Primary congenital anomalies of the coronary arteries: a coronary: arteriographic study

Prevalence and location of coronary artery disease in anomalous aortic origin of coronary arteries

BACKGROUND

The prevalence and location of coronary artery disease (CAD) in anomalous aortic origin of a coronary artery (AAOCA) remain poorly documented in adults. We sought to assess the presence of CAD in proximal (or ectopic) and distal (or nonectopic) segments of AAOCA. We hypothesized that the representation of CAD may differ among the different courses of AAOCA.

METHODS

The presence of CAD was analyzed on coronary angiography and/or coronary computed tomography angiography in 390 patients (median age 64 years; 73% male) with AAOCA included in the anomalous coronary arteries multicentric registry.

RESULTS

AAOCA mainly involved circumflex artery (54.4%) and right coronary artery (RCA) (31.3%). All circumflex arteries had a retroaortic course; RCA mostly an interarterial course (98.4%). No CAD was found in the proximal segment of interarterial AAOCA, whereas 43.8% of retroaortic AAOCA, 28% of prepulmonic AAOCA and 20.8% subpulmonic AAOCA had CAD in their proximal segments (P < 0.001). CAD was more prevalent in proximal than in distal segments of retroaortic AAOCA (OR: 3.1, 95% CI: 1.8-5.4, P < 0.001). On multivariate analysis, a retroaortic course was associated with an increased prevalence of CAD in the proximal segment (adjusted OR 3.4, 95% CI: 1.3-10.7, P = 0.022).

CONCLUSION

Increased prevalence of CAD was found in the proximal segment of retroaortic AAOCA compared to the proximal segments of other AAOCA, whereas no CAD was observed in the proximal segment of interarterial AAOCA. The mechanisms underlying these differences are not yet clearly identified.

Right and Left Coronary and Conus Arteries Originating from Three Separate Ostia in the Right Valsalva Sinus in a Japanese Cadaver: A Case Study with Literature Review

A rare case of an anomalous location of the orifice of the coronary artery was found in a 99-year-old male cadaver undergoing routine dissection. The presence of the right coronary artery (RCA), left coronary artery (LCA), and conus artery (conus branch) originating from the right Valsalva sinus are the characteristic findings of this case. Then, the LCA passed through the aorta and the pulmonary artery. The LCA and RCA branches were normal. These findings are useful for future surgical procedures, including cardiac catheterization.

Anomalous circumflex artery: a benign variant generating a malignant potential after valve surgery

Coronary artery anomalies are a diverse group of congenital disorders presenting with highly variable clinical manifestations. The anomalous origin of left circumflex artery from the right coronary sinus following a retro-aortic trajectory is a well-recognized anatomic variation. Despite its benign course, it can prove lethal in association with valvular surgery. When single aortic valve replacement or combined with mitral valve replacement is performed, the aberrant coronary vessel may be compressed by or between the prosthetic rings triggering postoperative lateral myocardial ischemia. If left untreated, the patient is at risk of sudden death or myocardial infarction with its detrimental complications. Skeletonization and mobilization of the aberrant coronary artery is the most widely accepted intervention, but valve downsizing or concomitant surgical or transcatheter revascularization have also been described. However, large series are lacking from the literature. Therefore, no guidelines exist. This study is a thorough review of the literature concerning the aforementioned anomaly in association with valvular surgery.

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.

Long-term outcomes after repair for anomalous right coronary artery from the pulmonary artery

Anomalous right coronary artery from pulmonary artery (ARCAPA) is a rare congenital heart disease that can lead to abnormal coronary perfusion and a need for surgical repair. Here, we report the outcomes of patients who underwent ARCAPA surgery within the Pediatric Cardiac Care Consortium (PCCC), a North American registry of interventions for paediatric heart diseases. We queried the PCCC for patients undergoing surgical repair for ARCAPA at <18 years of age between 1982 and 2003. Outcomes were obtained from the PCCC and after linkage with the National Death Index (NDI) and the Organ Procurement and Transplantation Network (OPTN) through 2019. Twenty-four patients (males: 15) were identified having surgery for ARCAPA at a median age of 5.8 (IQR 2.7-10.3) years. Of them, 23 cases were considered "simple" (without major intracardiac disease) and one "complex" (co-existing with tetralogy of Fallot). Five patients presented with symptoms [chest pain (1), dyspnoea on exertion (2) or history of syncope (2)]; while the remaining 19 patients were referred for evaluation of either murmur or co-existing CHD. There was no in-hospital mortality after the surgical repair. Fourteen patients had sufficient identifiers for NDI/OPTN linkage; among them, only one death occurred from unrelated non-cardiac causes within a median period of 19.4 years of follow-up (IQR: 18-24.6). Outcomes were excellent after reimplantation up to 25 years later and further longitudinal monitoring is important to understand the interaction of pre-existing coronary pathology with the effects of ageing.

Utilization and outcomes of transcatheter coil embolization for various coronary artery lesions: Single-center 12-year experience

OBJECTIVE

Determining the outcomes of transcatheter coil embolization (TCE) for several coronary artery lesions.

BACKGROUND

TCE has been used as a treatment modality for various lesions in the coronary circulation. However, data on the efficacy and safety of TCE to treat coronary artery fistula (CAF), left internal mammary artery (LIMA) side-branch, coronary artery perforation (CAP), coronary artery aneurysm (CAA), and coronary artery pseudoaneurysm (CAPA) are limited.

METHODS

We conducted a retrospective, descriptive analysis of all TCE devices in coronary lesions at our center from 2007 to 2019. Forty-one studied lesions included 25 CAF, 7 LIMA side-branch, 5 CAP, 2 CAA, and 2 CAPA. Short- and 1-year mortality and hospital readmission were reported, in addition to coil-related complications and procedural success.

RESULTS

The utilization rate of TCE in coronary artery lesions at our center was found to be 33.8 per 100,000 percutaneous coronary intervention procedures over 12 years. Successful angiographic closure was achieved in 37 out of 41 (87.8%) cases (88, 100, 60, 100, and 100% of CAF, LIMA side-branch, CAP, CAA, and CAPA, respectively). No adverse events were directly related to TCE among the LIMA, CAA, and CAPA cases, and only one patient with CAF required reintervention at 3 months due to coil migration.

CONCLUSIONS

Coil embolization in our institution was safe and effective in treating different coronary circulation abnormalities with a 87.8% overall success rate. Further study on the use of vascular plug devices in cases such as CAF or LIMA side-branch would be beneficial to understand the treatment options better.

Prevalence Rates of Congenital Coronary Anomalies and Coronary Variations in Adult Indian Population Using Dual-Source Computed Tomography Coronary Angiography: Analysis of Regional Distribution of Coronary Anomalies and the Need for Standardized Reporting Formats

Background  Congenital coronary artery anomalies (CCAA) are predominantly discovered as incidental findings on computed tomography coronary angiography (CTCA) of adults. They are rare but significant, considering their importance during endovascular or surgical interventions. This study describes the prevalence of CCAA and coronary variants (CV) in adults as identified by CTCA.

Methods  It is a retrospective evaluation of 7,694 CTCAs of adults performed in a tertiary care facility in North India.

Results  CCAA and CV were observed in a total of 9.6% of patients. The most common CV was myocardial bridging, observed in 7.1%. Anomalies of origin and course were detected in 2.3% of the patients. The frequency of these anomalies in the right coronary artery, left main, left circumflex artery, and the left anterior descending artery arteries were 1.06, 0.41, 0.03, and 0.38%, respectively. The single coronary pattern was seen in 0.05% and coronary artery fistulas in 0.03%. Scrutiny of data on Indian regional distribution revealed differing definitions and inclusion and exclusion criteria, making comparisons difficult, highlighting the need for uniform definitions as well as the need to adopt a standardized reporting template and format.

Conclusion  The prevalence of CCAA and CV is 9.6% in adult Indian patients undergoing CTCA. Prior knowledge of these anatomical finding can prevent a catastrophe during surgery or endovascular interventions. Hence, it is important that clinicians, as well as radiologists, are aware of these entities.

Prevalence and Pattern of Congenital Coronary Artery Anomalies in Patients Undergoing Coronary Angiography at a Tertiary Care Hospital of Northern India

Objectives: To evaluate the prevalence and pattern of congenital coronary artery anomalies (CAAs) in the adult population undergoing catheter coronary angiography.

Methods: The coronary angiograms done between October 2015 and September 2020 were reviewed for the presence of coronary anomalies based upon Angelini's classification. The medical record of patients with anomalies was reviewed for symptomatology and indication of angiography.

Results: CAAs were found in 129 (87 males and 42 females) of 6,258 patients giving a prevalence of 2.06%. The mean age was 57.8 ± 11.8 (range 32-81) years. Among these, the anomalous origin and course of the coronaries were the most common anomaly seen in 81 (1.29%) patients, followed by intrinsic anomalies of the coronary arterial system in 44 (0.7%) patients and anomalies of coronary termination and anomalous anastomotic vessels in 2 (0.03%) patients each. Overall, the absence of the left main trunk with a separate origin of the left anterior descending (LAD) and the circumflex artery was the commonest anomaly seen in 46 (0.74%) patients, followed by dual LAD in 35 (0.56%) patients. The anomalous origin of the right coronary artery (RCA) from the left sinus was seen in 14 patients (0.22%) and that of the circumflex artery from the right sinus or right coronary artery was seen in 11 patients (0.17%). The origin of the left main and RCA from ascending aorta was found in eight (0.13%) patients. One (0.02%) patient had a single coronary artery, and another one (0.02%) had all the three coronary arteries arising from the right sinus; however, with separate ostia. The split RCA was seen in nine (0.14%) patients and there were two (0.03%) patients each of coronary artery fistulae, and of anomalous anastomotic vessels.

Conclusions: The prevalence of congenital coronary anomalies in this study was 2.06%. The commonest anomaly was that of origin and courses of the vessels, however, the pattern of anomalies is different from previous studies.

Anomalous origin of coronary artery from the opposite aortic sinus of Valsalva-a single center experience with a therapeutic conundrum

Background: Coronary artery anomalies are rare congenital abnormalities, most often found incidentally on conventional coronary angiography and CT angiography (CTA). CTA better delineates the origin and course of anomalous coronaries. Anomalous origin of coronary artery from the opposite aortic sinus of Valsalva (ACAOS) has a prevalence of 1% with a very few having an interarterial (malignant) course. There is limited literature, especially in the Indian population, dealing with this topic.

Methods: In this retrospective observational study, angiographic data of 8500 consecutive patients from June 2011 to December 2019 at a large tertiary care hospital in western India was analyzed. Patients diagnosed with ACAOS underwent CTA for delineation of the exact anatomy. Those with a non-malignant course with evidence of ischemia clinically or on stress myocardial perfusion imaging (MPI), underwent PCI. Others with a non-malignant course were medically managed. Patients with malignant (interarterial) course were revascularized by coronary artery bypass graft (CABG) surgery in case of LCA involvement or positive MPI test. Asymptomatic patients with negative MPI were managed medically. Clinical follow-up over 12 months of patients undergoing PCI and those with a malignant course showed no major adverse cardiovascular events (MACE).

Results: Of the 8500 patients studied, 74 (0.87%) had ACAOS. Of these, 51 (68.9%) patients had anomalous origin of right coronary artery (RCA) from the left aortic sinus, 21 (28.4%) had anomalous origin of the circumflex artery (Cx) from the right aortic sinus and two patients (2.7%) had an anomalous origin of the left main coronary artery (LCA) from the right aortic sinus. Interarterial course was found in five (6.7%) patients. Of these, four patients underwent CABG-one asymptomatic patient with LCA from right aortic sinus and three with positive MPI in anomalous RCA. All five patients with malignant course and ten patients who underwent PCI were free of MACE over 12 months’ clinical follow up.

Conclusions: ACAOS is a rare anomaly and if interarterial course is excluded, then PCI is feasible in selected cases with significant stenosis. Patients with malignant course with inducible ischemia or LCA involvement should undergo surgical revascularisation.

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.

A Single Coronary Artery Anomaly: Right Coronary Artery as a Branch From the Left Anterior Descending Artery

An anomalous origin of the right coronary artery (RCA) from the left anterior descending artery (LAD), also known as a single coronary artery, is an extremely rare finding in clinical practice. It is usually a benign anomaly; however, symptoms are highly dependent on the course that the anomalous RCA takes after branching off of the LAD. We present a case of a patient who had decompensated heart failure and was detected to have a single coronary artery. The patient was treated with guideline-directed medical therapy with notable improvement in clinical status in the following days. Enhanced awareness of congenital cardiac anomalies may help guide management.

Diagnosis and percutaneous coronary intervention of an anomalous right coronary artery originating from the middle of the left anterior descending artery: a case report

A single left coronary artery is a very rare anomaly in which only the left coronary artery arises from the aortic trunk by a single coronary ostium and supplies the entire heart. The present report is one of the few describing a patient with an anomalous right coronary artery originating from the middle of the left anterior descending artery. The patient presented with acute myocardial infarction with the culprit lesion on the left circumflex artery. Multivessel angioplasty was successfully performed in a two-step approach: the first for the culprit lesion and the second on the anomalous coronary artery. Decisions about treatment modalities for an anomalous coronary artery should be made only after considering the patient’s clinical characteristics and performing additional imaging diagnostics with a clearly defined coronary anatomy.

Left anterior descending artery hyper dominance giving rise to the posterior descending artery: an extremely rare coronary anomaly and its clinical implications

The prevalence of congenital coronary artery anomalies is approximately 1% in the general population. They are a common cause of sudden death in younger persons. The origination of the posterior descending artery (PDA) from left anterior descending (LAD) artery is an extremely rare anomaly. We present a case of a 54-year-old female who presented with diabetic ketoacidosis with co-existing non-ST elevation myocardial infarction, therefore, had an invasive angiogram that identified the anomalous origin of PDA from LAD. It is vital to define coronary anatomy as anomalies dictate which cardiac intervention should be attempted in cases of ischemia.

Trends and predictors of coronary revascularization in patients with coronary artery anomalies and acute myocardial infarction: a nationwide analysis of 8131 patients

OBJECTIVE

Acute myocardial infarction (AMI) is rarely associated with coronary artery anomalies (CAA). This confluence makes it difficult to identify and treat the culprit lesion with percutaneous coronary intervention (PCI). Our objective was to evaluate trends and predictors of revascularization in patients with CAA and AMI using a large national database.

METHODS

We included adult patients with CAA presenting as ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) and undergoing coronary angiography from Nationwide Inpatient Sample from 2000 to 2011, using ICD-9 diagnosis code of 746.85 for CAA. Chi-square test for trend was used to compare revascularization rates over time. Multivariate logistic regression was used to identify predictors of revascularization.

RESULTS

There were almost 4.7 million subjects with AMI undergoing coronary angiography from 2000 to 2011. Of these, there were 8131 patients with CAA, including 3425 STEMI and 4706 NSTEMI patients. Mean age of the CAA population was 59 years with 63.6% males. Overall PCI rate was 47.8% and coronary artery bypass grafting rate was 8.8%. In STEMI patients with CAA, PCI rate increased from 49.9% in 2000 to 77.8% in 2011 (P < 0.001). In NSTEMI patients with CAA, PCI rate remained unchanged from 33.3% in 2000 to 37.3% in 2011 (P = 0.34). Revascularization trends in AMI patients with CAA mirrored those in AMI patients without CAA.

CONCLUSION

Despite the technical challenges associated with PCI in CAA, PCI rates in STEMI patients with CAA continue to increase over time. On the contrary, PCI rates continue to remain low in CAA patients with NSTEMI, reflecting overall contemporary NSTEMI treatment trends.

Incidence, Characteristics and Atherosclerotic Involvement of Coronary Artery Anomalies in Adult Population Undergoing Catheter Coronary Angiography

Background

Coronary artery anomalies (CAAs) are rare disorders of coronary anatomy with varied clinical presentations. There are widespread geographic variations in incidence and patterns of these anomalies, with limited data from North Indian population. We performed a retrospective study to evaluate the incidence, characteristics and atherosclerotic involvement of CAAs in adult population undergoing catheter coronary angiography.

Methods

Serial coronary angiographies performed at our institution over a period of 2.5 years (from January 2017 to June 2019) were retrospectively analyzed. We identified patients with anomalous coronaries and studied their clinical characteristics and angiographic profiles.

Results

Among 3,233 coronary angiograms analyzed, CAAs were found in 99 patients with an incidence of 3.06%. Mean age of the patients was 56.2 ± 12.9 years (range: 20 - 86 years), with 74.75% being males and 25.25% females. Split right coronary artery (RCA) was the most common coronary anomaly, being seen in 27 patients; with an angiographic incidence of 0.84%. Dual left anterior descending artery (LAD) was the second most common anomaly and was seen in 22 cases with an angiographic incidence of 0.68%. Absent left main trunk was noted in 14 patients (0.43%). Ectopic origin of RCA from left sinus was seen in 12 patients (0.37%), while ectopic origin of RCA from ascending aorta was seen in four patients (0.12%). Ectopic origin of left circumflex artery (LCX) from right sinus or RCA was noted in 13 patients (0.40%). One patient (0.03%) had a superdominant LAD supplying the posterior descending artery (PDA). Coronary artery fistulae were seen in six patients (0.18%). Significant coronary artery disease (CAD) was seen in 89 of 268 (33.21%) normal vessels, whereas it was seen in 56 of 114 (49.12%) of anomalous vessels. This difference was statistically significant (P = 0.003).

Conclusions

The incidence of CAAs in our study was slightly higher than many of the previous angiographic series. The patterns of coronary anomalies in our study were different from most of the previous studies. Our study had higher incidence of atherosclerotic involvement of anomalous vessels as compared to normal vessels.

Percutaneous Coronary Intervention in A Rare Case of Single Coronary Ostium Presented with ST Elevation Myocardial Infarction

Anomalous aortic origin of the left coronary artery (AAOLCA) from the right sinus of Valsalva is a very rare coronary anomaly that can lead to sudden cardiac death (SCD), usually during or after strenuous exercise. The anatomical variation can follow five different courses: interarterial, subpulmonic (intraconal or intraseptal), prepulmonic, retroaortic, or retrocardiac. The interarterial variation is the pattern that has a stronger relationship with SCD. In patients with AAOLCA, ST-segment elevation myocardial infarction (STEMI) is a rare clinical presentation, and the management of an anomalous infarct-related coronary artery may be technically challenging. We report a case of a patient with an AAOLCA who presented with inferior STEMI and who underwent a successful percutaneous coronary intervention of the right coronary artery.

Prevalence and Spectrum of Coronary Anomalies Detected on Coronary Computed Tomography Angiography: A single centre experience in Oman

Objectives

Coronary artery anomalies (CAAs) are uncommon congenital abnormalities with a prevalence ranging from 0.2–2%. CAAs can be asymptomatic or less commonly present with life-threatening symptoms. This study aimed to investigate the prevalence and spectrum of CAAs in patients who underwent coronary computed tomography angiography (CCTA) in Oman.

Methods

This retrospective study was conducted at the National Heart Centre, Muscat, Oman between September 2012 and August 2018. All consecutive patients who had undergone CCTA were included.

Results

A total of 4,445 patients were included in this study. Of these, 59 patients (1.3%) were diagnosed with CAAs with a mean age of 52.6 years (range: 12–80 years) and an equal gender distribution. Among the patients with CAAs, the majority (69.5%) had anomalous origins from the opposite or non-coronary sinus. Right coronary artery arising from the left coronary sinus was the most common type (33.9%). Fewer patients (18.6%) had left circumflex arising from the right coronary sinus (RCS). Seven patients (11.9%) had left main arising from the RCS. Other CAAs were in the dual left anterior descending artery (8.5%), high coronary artery take-off (6.8%), single coronary ostia (6.8%) and coronary artery fistula (6.8%).

Conclusion

The prevalence of CAAs was 1.3% which is similar to the literature.

Familial clustering of cardiac conditions in patients with anomalous aortic origin of a coronary artery and myocardial bridges

BACKGROUND

Anomalous aortic origin of a coronary artery is the second leading cause of sudden cardiac arrest/death in young athletes in the United States of America. Limited data are available regarding family history in this patient population.

METHODS

Patients were evaluated prospectively from 12/2012 to 02/2017 in the Coronary Anomalies Program at Texas Children's Hospital. Relevant family history included the presence of CHD, sudden cardiac arrest/death, arrhythmia/pacemaker use, cardiomyopathy, and atherosclerotic coronary artery disease before the age of 50 years. The presence of one or more of these in 1st- or 2nd-degree relatives was considered significant.

RESULTS

Of 168 unrelated probands (171 patients total) included, 36 (21%) had significant family history involving 19 (53%) 1st-degree and 17 (47%) 2nd-degree relatives. Positive family history led to cardiology referral in nine (5%) patients and the presence of abnormal tests/symptoms in the remaining patients. Coronary anomalies in probands with positive family history were anomalous right (27), anomalous left (five), single right coronary artery (two), myocardial bridge (one), and anomalous circumflex coronary artery (one). Conditions present in their family members included sudden cardiac arrest/death (15, 42%), atherosclerotic coronary artery disease (14, 39%), cardiomyopathy (12, 33%), CHD (11, 31%), coronary anomalies (3, 8%), myocardial bridge (1, 3%), long-QT syndrome (2, 6%), and Wolff-Parkinson-White (1, 3%).

CONCLUSION

In patients with anomalous aortic origin of a coronary artery and/or myocardial bridges, there appears to be familial clustering of cardiac diseases in approximately 20% of patients, half of these with early occurrence of sudden cardiac arrest/death in the family.

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.

Right Coronary Artery Originating from the Left: Do Not Miss the Diagnosis!

Objective

Left circumflex (LCx) artery originating from the right coronary arterial (RCA) system has been reported as the most common form of anomalous origination of a coronary artery from the opposite sinus (ACAOS). However, some studies claim that RCA originating from the left coronary sinus (LCS) is the most frequent form. The aim of this study was to determine the most common type of ACAOS in a single center.

Materials and Methods

The database of the catheterization laboratory was retrospectively searched. All patients who were performed coronary angiography between 1999 and 2006 were included to registry. All examinations were carefully analyzed to determine the most frequent type of ACAOS.

Results

We detected ACAOS in 35 cases (16 RCA originating from the LCS, 13 LCx from the RCS or the RCA, and 6 others) out of 5165 coronary angiograms. The most common form was RCA originating from LCS. Moreover, we revealed that 5 cases with RCA originating from the LCS were previously misdiagnosed and not reported as a coronary anomaly.

Conclusions

RCA originating from the LCS was the most common form of ACAOS in our registry. The high change of misdiagnosis or underreporting of this anomaly could have biased the true prevalence.

Congenital absence of the right coronary artery: A case report and literature review

RATIONALE

Congenital absence of the right coronary artery (RCA) is a rare congenital malformation of the cardiovascular system which may have fatal consequences.

PATIENT CONCERNS

A 63-year-old man with a 5-year history of chest pain after exertion which had aggravated for >1 month was advised for admission and computed tomography angiography (CTA) examination of the coronary artery to screen for coronary artery disease (CAD).

DIAGNOSES

The coronary artery CTA showed absence of RCA arising form the aortic root after which a selective coronary angiography (SCA) examination was done that confirmed the diagnosis of congenital absence of RCA.

INTERVENTIONS

As the patient refused to receive a coronary artery stent implantation citing his financial condition, only symptomatic treatment was given.

OUTCOMES

The patient requested to be discharged from the hospital against the advice of his doctors 1 week later. A query made by the telephone suggested that the patient's symptoms were under control by use of prescribed medications only.

LESSONS

Although being a rare condition, a coronary artery CTA examination can be utilized to screen for congenital absence of RCA and other varieties of cardiovascular malformation whereas SCA can be performed to confirm the diagnosis.

Prevalence and spectrum of coronary artery anomalies in 8021 patients: A single center study in South India

Objective

To identify the prevalence of coronary artery anomalies (CAAs) and their subtypes based on Angelini et al. classification in symptomatic yet stable population of South India using 64- slice dual source multi detector CT coronary angiography (MDCT-CA).

Methods

We retrospectively reviewed reports of 8021 symptomatic patients predominantly South Indians who were referred for CT coronary angiography (CT-CA) to our tertiary cardiac care center in Hyderabad, India from January 2011 to March 2017.

Results

We identified a total of 838 coronary artery anomalies in 812 patients with a prevalence of 10.09%. 96.9% of patients were older than 30 years of age with a M:F ratio of 1.39:1. Coronary artery disease (CAD) was seen in 61.5% of these patients. Among these anomalies, myocardial bridging (MB) was the most common anomaly followed by anomalous location of coronary ostium at improper sinus (ACOIS).

Conclusion

There is no significant difference in prevalence of CAAs (including and excluding MB) in Indian and World population. CAAs were more common in males than females and most of these patients remain asymptomatic during first three decades of their life. Myocardial bridging is the most common anomaly detected by MDCT-CA followed by ACOIS. Right coronary artery (RCA) arising from left coronary sinus (LCS) is the most commonly encountered ACOIS.

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.

Cardiac Computed Tomography: Before and After Cardiac Surgery

Cardiac computed tomography angiography (CCTA) is a noninvasive imaging technique that has been rapidly adopted into clinical practice. Over the past decade, technological advances have improved CCTA accuracy, and there is an increasing amount of data supporting its prognostic value in the assessment of coronary artery disease. Recently, "appropriate use criteria" has been used as a tool to minimize inappropriate testing and reduce patient exposure to unnecessary risk and inconclusive studies. This review will summarize the appropriate uses of CCTA in patients before and after cardiac surgery. Although the most common indication for CCTA is assessment of patency of native coronary arteries, other potential perioperative uses (eg, assessment of congenital heart disease, valvular heart disease, pericardial disease, myocardial disease, cardiac anatomy, bypass grafts, aortic disease, and cardiac masses) will be reviewed.

Congenital coronary artery anomalies in adults: review of 111 cases from a single-centre experience

BACKGROUND

Coronary artery anomalies are a heterogeneous group of congenital disorders presenting with a wide spectrum of symptoms, ranging from vague chest pain to sudden cardiac death. Despite available data, there is no consensus about the classification, nomenclature, and outcomes of coronary anomalies in the normally connected heart. In this study, we aimed to investigate clinical and angiographic characteristics of coronary arterial anomalies, as well as the frequency of atherosclerotic involvement in anomalous coronaries, diagnosed at a tertiary referral centre.

METHODS

We retrospectively reviewed coronary angiograms performed between 2011 and 2015 for the presence of a coronary anomaly. A total of 111 patients with a final diagnosis of coronary anomaly were included in the study group. We also recruited 110 age- and sex-matched patients who underwent coronary angiography because of symptomatic coronary artery disease as controls.

RESULTS

Among 36,893 coronary angiograms, 111 (0.30%) major coronary anomalies were found. Compared with controls, the prevalence of significant atherosclerotic coronary disease was lower in patients with coronary anomalies and stable symptoms (p=0.02); however, the prevalence of significant coronary atherosclerosis was similar among patients admitted with unstable angina or myocardial infarction (p>0.05). Compared with controls, patients with an anomalous left anterior descending coronary artery had significantly less atherosclerotic involvement than those in whom the left anterior descending artery was not anomalous (p=0.005).

CONCLUSIONS

Although coronary artery anomalies are cited as a cause for myocardial ischaemia, atherosclerotic coronary artery disease is also frequent and may offer an alternative explanation to ischaemic symptoms. No predisposition to accelerated atherosclerosis was found, however, and atherosclerotic involvement was less frequent in some anomalous vessels.

Successful percutaneous coil embolization of a severely tortuous coronary artery fistula using the mother-child-grandchild technique via a GuideLiner catheter

Coronary artery fistula is an uncommon congenital disease that requires invasive treatment for symptomatic patients. Although percutaneous intervention has become the popular treatment option, surgical treatment is preferred for severely tortuous coronary artery fistulas. We report a case of an extremely tortuous coronary artery fistula successfully treated with the support of the GuideLiner catheter and the mother-grandchild technique.

The prevalence of coronary artery anomalies in Qassim Province detected by cardiac computed tomography angiography

BACKGROUND

Coronary artery anomalies (CAAs) affect about 1% of the general population based on invasive coronary angiography (ICA) data, computed tomography angiography (CTA) enables better visualization of the origin, course, relation to the adjacent structures, and termination of CAAs compared to ICA.

OBJECTIVE

The aim of our work is to estimate the frequency of CAAs in Qassim province among patients underwent cardiac CTA at Prince Sultan Cardiac Center.

METHODS

Retrospective analysis of the CTA data of 2235 patients between 2009 and 2015.

RESULTS

The prevalence of CAAs in our study was 1.029%. Among the 2235 patients, 241 (10.78%) had CAAs or coronary variants, 198 (8.85%) had myocardial bridging, 34 (1.52%) had a variable location of the Coronary Ostia, Twenty two (0.98%) had a separate origin of left anterior descending (LAD) and left circumflex coronary (LCX) arteries, ten (0.447%) had a separate origin of the RCA and the Conus artery. Seventeen (0.76%) had an anomalous origin of the coronaries. Six (0.268%) had a coronary artery fistula, which is connected mainly to the right heart chambers, one of these fistulas was complicated by acute myocardial infarction.

CONCLUSIONS

The incidence of CAAs in our patient population was similar to the former studies, CTA is an excellent tool for diagnosis and guiding the management of the CAAs.

Coronary anatomy, anatomic variations and anomalies: a retrospective coronary angiography study

INTRODUCTION

The incidence of coronary artery anomalies (CAAs) varies from 0.2% to 8.4%. Knowledge of such anatomical variations is important as coronary procedures are regularly performed these days. We aimed to find the coronary dominance pattern, intermediate artery (IMA) frequency and CAA incidence in our clinic, and compare them to those in the literature.

METHODS

The medical reports of 5,548 patients who had undergone coronary angiography (CAG) between 2005 and 2009 were retrospectively investigated. Dominance pattern and presence of IMA and CAA were recorded. CAAs were described using two different classifications: Angelini and Khatami's classification, and a new modified classification that was derived from Angelini and Khatami's classification. Some procedural details and clinical features of the patients with CAA were also investigated.

RESULTS

Coronary dominance pattern was: 81.6% right coronary artery, 12.2% circumflex artery and 6.2% co-dominant. IMA was present in 613 (11.0%) patients. The incidences of overall anomaly were 2.7% and 1.4%, according to the different classifications. Absent left main coronary artery, which was the most common anomaly in the present study, was found in 51 (0.9%) patients. Incidences of myocardial bridge, coronary arteriovenous fistulae and aneurysms were 1.1%, 0.2% and 0.3%, respectively.

CONCLUSION

CAAs are generally asymptomatic, isolated lesions. Some may lead to anginal symptoms, myocardial infarction or sudden death. We found that CAA was associated with increased radiation and contrast exposure in patients who underwent CAG. This risk could be reduced if appropriate catheters were designed and training programmes on ostial cannulation were developed.

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.

Prevalence of congenital coronary artery anomalies as shown by multi-slice computed tomography coronary angiography: a single-centre study from Turkey

Objective Coronary artery anomaly (CAA) is a remarkable etiological factor for sudden cardiac death in young adults. The incidence of CAA is unknown, with most reliable data available based on postmortem/angiography investigations. This study aimed to assess the prevalence of different forms of coronary anomalies, and to investigate the relationships between demographic data and occurrence of CAA. Methods A total of 2401 consecutive patients (1805 men; mean age, 56 ± 11.7 years), who were referred between January 2005 and December 2008 for noninvasive multi-slice computed tomography (MSCT) imaging, were retrospectively analysed. Results A total of 225 cases (191 men; mean age, 55.9 ± 12) of CAAs were identified (9.37%). Because 11 patients had multiple muscular bridges of the coronary arteries, 236 coronary artery anomalies were found in these 225 patients. Cases were classified into three groups: group 1, coronary anomalies of origin and distribution (n = 36, 1.5%); group 2, anomalies of intrinsic coronary arterial anatomy (n = 180, 7.49%); and group 3, anomalies of coronary termination (n = 9, 0.4%). Conclusion The prevalence of CAA was 9.37% in our single-centre study, which is consistent with previous research. A minimally invasive tool, such as MSCT angiography, should be used to identify CAA.

Anomalous Coronary Artery: Run of a Lifetime

The anatomy of the coronary circulation is well described with incidence of congenital anomalies of approximately 0.3% to 1.0%. Although often incidental, 20% are life-threatening. A 25-year-old woman with syncopal episodes collapsed following a 10-km run. Coronary anatomy evaluation showed an anomalous left main coronary artery originating from the right sinus of valsalva and following a course between the aorta and the pulmonary outflow tract. Percutaneous coronary intervention was followed by eventual surgical revascularization. Abnormal course of coronary arteries plays a role in the pathogenesis of sudden death on exertion. Origin of the left main coronary from the right sinus of valsalva is a rare congenital anomaly. The expansion of the roots of the aorta and pulmonary trunk with exertion lead to compression of the coronary artery and syncope. Our patient raises awareness of a potentially fatal coronary artery path. Intraoperative identification of anomalous coronaries by utilizing intraoperative transesophageal echocardiography was critical.

Acute Anterior Myocardial Infarction Accompanied by Acute Inferior Myocardial Infarction: A Very Rare Coronary Artery Anomaly

Coronary artery anomalies are rare and mostly silent in clinical practice. First manifestation of this congenital abnormality can be devastating as syncope, acute coronary syndrome, and sudden cardiac death. Herein we report a case with coronary artery anomaly complicated with ST segment myocardial infarction in both inferior and anterior walls simultaneously diagnosed during primary percutaneous coronary intervention.

Anomalous right coronary artery: case series and review of literature

Anomalous right coronary arteries (ARCA) are extremely rare in general population. Although mostly asymptomatic and recognized incidentally on cardiac catheterizations, they can be catastrophic and can cause sudden cardiac death. Sudden cardiac deaths are more common when the anomalous vessel runs an inter-arterial course between the aorta and the pulmonary artery. Asymptomatic patients with malignant course of anomalous coronaries can pose clinical dilemmas. Based on prior experience, management of asymptomatic ARCA with malignant course should be subjected to a risk-benefit analysis. This case series begins with a brief description of four separate cases of ARCA. They had their origin in the left coronary sinus or off left anterior descending artery (LAD). Three of them had anterior course between aorta and pulmonary trunk, confirmed by coronary CT angiography (CTA). Whereas two of our patients presented with chronic symptoms, two presented as acute cases with electrocardiographically proven STEMI. These cases were managed differently; by conservative, surgical or interventional approaches. All four cases had good final outcomes. This goes to show how different treatment options can be employed in management of complications associated with anomalous coronary arteries. It is also interesting to note that the radial access provides better guide support that is needed to tackle complex lesions. Many operators have been using radial approach for anomalous coronary interventions. We have successfully employed radial technique after failed trans-femoral attempts and also in STEMI situations. Based on our experience, right radial approach appears to be safer and quicker.

Myocardial ischemia due to a type IV dual LAD with the long LAD arising from the right sinus of valsalva: a case report and literature review

We herein report the case of a 60-year-old man who presented with chest discomfort. Coronary angiography demonstrated that the short left anterior descending artery (LAD) arose from the left main coronary artery and the long LAD from the right coronary sinus of Valsalva, which was confirmed by 64-slice multidetector computed tomography coronary angiography. Single-photon emission computed tomography revealed a significant, almost irreversible degree of hypoperfusion in the anterior wall of the left ventricle, thus indicating that the short LAD was associated with myocardial ischemia and severe atherosclerotic lesions. Therefore, SPECT showed that the myocardium was largely necrotic, and we did not perform angioplasty for the short LAD.

Presence of anomalous coronary seen on angiogram is not associated with increased risk of significant coronary artery disease

It is unclear if anomalous coronary arteries are at higher risk for atherosclerosis. The link between anomalous coronary artery and early coronary artery disease has been suggested. The aim of this study is to determine whether the coronary artery anomaly predisposes to development of significant coronary disease. Using retrospective chart review, patients with documented anomalous coronary arteries recognized during coronary angiography between years 2000 to 2007 were analyzed. Prevalence of significant atherosclerotic coronary artery disease (defined as more than 50% luminal narrowing) was compared between normal and anomalous coronaries. A total of 147 patients with anomalous coronary arteries were found. Right coronary artery was the most common anomalous artery 128 of 148 (86.5%) in our dataset. There was no difference in the occurrence of atherosclerosis between anomalous and nonanomalous coronaries. Significant atherosclerosis was present in 59 of the 148 anomalous coronary arteries (37.8%), and 112 of the 293 nonanomalous coronary arteries (38.2%, p = 0.9). On the basis of our study, there is no evidence that anomalous coronary arteries predispose to significant coronary artery disease in comparison to normal coronary arteries.

Anomalous origin of the right coronary artery with concomitant myxomatous mitral valve disease: a rare coexistence

A 45-year-old man previously diagnosed with myxomatous mitral valve disease was admitted to our hospital with chest pain at rest and on effort. Contrast-enhanced CT revealed that the patient's right coronary artery originated from the left sinus Valsalva, which was compressed between the aortic and pulmonary roots. This anatomical abnormality can be associated with sudden death, syncope and chest pain. Ultrasonography showed mitral valve prolapse with severe regurgitation. Surgical repair was performed, which included coronary artery bypass graft and mitral valvoplasty with tricuspid annuloplasty. The postoperative course was uneventful and the patient remains asymptomatic. This is the first description of the coexistence of an anomalous origin of the right coronary artery with myxomatous mitral valve disease.

Congenital coronary anomalies detected by coronary computed tomography compared to invasive coronary angiography

Background

As coronary computed tomography angiography (CCTA) has emerged as a non-invasive alternative for evaluation of coronary anatomy with a lower referral threshold than invasive coronary angiography (ICA), the prevalence of coronary anomalies in CCTA may more closely reflect the true prevalence in the general population. Morphological features of coronary anomalies can be evaluated more precisely by CCTA than by ICA, which might lead to a higher identification of congenital coronary anomalies in CCTA compared to ICA.

To evaluate the incidence, clinical and morphological features of the anatomy of patients with coronary anomalies detected either by coronary computed tomography angiography (CCTA) with prospective ECG-triggering or invasive coronary angiography (ICA).

Methods

Consecutive patients underwent 64-slice CCTA (n = 1′759) with prospective ECG-triggering or ICA (n = 9′782) and coronary anatomy was evaluated for identification of coronary anomalies to predefined criteria (origin, course and termination) according to international recommendations.

Results

The prevalence of coronary anomalies was 7.9% (n = 138) in CCTA and 2.1% in ICA (n = 203; p < 0.01). The most commonly coronary anomaly detected by CCTA was myocardial bridging 42.8% (n = 59) vs. 21.2% (n = 43); p < 0.01, while with ICA an absent left main trunk was the most observed anomaly 36.0% (n = 73; p < 0.01). In 9.4% (n = 13) of identified coronary anomalies in CCTA 9.4% were potentially serious coronary anaomalies, defined as a course of the coronary artery between aorta and pulmonary artery were identified.

Conclusion

The prevalence of coronary anomalies is substantially higher with CCTA than ICA even after exclusion of patients with myocardial bridging which is more frequently found with CCTA. This suggests that the true prevalence of coronary anomalies in the general population may have been underestimated based on ICA.

Coronary artery disease in congenital single coronary artery in adults: A Dutch case series

AIM: To assess the current diagnostic and therapeutic management and the clinical implications of congenital single coronary artery (SCA) in adults.

METHODS: We identified 15 patients with a SCA detected from four Dutch angiography centers in the period between 2010 and 2013. Symptomatic patients who underwent routine diagnostic coronary angiography (CAG) for suspected coronary artery disease and who incidentally were found to have isolated SCA were analyzed.

RESULTS: Fifteen (7 females) with a mean age of 58.5 ± 13.78 years (range 43-86) had a SCA. Conventional CAG demonstrated congenital isolated SCA originating as a single ostium from the right sinus of Valsalva in 6 patients and originating from the left in 9 patients. Minimal to moderate coronary atherosclerotic changes were found in 4, and severe stenotic lesions in another 4 patients. Seven patients were free of coronary atherosclerosis. Runs of non-sustained ventricular tachycardia were documented in 2 patients, one of whom demonstrated transmural ischemic changes on presentation. Myocardial perfusion scintigraphic evidence of transmural myocardial ischemia was found in 1 patient due to kinking and squeezing of the SCA with an interarterial course between the aorta and pulmonary artery. Multi-slice computed tomography (MSCT) was helpful to delineate the course of the anomalous artery relative to the aorta and pulmonary artery. Percutaneous coronary intervention was successfully performed in 3 patients. Eight patients were managed medically. Arterial bypass graft was performed in 4 patients with the squeezed SCA.

CONCLUSION: SCA may be associated with transient transmural myocardial ischemia and aborted sudden death in the absence of coronary atherosclerosis. The availability and sophistication of MSCT facilitates the delineation of the course of a SCA. We present a Dutch case series and review of the literature.

The prevalence of coronary anomalies in a single center of Korea: origination, course, and termination anomalies of aberrant coronary arteries detected by ECG-gated cardiac MDCT

Background

Coronary anomalies are rare congenital abnormalities often found incidentally on conventional coronary angiography (CCA) or coronary CT angiography (CTA). They may result in various clinical outcomes. CCA is invasive and not able to demonstrate all coronary anomalies in detail, especially those with complex courses. Multidetector computed tomography (MDCT) enables visualization of the origin and course of coronary arteries. The objective of this study was to investigate the prevalence of origin and termination coronary artery anomalies and the course of these anomalies in patients in a single center in Korea.

Methods

To diagnose coronary anomalies, the angiographic data of 8,864 consecutive patients undergoing 64- or 320-MDCT from September 2005 to November 2011 were analyzed retrospectively.

Results

Among the 8,864 patients, 103 (1.16%) had coronary anomalies. Ninety (87.4%) patients had origin and distribution anomalies, and 13 (12.6%) patients had a coronary artery fistula. The most common anomaly (41, 39.8%) was an anomalous origin of the right coronary artery (RCA). Of these, three patients received a coronary artery bypass graft.

Conclusions

The prevalence of coronary anomalies in a single center of Korea was 1.16%. The incidence and patterns of coronary artery anomalies in our patient population were similar to those of previous studies.

Aortic root disease in athletes: aortic root dilation, anomalous coronary artery, bicuspid aortic valve, and Marfan's syndrome

Two professional athletes in the U.S. National Basketball Association required surgery for aortic root dilation in 2012. These cases have attracted attention in sports medicine to the importance of aortic root disease in athletes. In addition to aortic root dilation, other forms of aortic disease include anomalous coronary artery, bicuspid aortic valve, and Marfan's syndrome. In this review, electronic database literature searches were performed using the terms "aortic root" and "athletes." The literature search produced 122 manuscripts. Of these, 22 were on aortic root dilation, 21 on anomalous coronary arteries, 12 on bicuspid aortic valves, and 8 on Marfan's syndrome. Aortic root dilation is a condition involving pathologic dilation of the aortic root, which can lead to life-threatening sequelae. Prevalence of the condition among athletes and higher risk athletes in particular sports needs to be better delineated. Normative parameters for aortic root diameter in the general population are proportionate to anthropomorphic variables, but this has not been validated for athletes at the extremes of anthropomorphic indices. Although echocardiography is the favored screening modality, computed tomography (CT) and cardiac magnetic resonance imaging (MRI) are also used for diagnosis and surgical planning. Medical management has utilized beta-blockers, with more recent use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and statins. Indications for surgery are based on comorbidities, degree of dilation, and rate of progression. Management decisions for aortic root dilation in athletes are nuanced and will benefit from the development of evidence-based guidelines. Anomalous coronary artery is another form of aortic disease with relevance in athletes. Diagnosis has traditionally been through cardiac catheterization, but more recently has included evaluation with echocardiography, multislice CT, and MRI. Athletes with this condition should be restricted from participation in competitive sports, but can be cleared for participation 6 months after surgical repair. Bicuspid aortic valve is another form of aortic root disease with significance in athletes. Although echocardiography has traditionally been used for diagnosis, CT and MRI have proven more sensitive and specific. Management of bicuspid aortic valve consists of surveillance through echocardiography, medical therapy with beta-blockers and ARBs, and surgery. Guidelines for sports participation are based on the presence of aortic stenosis, aortic regurgitation, and aortic root dilation. Marfan's syndrome is a genetic disorder with a number of cardiac manifestations including aortic root dilation, aneurysm, and dissection. Medical management involves beta-blockers and ARBs. Thresholds for surgical management differ from the general population. With regard to sports participation, the most important consideration is early detection. Athletes with the stigmata of Marfan's syndrome or with family history should be tested. Further research should determine whether more aggressive screening is warranted in sports with taller athletes. Athletes with Marfan's syndrome should be restricted from activities involving collision and heavy contact, avoid isometric exercise, and only participate in activities with low intensity, low dynamic, and low static components. In summary, many forms of aortic root disease afflict athletes and need to be appreciated by sports medicine practitioners because of their potential to lead to tragic but preventable deaths in an otherwise healthy population.

The anatomic basis for ventricular arrhythmia in the normal heart: what the student of anatomy needs to know

The traditional route for teaching cardiac anatomy involves didactic instruction, cadaver dissections, and familiarization with the main structure and relationships of the cardiac chambers, valves, and vasculature. In contemporary cardiac electrophysiology, however, a very different view of anatomy is required including details rarely appreciated with a general overview. In this review, we discuss the critical advances in cardiac electrophysiology that were possible only because of understanding detailed anatomic relationships. While we briefly discuss the clinical relevance, we explain in depth the necessary structural information for the student of clinical anatomy. Interspersed through the text are boxes that highlight and summarize the critical pieces of knowledge to be borne in mind while studying the fascinating structural anatomy of the human heart.

[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.

Multidetector computed tomography imaging of coronary artery anomalies

PURPOSE

The purpose of the study was to determine the prevalence of coronary artery anomalies and to demonstrate in which cases multidetector computed tomography has an additional clinical value compared with the conventional angiography.

MATERIAL AND METHODS

A total of 2375 multidetector computed tomography studies were retrospectively reviewed to determine the dominance of the coronary artery anomalies. The classification of coronary artery anomalies was made according to anatomical criteria--origin, course, intrinsic anatomy, and termination--and clinical relevance--benign versus malignant.

RESULTS

The coronary artery system was right dominant in 83.99%, left dominant in 8.0%, and co-dominant in 9.01% of the cases. The incidence of the origin and/or course anomalies was 1.76%, that of fistulas was 0.42%, and that of myocardial bridges was 10.82%. Multidetector computed tomography was performed after conventional angiography in 23 cases and it provided additional information regarding its origin and proximal course, as well as its relationship with the aortic root and main pulmonary trunk in 100% of the cases; eight malignant cases were found. In addition, in all of (100%) the six cases with coronary artery fistulas, conventional angiography failed to detect their terminations, which were clearly depicted by multidetector computed tomography.

CONCLUSION

Multidetector computed tomographic angiography is superior to conventional angiography in delineating the ostial origin and proximal course of anomalous coronary arteries. Furthermore, it reveals the exact relationship of anomalous coronary arteries with the aorta and the pulmonary artery. Anomalies of the intrinsic anatomy and the termination of coronary arteries are also better visualised with multidetector computed tomography.