Anomalous origins of the coronary arteries: current knowledge and future perspectives

Hypoplastic and Congenital Absence of Coronary Arteries and Its Correlation with Clinical Implications of Cardiac Circulation: A Systematic Review and Meta-Analysis

Background: Coronary arteries originate from the first portion of the aorta, emerging from the right and left aortic sinuses. They traverse through the subepicardium and coronary sulcus to supply the myocardium during diastolic function. The objective of this review was to understand how the hypoplasia and agenesis of the coronary arteries are associated with cardiac pathologies. Methods: The databases Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS were researched until January 2024. An assurance tool for anatomical studies (AQUA) was used to evaluate methodological quality. The pooled prevalence was estimated using a random effects model. Results: A total of three studies met the established selection criteria for inclusion in this meta-analysis. The prevalence of coronary artery variants was 3% (CI = 2% to 8%), with a heterogeneity of 77%. The other studies were analyzed descriptively, along with their respective clinical considerations in the presence of the variant. Conclusions: Hypoplasia and the congenital absence of the coronary arteries are often incidental findings and understanding these variants is crucial to prevent misdiagnosis. Additionally, it is essential to exercise caution when considering surgical management for hearts with these variants.

Anomalous origin of the left coronary artery from the pulmonary artery as a rare cause of mitral valve prolapse: a case report

BACKGROUND

 Mitral valve prolapse (MVP) is an etiologically heterogeneous disorder. Early diagnosis and prompt treatment of the underlying disease are of great significance. Herein, we present a rare case of MVP caused by anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).

CASE PRESENTATION

A 22-year-old female presented with a 16-year history of anterior mitral leaflet prolapse. However, she had never experienced any discomfort before. At a routine follow-up, a transthoracic echocardiogram showed anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation, and a retrograde blood flow from an extremely dilated left coronary artery (LCA). Further coronary angiography and coronary computed tomography angiography confirmed the diagnosis of ALCAPA. She subsequently underwent successful LCA reimplantation and concomitant mitral valve replacement. Intraoperatively, her mitral annulus was mildly dilated, anterior mitral valve leaflet appeared markedly thickened with rolled edges, and a chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened.

CONCLUSIONS

ALCAPA is a rare and potentially life-threatening congenital coronary artery anomaly that may cause mitral valve prolapse. Echocardiogram is an important screening tool for this disorder.

Intravascular ultrasound-guided stent implantation in reimplanted left main coronary artery of a 15-year-old child: a case report

BACKGROUND

Only a few cases have been reported about clinical value of percutaneous coronary intervention (PCI) and intravascular ultrasound (IVUS) in patients with stenosis of a re-implanted left main coronary artery (LMCA).

CASE SUMMARY

We herein report a rare case of restenosis after direct reimplantation of an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in a 15-year-old girl. At the first evaluation, she had mildly reduced systolic dysfunction with left ventricular ejection fraction of 47%. Three months after surgical repair, the patient developed recurrent precordial pain. Consequent imaging tests and IVUS revealed a restenosis of the LMCA characterized as an attenuated plaque with a large plaque burden. A drug-eluting stent was implanted with IVUS guidance. Follow-up revealed a patent LMCA and preserved systolic function.

DISCUSSION

The current case demonstrated that IVUS-guided PCI can be feasible in the treatment of coronary artery stenosis after repair of an ALCAPA. Further study is needed to explore the pathophysiological mechanism of this condition and the clinical value of PCI and IVUS in patients with stenosis of the LMCA.

Tetralogy of fallot in addition to anomalous aortic origin of a coronary artery in a 1-year-old boy: a case report

Background

Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital heart disease, characterized by the coronary artery inappropriately originates from the aorta. It is usually classified according to the sinus where the coronary artery arises from, while anomalous origin of the right coronary being the most common type.

Case presentation

In this case report, we described a rare case of Tetralogy of Fallot (TOF) in a 1-year-old boy, who also had the anomalous right coronary artery that originated from the left coronary sinus without an intramural segment. Besides TOF repair, lateral pulmonary translocation was undertaken in order to avoid risks of myocardial ischemia.

Conclusion

We successfully completed a one-stage operation consisting of TOF repair and pulmonary artery translocation in a 1-year-old boy. We advocated early operation of pulmonic translocation for AAOCA patients without an intramural segment instead of unroofing procedure.

Anomalous Coronary Arteries: When to Follow-up, Risk Stratify, and Plan Intervention

PURPOSE OF REVIEW

Coronary artery anomalies are a diverse group of entities, ranging from benign variations of normal anatomy to life-threatening conditions. There is, however, no universal consensus in their classification, risk stratification, and management. The aim of this review is to develop a straightforward clinical approach for the assessment and care of patients with anomalous coronary arteries.

RECENT FINDINGS

Autopsy series and population screening studies have recently provided useful clinical data on the prevalence and outcomes of coronary anomalies. Also, findings on coronary computed tomography angiography, magnetic resonance imaging, and invasive angiography, enriched with fractional flow reserve and intravascular ultrasound, have allowed identification of several high-risk features associated with specific coronary anomalies. Management of patients with anomalous coronary arteries requires an individualized approach based on clinical, physiological, and anatomic features. High-quality studies are paramount for further development of this fascinating field.

CT evaluation of unrepaired/incidental congenital cardiovascular diseases in adults

Congenital heart disease (CHD) affects approximately one million people in the USA with the number increasing by 5% each year. Patients are usually both diagnosed and treated in infancy, however many of them may have subclinical CHD that remains undiagnosed until late adulthood. Patients with complex CHD tend to be symptomatic and are diagnosed at a younger age than those with a single defect. CHDs can be divided into three categories, including cardiac, great vessels and coronary artery anomalies. Recent advances in computed tomography (CT) technology with faster acquisition time and improved spatial resolution allow for detailed evaluation of cardiac morphology and function. The concomitant increased utilization of CT has simultaneously led to more sensitive detection and more thorough diagnosis of CHD. Recognition of and understanding the imaging attributes specific to each anomaly is important for radiologists in order to make a correct and definite diagnosis. This article reviews the spectrum of CHDs, which persist into adulthood that may be encountered by radiologists on CT.

Anomalous origin of the left coronary artery from the right aortic sinus: probably benign variant associated with a subpulmonic intramyocardial course - a case report

BACKGROUND

Anomalous aortic origin of the left coronary artery (AAOLCA) from the right aortic sinus is a rare congenital anomaly associated with significantly increased risk of myocardial ischemia, arrhythmias and sudden cardiac death. This refers specifically to AAOLCA associated with interarterial and/or intramural course. Much less is known about anomalous origin of the left coronary artery from the right aortic sinus associated with a subpulmonic intramyocardial course.

CASE PRESENTATION

We report a 12 year old girl who complained of recurrent episodes of chest pain lasting for some minutes and not associated to exercise. Echocardiography revealed AAOLCA from the right aortic sinus taking a subpulmonic course within the conal septum. The diagnosis was confirmed by CT-scan and selective coronary angiography. Treadmill test, Holter-ECG and bicycle-stress echocardiography revealed no evidence of myocardial ischemia reflecting unimpaired diastolic flow in the left coronary artery. According to the nature of the complaints and in the absence of signs of myocardial ischemia the episodes of chest pain were classified as idiopathic and not associated to the coronary anomaly. We opted for a conservative approach with regular follow-up visits. During a follow-up of 2 years without restriction of sports activities the patient has been asymptomatic.

CONCLUSION

According to the literature AAOLCA with subpulmonary intramyocardial course appears to be associated with significantly less clinical problems than AAOLCA taking an interarterial course. The diagnosis can be suspected based on echocardiography and confirmed by contrast-enhanced computed tomography. Until now there are only few data concerning the natural history and incidence of complications in this specific anomaly. Despite the probably benign nature we recommend regular follow-up examinations including stress-testing in these patients.