Clinical consequences of anomalous coronary arteries

Relationship between impaired repolarization parameters and poor cardiovascular clinical outcomes in patients with potentially serious coronary artery anomalies

BACKGROUND

Congenital coronary artery anomalies (CCAAs) have the potential for life-threatening complications, including malignant ventricular arrhythmias and sudden cardiac death (SCD). In this study, we aimed to evaluate the relationship between impaired repolarization parameters and poor cardiovascular clinical outcomes in patients with potentially serious CCAAs.

METHODS

This retrospective study included 85 potentially serious CCAA patients (mean age: 54.7 ± 13.6 years; male:44) who were diagnosed with conventional and coronary computed tomography angiography (CCTA). All patients underwent transthoracic echocardiography and 12-lead surface electrocardiography. Cardiac events were defined as sustained ventricular tachycardia or fibrillation, syncope, cardiac arrest and SCD.

RESULTS

The presence of interarterial course (IAC) was confirmed by CCTA in 37 (43.5%) patients. During a median follow-up time of 24 (18-50) months, a total of 11 (12.9%) patients experienced cardiac events. The presence of IAC was significantly more frequent and Tp-e interval, Tp-e/QTc ratio and frontal QRS/T angle (fQRSTa) were significantly greater in patients with poor clinical outcomes. Moreover, the presence of IAC, high Tp-e/QTc ratio and high fQRSTa were found to be independent predictors of poor clinical outcomes and decreased long-term cardiac event-free survival in these patients. A net reclassification index was +1.0 for the Tp-e/QTc ratio and +1.3 for fQRSTa which were confirmable for additional predictability of these repolarization abnormalities.

CONCLUSION

Impaired repolarization parameters, including wider fQRSTa, prolonged Tp-e interval, and increased Tp-e/QTc ratio, and IAC may be associated with poor cardiovascular clinical outcomes in potentially serious CCAA patients.

Woven-like change following intracoronary thrombosis recanalization: a case report

Background

A woven coronary artery is a rare congenital coronary anomaly and incidentally found in coronary angiogram. Coronary angiography is the major diagnostic modality, which shows the main trunk of coronary divides into several channels which later reconnect with normal blood flow (J Int Cardiol 113:121-123 2006). However, some cases and reviews inferred that this characteristic might be mimicked by recanalized coronary thrombus, which occurs following thrombotic occlusion. In some case, the multiple intraluminal channels have a ‘Swiss cheese’, a ‘Spider web-like’, a ‘Honeycomb’ or a ‘Lotus root’ appearance and most of them appear in local segment (Int J Cardiol 186: 239–240, 2015). As these images are nonspecific findings, there is no angiographic uniform definition of intracoronary thrombus. More information about the characteristics and the development of this woven-like structure is needed.

Case presentation

A 67-year-old male patient was admitted to our hospital because of chest pain. Coronary artery angiogram revealed that the right coronary artery (RCA) divided into multiple thin channels from proximal to distal, which was similar to the so-called woven coronary artery. Compared with his prior coronary angiograms which showed a tiny hazy lesion in distal segment of RCA, we found the woven-like phenomena should be caused by a late-stage recanalized coronary thrombus. Percutaneous coronary intervention (PCI) was performed to restore the RCA flow, and the angina symptom was extremely improved during clinical follow-up.

Conclusions

The diagnostic criteria of woven coronary artery was based on angiographic image. However, some cases and reviews inferred that thrombotic recanalization might also share the same characteristic. In this case, we collected the baseline angiograms and intracoronary images then successfully diagnosed the woven-like RCA as thrombotic recanalization. For this kind of woven-like coronary artery, PCI could be a better treatment strategy. Detailed history collection and intracoronary image techniques should be emphasized in future clinical practice in the differentiating and treatment of woven-like phenomena.

Woven coronary artery anomaly presenting as sudden cardiac death

Woven coronary artery is a rare anomaly characterized by thin channels arising from the coronary artery and reanastomosing at the distal arterial segment. To our knowledge, no data are available currently on the histologic structure of the woven segment. A 39-year-old man presented with sudden atypical chest pain while he was practicing cycling. During the transfer of the patient to the hospital, he suffered cardiac arrest. After 50 min of cardiopulmonary resuscitation, the patient could not return to sinus rhythm and died. At autopsy, the patient presented a woven right coronary artery associated with an old myocardial infarct of the posterior wall of the left ventricle. We describe for the first time a case of woven coronary artery associated with sudden death. This case allowed us to study the histopathology of the channels that make up the malformation. These showed well-conformed walls with absence of breaches. A complete review of the literature on the subject is included.

The clinical anatomy of the coronary arteries

There are a manifold number of variations and anomalies of the origin and course of coronary arteries described in the literature. The incidence of such variations in the general population is reported to range between 0.3 and 1.6 %. Although uncommon, they may be benign or produce symptoms ranging from mild dyspnea to sudden cardiac death, and have been associated with an increased risk of accelerated atherosclerosis and perfusion defects. Thus, in order to effectively utilize the increasing number of therapeutic options available for treating coronary artery diseases, an appreciation of the likely normal and variable arrangements of the coronary arteries is essential. This review will describe the normal anatomy of the coronary arteries as well as the common variations with potential clinical effects.

An infant with respiratory distress

Infants with previously undiagnosed cardiac conditions may present to the emergency department with nonspecific signs and respiratory symptoms. These patients may be erroneously diagnosed as having bronchiolitis. We report a 2-month-old female infant who presented with respiratory distress and showed no improvement with nebulized albuterol treatment. This infant was found to have anomalous origin of the left coronary artery from the pulmonary artery.

Coronary artery anomalies diagnosed by magnetic resonance angiography

Coronary artery anomalies are uncommon entities that may be associated with sudden death. Because of its 2-D projection imaging nature, conventional X-ray coronary angiography may not accurately delineate the origins and course of aberrant coronary arteries with respect to the great vessels. Non-invasive, cross-sectional imaging techniques such as coronary CT angiography and magnetic resonance angiography are increasingly used in clinical practice to diagnose coronary artery anomalies. Although this study reviews coronary artery anatomy and selected anomalies as seen with true fast imaging with steady-state precession magnetic resonance angiography, the information provided is equally applicable to electrocardiogram-gated coronary CT angiography.

Cardiovascular disease in athletes

Cardiovascular disease (CVD) is the leading cause of death in the United States, resulting in increased awareness of the preventive importance of regular physical activity. Because athletes are considered physically fit, occurrence of sudden athlete death from CVD is perplexing. Regular intense physical activity can cause changes to the cardiovascular system that mimic known CVD processes. Therefore, screening of athletes for conditions that may increase risk for sudden cardiac death (SCD) is challenging. This article focuses on this problem, discussing the athlete's heart, SCD and associated CV conditions, and preparticipation screening. We also review recommendations of the 26th Bethesda Conference on determining eligibility for competition in athletes with known CV abnormalities, and how the recommendations relate to individual disease processes.