expect increasing rates of incidental detection of this anomaly. Although CTCA and magnetic resonance coronary angiography can effectively characterize these lesions anatomically, they fail to describe and quantitatively assess the basic defect that leads to coronary insufficiency, such as mural intussusception. The key challenge lies in the identification of which patients are at risk of SCD and, therefore, who should be offered corrective surgical or (potentially) percutaneous intervention. Conventional, noninvasive stress testing has limited sensitivity, but emerging, invasive stress tests, which utilize intravascular ultrasonography and measurements of fractional flow reserve, show the potential to provide more-accurate hemodynamic and prognostic assessment.