Anomalous origin of the right coronary artery from the left sinus of Valsalva

Coronary anomaly and coronary artery fistula as cause of angina pectoris with literature review

Coronary artery fistulas are rare anomalies of the coronary arteries that may sometimes cause symptoms by shunting blood flow away from the myocardial capillary network. We report the case of a 46-year old lady which shows the right coronary cusp giving rise to left main coronary artery called anomalous origin of a coronary artery (AOCA), and also a fistula between the left coronary artery and pulmonary artery. We describe our diagnostic approach and review the literature on the epidemiology, pathophysiology, the diagnostic modalities, and treatment options.

Congenital coronary artery anomalies

Congenital coronary artery anomalies are rare but can carry a significant risk of myocardial ischemia, myocardial dysfunction, congestive heart failure, and sudden death. This risk seems to be highest during childhood and adolescence; therefore, an understanding of these anomalies is important for the pediatrician and pediatric cardiologist. This article focuses on the anatomic features, mode of presentation, diagnostic findings, and surgical treatments that are available for the two most common types of isolated congenital coronary anomalies that are associated with myocardial ischemia during childhood: (1) anomalous origin of a coronary artery from the opposite sinus of Valsalva with an interarterial course between the great arteries and (2) anomalous origin of a coronary artery from the pulmonary artery. A brief discussion of coronary artery fistulous connections completes the article.

Prospective echocardiographic diagnosis and surgical repair of anomalous origin of a coronary artery from the opposite sinus with an interarterial course

OBJECTIVES

In this study, we sought to describe the mode of presentation, anatomic features, diagnostic techniques, and surgical outcome in a group of patients with anomalous origin of a coronary artery from the opposite sinus with an interarterial course between the great arteries (AOCA).

BACKGROUND

Anomalous origin of a coronary artery from the opposite sinus with an interarterial course is associated with myocardial ischemia and sudden cardiac death, particularly in adolescents and young adults.

METHODS

The cardiology database at Children's Hospital of Wisconsin was reviewed to identify all patients diagnosed with AOCA.

RESULTS

From September 1997 to August 2002, 10 patients were identified with AOCA; all were children/adolescents (age range, 3 months to 20 years; weight range, 4.7 to 72 kg), and nine were diagnosed prospectively by transthoracic echocardiography (TTE). Symptoms of cardiac ischemia initiated investigation in 4/10 patients at a mean age of 16 +/- 2.8 years; the other six had TTE for suspected congenital heart disease/musculoskeletal chest pain. The left coronary artery originated from the right sinus in six patients, and the right coronary artery originated from the left sinus in four patients. An intramural course of the AOCA within the anterior aortic wall was found in 9/10 patients and was reliably identified by TTE; the other patient had an intramyocardial course of the anomalous coronary. Surgical repair was performed in 8/10 patients at a mean age of 13 +/- 4.7 years. Unroofing of the intramural portion of the AOCA to relocate the ostia in the appropriate sinus was successfully performed in seven patients. All patients status post unroofing were asymptomatic with patent coronary flow by Doppler and normal exercise treadmill testing at a median follow-up interval of 1.5 years.

CONCLUSIONS

Anomalous origin of a coronary artery from the opposite sinus with an interarterial course is frequently characterized by an intramural course, which can be prospectively identified by TTE. Unroofing the intramural segment without bypass grafting can reliably repair the intramural form of AOCA.

Failure to diagnose congenital heart disease in infancy

OBJECTIVE

To identify factors that predict failure to diagnose congenital heart disease in newborns.

DESIGN

All fatal cases in the Baltimore-Washington Infant Study were compiled. The Baltimore-Washington Infant Study includes 4390 cases of infants with congenital cardiovascular malformations identified in a population-based study between 1981 and 1989 in the Baltimore-Washington metropolitan area. Death occurred in 800 such infants in the first year of life. In 76 of these infants, death occurred before diagnosis of heart disease. These cases were identified by community search of autopsy records. Their characteristics are compared with those of infants who died after a cardiac diagnosis was made.

RESULTS

Infant characteristics (birth weight, gestational age, intrauterine growth retardation, and chromosomal anomaly) are associated with death of infants with congenital cardiovascular malformations and with death of such infants before diagnosis. Diagnoses of coarctation of the aorta, Ebstein's anomaly, atrial septal defect, and truncus arteriosus are overrepresented in infants found by community search, particularly in those infants without associated malformations. Paternal education is associated with failure to diagnose congenital heart disease in life but other sociodemographic characteristics of the infant's family are not.

CONCLUSIONS

Diagnosis of congenital cardiovascular malformations requires close observation in the neonatal period. Analysis of age at death of infants with undiagnosed congenital cardiovascular malformation suggests that such infants may be at risk if discharged within the first 2 days of life.

Anomalous origin of the right coronary artery from the left sinus of valsalva: transthoracic echocardiographic diagnosis

Anomalous origin of the right coronary artery from the left sinus of Valsalva is a rare congenital defect that can be difficult to diagnose by echocardiography. We describe an infant with a ventricular septal defect that was diagnosed prospectively by transthoracic echocardiography as an anomalous origin of the right coronary artery from the left sinus of Valsalva. Subcostal imaging and Doppler color flow mapping were instrumental in the echocardiographic diagnosis of this unusual coronary abnormality.