[Congenital coronary artery anomalies with origin in the contralateral sinus of Valsalva: which approach should we take?]

Coronary artery bypass grafting experience in the setting of an anomalous origin of the right coronary artery from the left sinus of Valsalva: Midterm results

BACKGROUND

An anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva with an interarterial course is a rare congenital anomaly. We aimed to assess midterm results after coronary artery bypass grafting (CABG) for the treatment of anomalous RCA arising from the left sinus of Valsalva.

METHODS

From 2008 to 2012, 16 patients underwent CABG for treatment of an anomalous origin of the RCA from the left sinus of Valsalva. Details such as risk factors, operative details, and results of multislice coronary angiography follow-up were assessed.

RESULTS

The mean age of the patients was 34.8 ± 4.68 years, and most of them were male (15 out of 16, 93.75%). They received a mean of 1.5 ± 0.87 grafts. Closure of the RCA was completed in all patients except one (15 out of 16), who developed ischemic symptoms upon closing the proximal part of the RCA. One in-hospital death occurred. Among the remaining patients, symptoms persisted in 2 out of 15. The mean follow-up time was 63.4 ± 28.6 months. All patients had patent vessels on 5-year follow-up multislice computed tomography scans, except one patient who showed RCA graft occlusion on the 1-year follow-up scan.

CONCLUSION

The CABG of the RCA with anomalous origin can be done safely with excellent early and midterm results. Proximal RCA ligation is an essential step to the success of CABG, but intraoperative challenge testing is required to confirm the sufficiency of the internal thoracic artery graft to reperfuse the supplied territory.

A case report of intramyocardial bridge on right coronary artery

Intramyocardial bridges are a coronary circulation anomaly. They usually occur on the path of the anterior descending artery and are classified as superficial or deep. During a routine autopsy, we found—and report—an intramyocardial bridge in large part of the right coronary artery pathway, including the sinoatrial and posterior descending branch. The patient did not show signs of coronary insufficiency, and died from an acute respiratory failure caused by aspiration pneumonia. Due to the infrequency of cases of intramyocardial bridges of the right coronary artery without concomitant clinical symptoms or signs, we conducted a literature review in this regard.

Overview of coronary artery variants, aberrations and anomalies

Coronary artery anomalies and variants are relatively uncommon congenital disorders of the coronary artery anatomy and constitute the second most common cause of sudden cardiac death in young competitive athletes. The rapid advancement of imaging techniques, including computed tomography, magnetic resonance imaging, intravascular ultrasound and optical coherence tomography, have provided us with a wealth of new information on the subject. Anomalous origin of a coronary artery from the contralateral sinus is the anomaly most frequently associated with sudden cardiac death, in particular if the anomalous coronary artery has a course between the aorta and the pulmonary artery. However, other coronary anomalies, like anomalous origin of the left coronary artery from the pulmonary artery, atresia of the left main stem and coronary fistulae, have also been implicated in cases of sudden cardiac death. Patients are usually asymptomatic, and in most of the cases, coronary anomalies are discovered incidentally during coronary angiography or on autopsy following sudden cardiac death. However, in some cases, symptoms like angina, syncope, heart failure and myocardial infarction may occur. The aims of this article are to present a brief overview of the diverse coronary variants and anomalies, focusing especially on anatomical features, clinical manifestations, risk of sudden cardiac death and pathophysiologic mechanism of symptoms, as well as to provide valuable information regarding diagnostic workup, follow-up, therapeutic choices and timing of surgical treatment.

Congenital anomalies of the coronary arteries

Congenital coronary artery anomalies are modifications of their origin, course or structure and its incidence varies between 0,2 and 5,6% of the general population. Although the majority is asymptomatic, they are the second leading cause of sudden cardiac death in young athletes. The aim of this study is to highlight the main anomalies with hemodynamic significance, including the anomalous origin of a coronary artery from the opposite sinus and anomalous origin of the left coronary artery from pulmonary artery. The anomalous aortic origin of a coronary artery from the opposite sinus accounts for 14-16% of all cardiac deaths, that unexpectedly occur in healthy children or young athletes during or immediately after exercise. The mechanism responsible for the compression/occlusion of the coronary artery originating from the opposite sinus is still unclear and there are several proposed mechanisms. The clinical presentation of these patients is variable and physical examination is normal in most individuals. Transthoracic echocardiogram is the diagnostic test most commonly used. Treatment and management are controversial topic. The anomalous origin of the left coronary artery from pulmonary artery is a very rare condition and without surgery, most infants die within the first 12 months of life. The echocardiogram is also the method of choice for diagnostic confirmation. The diagnosis of this congenital anomaly in an infant, usually seriously ill, is an indication for urgent surgery. Because these anomalies produce hemodynamic changes, it is important an early diagnosis and treatment.

ST elevation myocardial infarction in patients with anomalous left main coronary artery: Case series and review of the literature

Anomalous left main coronary artery is rare. We present four cases where anomalous left main coronary artery was diagnosed during emergent cardiac catheterization for ST elevation myocardial infarction. Procedural characteristics, technical challenges, and relevant literature are discussed.

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 Origination of Right Coronary Artery from Left Sinus in Asymptomatic Young Male Presenting with Positive Ischemic Response on Treadmill Test

Anomalous origination of coronary artery from the opposite sinus (ACAOS) is a rare coronary artery anomaly. Right ACAOS with interarterial course is a type of ACAOS, which conveys a high risk for myocardial ischemia or sudden death. We reported a case of right ACAOS with interarterial course in otherwise healthy young male. He was asymptomatic, until an obligatory medical check-up with treadmill test showed a sign of positive ischemic response. Further work-up revealed that he had right ACAOS with interarterial course. Watchful observation was applied to him, while strenuous physical activity and competitive sport were absolutely prohibited.

[Single coronary artery and right aortic arch]

Coronary anomalies are mostly asymptomatic and diagnosed incidentally during coronary angiography or echocardiography. However, they must be taken into account in the differential diagnosis of angina, dyspnea, syncope, acute myocardial infarction or sudden death in young patients. The case is presented of two rare anomalies, single coronary artery originating from right sinus of Valsalva and right aortic arch, in a 65 year-old patient with atherosclerotic coronary artery disease treated percutaneously.

Usefulness of echocardiography in preparticipation screening of competitive athletes

INTRODUCTION AND OBJECTIVES

Despite the established diagnostic value of the electrocardiogram in preparticipation screening of athletes, some cardiac structural changes can be missed, particularly in early disease stages. The aim of this study was to evaluate the prevalence of cardiac structural changes via the systematic use of echocardiography in preparticipation screening of competitive athletes.

METHODS

Professional athletes or participants in a competitive athletic program underwent a screening that included family and personal medical history, physical examination, electrocardiography, exercise testing, and Doppler echocardiography.

RESULTS

A total of 2688 athletes (67% men; mean age [standard deviation], 21 [10] years) were included. Most of the echocardiographic evaluations (92.5%) were normal and only 203 (7.5%) showed changes; the most frequent change was left ventricular hypertrophy, seen in 50 athletes (1.8%). Cessation of athletic activity was indicated in 4 athletes (0.14%): 2 for hypertrophic cardiomyopathy (electrocardiography had shown changes that did not meet diagnostic criteria), 1 pectus excavatum with compression of the right ventricle, and 1 significant pulmonary valve stenosis; the rest of the changes did not entail cessation of athletic activity and only indicated periodic monitoring.

CONCLUSIONS

Although rare, some cardiac structural changes can be missed on physical examination and electrocardiography; in contrast, they are easily recognized with echocardiography. These findings suggest the use of echocardiography in at least the first preparticipation screening of competitive athletes to improve the effectiveness of programs aimed at preventing sudden death in athletes.

Percutaneous Intervention in a single coronary artery: evaluation of multislice tomography and its feasibility

The presence of only a single coronary artery is a rare congenital coronary artery anomaly. In most cases, it is an incidental finding on coronary angiography and has no clinical significance. However, it can cause angina, myocardial infarction or even sudden death, particularly in young patients in whom the course of the artery runs between the aorta and pulmonary artery. In such cases, angiographic assessment may be difficult. Multislice coronary computed tomography might be better for visualizing the anatomy of the coronary artery tree in these patients. This article describes the cases of three patients with a single coronary artery and associated atherosclerotic coronary artery disease in whom a diagnosis was made using coronary angiography and multislice computed tomography.

Congenital coronary arteries anomalies: review of the literature and multidetector computed tomography (MDCT)-appearance

The prevalence of coronary arteries congenital anomalies is 1 to 2% in the general population. Although the spectrum of their clinical manifestations is very broad from total inocuity to lethal, anomalies of coronary arteries need to be recognized by clinicians in certain circumstances: they are the first cause of death in young adults under physical exercise and an abnormal course of a coronary artery can complicate a cardiac surgery. Therefore, a non-invasive test is highly suitable for detecting anomalies of coronary arteries and multidetector computed tomography (MDCT) is likely to be the best one. To understand how anomalies of coronary arteries may occur, we have reviewed the recent literature about their development. Then, the main types of anomalies are presented with their clinical context, and representative MDCT images from our personal database are used for illustration.