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

Congenital absence of right coronary artery: a rare coronary anomaly: case report

Single coronary artery is a rare congenital anomaly in which a single coronary artery arises from the aortic root that supplies the entire heart. It has variable clinical presentations ranging from a completely benign course to sudden cardiac death. Identifying and categorizing to high-risk type based on clinical presentation and anatomical features can present adverse cardiac events and provides better prognosis.

Coronary Artery Anomalies - State of the Art Review

Coronary artery anomalies (CAAs) comprise a wide spectrum of anatomic entities, with diverse clinical phenotypes. We present a case of an anomalous right coronary artery arising from the left aortic sinus with an interarterial course, a potentially fatal condition that can precipitate ischemia and sudden cardiac death. CAAs are increasingly detected in adults, mostly as incidental findings in the course of cardiac evaluation. This is due to the expanding use of invasive and noninvasive cardiac imaging, usually in the work-up for possible CAD. The prognostic implications of CAAs in this group of patients remain unclear. In AAOCA patients, appropriate work-up with anatomical and functional imaging should be performed for risk stratification. An individualized approach to management should be adopted, considering symptoms, age, sporting activities and the presence of high-risk anatomical features and physiologic consequences (such as ischemia, myocardial fibrosis, or cardiac arrhythmias) detected on multimodality imaging or other functional cardiac investigations. This comprehensive and up to date review seeks to crystallize current data in the recent literature, and proposes a clinical management algorithm for the clinician faced with the conundrum of managing such conditions.

Single coronary artery diagnosed in the perinatal period: A case report

OBJECTIVE

Having a single coronary artery (SCA) is a rare congenital anomaly in which a single artery arises from the aorta. Although most cases of SCA are asymptomatic and incidental, its effects during the perinatal period remain unknown. Herein, we report a case of pregnant woman with suspected SCA, based on transthoracic echocardiography (TTE) findings.

CASE REPORT

A 33-year-old multiparous woman presented with preterm premature rupture of the membrane at 29 weeks gestation. The patient's preoperative electrocardiogram (ECG) showed slight ST changes. TTE showed dilated right coronary artery and hypoplastic left coronary artery. Cesarean section was performed at 30 weeks of gestation due to non-reassuring fetal status. Although poor oxygenation was observed postoperatively, the patient was managed appropriately. She was diagnosed with SCA based on coronary computed tomographic angiography findings one month after delivery.

CONCLUSION

Pregnant women with SCA require careful perinatal care.

Diagnosis and demonstration of single coronary artery by multidetector CT angiography: series of two cases

Background

Single coronary artery (SCA) is a rare anomaly, usually diagnosed incidentally during coronary artery angiogram. Individuals with this anomaly mostly remain asymptomatic while some present with symptoms such as chest pain, dyspnoea and even sudden death. The origin and the proximal course of anomalous coronary artery are the main prognostic factors. Several classification systems have been proposed based on the site of origin and anatomical distribution of anomalous artery. Coronary computed tomography angiography has become the reference method for such an assessment noninvasively. Herein, we report a series of two cases of SCA diagnosed on CT angiography. In one case it was single left coronary artery associated with other congenital cardiac anomalies, whereas in other it was single right coronary artery and was an isolated anomaly.

Case presentation

Our first case was of a 19-year-old female who presented with chest pain and dyspnoea. Transthoracic Echocardiography (TTE) features were suggestive of Tetralogy of Fallot (TOF) with infective endocarditis. Cardiac CT angiography revealed the presence of a large SCA arising from left aortic sinus with absence of normal origin of right coronary artery (RCA). This artery was dividing into and supplying different coronary arterial territories with pre-pulmonic course of RCA. The patient underwent Aortic valve replacement with pulmonary Commissurotomy and improved in post-operative period. Our second case was of a 50-year-old man with complaints of breathlessness and normal ECG and Echocardiography examination findings. Coronary CT angiography revealed the presence of SCA arising from right aortic sinus and supplying the territories of both RCA and Left coronary artery (LCA). The patient was managed conservatively with emphasis on aggressive control of risk factors.

Conclusions

SCA is a rare anomaly and may lead to catastrophic life threatening complications. The accurate delineation of the origin and course of the anomalous vessel is of paramount importance while planning surgical intervention. Management usually involves a multi-disciplinary approach with cardiologists and cardiac surgeons aiming for deciding an individual plan based on presentation and anatomy of each case.

Coronary Artery Anomalies

Coronary artery anomalies (CAAs) are a group of congenital conditions characterized by abnormal origin or course of any of the 3 main epicardial coronary arteries. Although CAAs have been identified as a common underlying condition in young athletes with sudden cardiac death, the widespread use of invasive and noninvasive coronary imaging has led to increased recognition of CAAs among adults. CAAS are often discovered as an incidental finding during the diagnostic workup for ischemic heart disease. The clinical correlates and prognostic implication of CAAs remain poorly understood in this context, and guideline-recommended therapeutic choices are supported by a low level of scientific evidence. Several studies have examined whether assessment of CAA-related myocardial ischemia can improve risk stratification in these patients, suggesting that multimodality imaging and functional tests may be key in the management of CAAs. The aim of this review is to outline definitions, classification, and epidemiology of the most relevant CAAs, highlighting recent advances and the potential impact of multimodality evaluation, and to discuss current therapeutic opportunities.

Case Report: Congenital Coronary Artery Ring With Single Left Coronary Ostium and Fistula: A Previously Unreported Anatomy

Background: Single coronary ostium concomitant with coronary artery fistula is a very rare congenital anomaly. Apart from that, the combination of a closed loop of the coronary artery has never been reported. Case presentation: Herein, we present a 7-year-old girl diagnosed as single left coronary ostium with a giant coronary trunk, coronary artery to right ventricle fistula, and coronary artery ring. The coronary fistula was surgically ligated with off-pump strategy and the patient discharged on postoperative day 5 and free of symptoms during the 3 years of follow-up. Conclusion: To our knowledge, the presented congenital coronary anomaly is the first to be reported in the literature with the name of congenital coronary artery ring with single left coronary ostium and fistula.

A Rare Anatomical Variant: Congenital Absence of the Right Coronary Artery with Left Circumflex Artery Supplying the Right Coronary Artery (RCA) Territory

Patient: Female, 66-year-old

Final Diagnosis: Coronary artery anomalies

Symptoms: Chest discomfort • shortness of breath

Medication: —

Clinical Procedure: Coronary angiography

Specialty: Cardiology

Left anterior descending/right coronary artery bifurcation angioplasty in a rare case of single coronary artery: a case report

Background

Single coronary artery (SCA) is a rare congenital coronary anomaly with incidence of 8–66 per 100 000 cases. Percutaneous coronary intervention (PCI) in patients with SCA is technically challenging. This is a case of bifurcation angioplasty involving left anterior descending/right coronary artery (LAD/RCA) in a patient with SCA and 1-year follow-up with computed tomography coronary angiography (CTCA).

Case summary

A 52-year-old female with history of PCI to LAD 4 months back, presented with non-ST-elevation myocardial infarction. Coronary angiogram showed 90% stenosis in mid-LAD, distal to the previous stent and proximal to an anomalously originating RCA from mid-LAD. She was planned for LAD/RCA provisional bifurcation angioplasty and a drug-eluting stent was deployed in LAD across RCA, following which patient developed angina with ischaemic electrocardiogram (ECG) changes due to significant pinching of RCA. Using Reverse crush technique, RCA was stented successfully with resolution of angina and ECG changes. At 1-year follow-up, patient is in New York Heart Association class I with normal left ventricular function and patent LAD/RCA bifurcation stent on CTCA.

Discussion

SCA poses a great challenge to interventional cardiologists during PCI, especially in the event of a complication. Detailed anatomical knowledge, appropriate hardware and operator expertise are the key factors for successful PCI of SCA. This is, to the best of our knowledge, the first case report of bifurcation angioplasty of LAD/RCA in a rare case of SCA. This case also describes the use of reverse crush technique as a bailout strategy during provisional bifurcation angioplasty.

Percutaneous Coronary Revascularization in Patients With Single Coronary Artery

INTRODUCTION

Single coronary artery (SCA) is a rare congenital coronary anomaly. Its incidence in various angiographic series is from 0.024% to 0.066%. Percutaneous coronary intervention (PCI) of coronary artery disease (CAD) in these patients is technically challenging.

METHODS

We retrospective analyzed the cardiac catheterization procedures of last 15 years and found 12 cases of SCA (incidence 0.084%). To determine the course of anomalous coronaries, angiographic "dot and eye" method and computed tomography (CT) were used. The course of the SCA was classified as per the modified Lipton criteria. PCI was performed as per the standard protocol for a significant epicardial coronary artery stenosis.

RESULTS

Out of total 12 patients of SCA, 9 patients had PCI of significant CAD. The mean age of 9 PCI patients was 63.8 ± 8.2 years (5 males, 4 females). The origin of the SCA was from the right sinus of Valsalva in 6 cases and from left sinus of Valsalva in 3 cases. Eleven successful PCI procedures were performed, which included PCI of left main, coronary bifurcation lesion, chronic total occlusion, and multi-vessel disease. Four patients had intravascular imaging and 3 patients had rotablation of calcified lesions.

CONCLUSION

PCI of SCA is technically challenging, which requires considerable expertise and experience. An appropriate selection of hardware along with technical expertise can make the procedure simpler with optimal end results.

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.

Prevalence, Spectrum, and Outcomes of Single Coronary Artery Detected on Coronary Computed Tomography Angiography (CCTA)

Background

Single coronary artery (SCA) is a rare congenital anomaly in which there is an isolated coronary artery that arises from a single coronary ostium and provides coronary blood supply to the entire myocardium. SCA is classified into different types based on the origin, branching pattern, and course. Although the majority of patients with SCA are asymptomatic, some patients can present with life-threatening symptoms.

Aim

To examine the prevalence, anatomical distribution, and outcome of the single coronary artery anomaly detected on coronary computed tomography angiography (CCTA) in a single center in Oman.

Methods

Retrospectively, we reviewed 4,445 patients who underwent coronary computed tomography angiography between September 2012 and August 2018 at the National Heart Center, Muscat, Oman. We identified patients with a single coronary artery, and we evaluated the origin, course, and outcome of SCA.

Results

We found 12 patients with single coronary artery among 4,445 patients with a mean age of 56.4 years (age range: 34 to 71 years; male : female ratio: 5 : 7). The most common class was RIII-C seen in 4 patients. Other SCA included RII-C, RII-A, and RII-S, two in each class. One patient had RI and one had LII-P. Two patients had coronary artery bypass graft. No major adverse cardiac events were reported over a mean follow-up of 25.3 months.

Conclusion

Single coronary artery (SCA) is a rare congenital anomaly classified into different types. In our study, the prevalence of SCA was 0.27% that is higher than the figures from previous reports.

Right single coronary artery as an incidental finding in Takotsubo syndrome and acute heart failure: Case report and review of the literature

INTRODUCTION

Single coronary artery (SCA) with no associated congenital heart disease is a rare congenital anomaly. Most cases are asymptomatic and incidental findings, but SCA can cause ischemia, congestive heart failure, and sudden cardiac death (SCD).

CASE REPORT

A 44-year-old woman presented with Takotsubo cardiomyopathy and cardiogenic shock. Selective cannulation of the left coronary artery (LCA) was not possible on coronary angiography (CA); an SCA was revealed arising from the right sinus, continuing distally as the circumflex artery and thereafter as the left anterior descending artery. Coronary computed tomography angiography (CCTA) confirmed left main atresia and no coronary stenosis. Cardiac magnetic resonance imaging (MRI) showed diffuse myocardial edema and no perfusion defects. The patient's clinical course was favorable under conservative management.

DISCUSSION

Our paper describes an incidental finding of right SCA. We report a Lipton type R-I, in which a dominant right SCA supplies the entire myocardium. It is the rarest SCA presentation, with an incidence of 0.0008%; only 15 cases have been reported in the literature, all of which were studied by CA. Of these 15, one had SCD, five angina, one ventricular arrhythmia and one complicated acute coronary syndrome. CCTA confirmed the diagnosis in seven patients, MRI in one and transesophageal echocardiography in another. Nine patients had coronary lesions. Two underwent coronary artery bypass grafting, one percutaneous intervention and 11 conservative treatment.

CONCLUSION

Right SCA with congenital absence of the LCA is one of the rarest coronary artery anomalies. In a significant percentage of patients it is associated with ischemia and can be life-threatening. CCTA and MRI are the modalities of choice for diagnosis and risk stratification.

Incidental congenital coronary artery vascular fistulas in adults: Evaluation with adenosine-13N-ammonia PET-CT

AIM

To assess the functionality of congenital coronary artery fistulas (CAFs) using adenosine stress 13N-ammonia positron emission tomography computed tomography (PET-CT).

METHODS

Congenital CAFs were incidentally detected during coronary angiography (CAG) procedures in 11 adult patients (six males and five females) with a mean age of 64.3 years (range 41-81). Patients were collected from three institutes in the Netherlands. The characteristics of the fistulas (origin, pathway and termination), multiplicity of the origins and pathways of the fistulous vessels were assessed by CAG. Five patients underwent adenosine pharmacologic stress 13N-ammonia PET-CT to assess myocardial perfusion and the functional behavior of the fistula.

RESULTS

Eleven patients with 12 CAFs, 10 unilateral and one bilateral, originating from the left anterior descending coronary artery (n = 8), right coronary artery (n = 2) and circumflex (n = 2). All fistulas were of the vascular type, terminating into either the pulmonary artery (n = 11) or coronary sinus (n = 1). The CAG delineated the characteristics of the fistula (origin, pathway and termination). Multiplicity of the origins and pathways of the fistulous vessels were common in most fistulas (8/12, 67% and 9/12, 75%, respectively). Multiplicity was common among the different fistula components (23/36, 64%). Adenosine pharmacologic stress 13N-ammonia PET-CT revealed normal myocardial perfusion and ejection fraction in all but one patient, who showed a reduced ejection fraction.

CONCLUSION

PET-CT may be helpful for assessing the functional status of congenital CAFs in selected patients regarding clinical decision-making. Studies with a larger patient series are warranted.

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.

Percutaneous coronary intervention in a case of anomalous single coronary artery

Anomalous origin of the right coronary artery is an uncommon entity with a reported incidence of 0.26%. The anomalous origin is usually from the left sinus of Valsalva. Anomalous origin of the right coronary artery (RCA) from the left anterior descending (LAD) artery is a rare occurrence. Symptomatic patients with associated significant coronary artery disease (CAD) may be treated with routine interventions such as percutaneous coronary intervention or coronary artery bypass surgery. We report a case of single coronary artery with severe proximal LAD stenosis. The RCA had its origin from the mid LAD. Coronary intervention was successfully carried out on the severe stenosis at the proximal LAD artery. These cases are rare. We discuss accurate diagnosis and appropriate management in such cases.

A rare case of single right coronary artery with congenital absence of left coronary artery in an adult: a case report

Single right coronary artery with congenital absence of left coronary artery is one of the rarest coronary artery anomalies. Most coronary anomalies are asymptomatic and incidental findings. We report a case of single right coronary artery with congenital absence of left coronary artery detected by coronary CT angiography. Physical examination revealed a well-nourished female with a blood pressure of 130/75 mmHg and a pulse rate of 56 beats per minute. The myocardial enzymes and blood lipid levels showed normal findings. The dynamic electrocardiogram revealed frequent ventricular premature beats. Dual-source CT angiography was performed for evaluation of coronary artery. The imaging showed a very large single coronary artery arising from the right coronary sinus of Valsalva, and demonstrated absence of the left coronary artery. Meanwhile, the findings were confirmed by coronary angiography.

Congenital coronary artery anomalies for the pathologist

Congenital coronary artery anomalies are rare. Pathologists are exposed to those in mainly two settings; in association with sudden death and usually extreme exercise in young adults, and in association with complex congenital heart disease in the pediatric and perinatal population. Pediatric pathologists, other pathologists and pathologists' assistants performing pediatric or forensic autopsies therefore need to be familiar with coronary artery anomalies.