Critical update and discussion of the prevalence, nature, mechanisms of action, and treatment options in potentially serious coronary anomalies

As widely discussed in recent literature, coronary artery anomalies only occasionally lead to potentially serious myocardial ischemic events. The most important group of coronary anomalies has been called anomalous coronary artery origin from an abnormal sinus or a site in the ascending aorta (ACAOS). Only some cases of right- or left-sided intramural-course ACAOS (R-ACAOS-IM or L-ACAOS-IM) can potentially cause significant symptoms or sudden cardiac death, typically during exertion in athletes. After an ACAOS-IM case is qualitatively identified, it is necessary to establish the severity of associated stenosis (which is always present to some degree in ACAOS-IM). The 3 stages of a comprehensive diagnostic process are: 1. initial screening of high-risk populations (young elite athletes, optimally by use of magnetic resonance imaging [MRI]) to identify the prevalence of similar cases in large populations (the denominator of any risk calculation); 2. evaluating symptoms (chest pain, syncope, or sudden death) and performing stress testing; 3. in patients found to carry ACAOS-IM, evaluating the severity of coronary obstruction by intravascular ultrasonography, which is an objective, definitive, and quantifying imaging modality for this condition, essential in selected carriers of such anomalies. The possible treatment alternatives are discussed and updated.

A very rare interarterial communication: total occlusion of right coronary artery with antegrade collateral supply from left circumflex artery through conus branch

PURPOSE

The purpose of the present case report is to describe an extremely rare and unusual coronary interarterial communication.

METHODS

A 65-year-old female patient admitted with acute coronary syndrome underwent a coronary angiography performed with Judkins technique to obtain standard angiographic views.

RESULTS

We have demonstrated a very rare interarterial communication traversing an unusual retroaortic path between the body of left circumflex artery and the conus branch of the right coronary artery.

CONCLUSION

Coronary interarterial communications are rarely encountered; however, may fulfill important tasks in the coronary circulation. Therefore, invasive cardiologists and cardiovascular surgeons should be aware of their presence.

Left Main Coronary Artery Aneurysm With Rare Quadfurcation Anatomy

Coronary artery aneurysms (CAAs) are found in a small percentage of coronary angiograms, with left main coronary artery (LMCA) aneurysms being the least common. We present a 63-year-old male patient with a history of chest pain and an abnormal nuclear stress test. Cardiac catheterization showed a large LMCA aneurysm with unusual quadfurcation left main (LM) anatomy, but otherwise showed no evidence of obstructive coronary artery disease. The patient remained clinically stable, and a repeat cardiac catheterization 2 years later showed unchanged coronary anatomy. Further medical management with close observation was elected. This case illustrates that in select cases, large LMCA aneurysms can be successfully managed medically without surgical or percutaneous interventions. To our knowledge, this is the first report of LMCA aneurysm with quadfurcation anatomy. In addition to the case description, a review of the literature is provided.

Exercise Capacity After Arterial Switch Operation in Patients with D-Transposition of Great Arteries: Does the Coronary Artery Anatomy Matter?

Variant coronary anatomy (VarCA) is frequent in D-Transposition of the great arteries (d-TGA). There are a paucity of data on the effect of the VarCA on the exercise capacity (XC) in patients with repaired d-TGA. This retrospective study included patients with d-TGA who underwent an arterial switch operation (ASO) and had at least one cardiopulmonary exercise test (CPET). Data from the treadmill CPET and simultaneously performed spirometry were collected. The parameters of CPET were compared between patients with usual anatomy vs. VarCA. Longitudinal changes in XC in patients with ASO were also analyzed. A total of 44 patients with either usual coronary anatomy (n = 27, 61%) or VarCA (n = 17, 39%) met inclusion criteria. There was no significant difference in oxygen consumption (%VO₂) at initial CPET (104 vs. 100%, p = 0.53) between the two groups. Abnormal %VO₂ (< 85%) was uncommon in both groups (n = 2, 7.4% vs. n = 4; 23.5%; p = ns). For longitudinal changes, there was no significant decline in %VO₂ in either group: (i) usual coronary anatomy (n = 15, median follow-up 4.8 years, %VO₂ 111 vs. 108%; p = 0.306) and (ii) VarCA (n = 10, median follow-up 6.6 years, %VO₂ 106 vs. 92%; p = 0.441). Spirometry was abnormal in 25 (59.5%) patients [restrictive (n = 8, 19.0%), obstructive (n = 15, 35.7%), and mixed (n = 2, 4.8%)] butabnormal spirometry had no impact on the XC. Patients with d-TGA who underwent neonatal ASO uniformly exhibited good XC without any longitudinal decline on medium-term follow-up, regardless of coronary artery anatomy. Although frequent (60%), abnormal spirometry was not associated with reduced exercise capacity.

An unusual anatomic variation of the Posterior Descending Coronary Artery

PURPOSE

To report a rare coronary anatomic variation.

METHODS

Review of the coronary angiogram of a patient with evidence of myocardial ischemia.

RESULTS

The posterior descending artery was aberrant, originating from a large intermediate brunch.

CONCLUSION

This anatomic variation has not been previously described.

Increased Coronary Tortuosity Is Associated with Increased Left Ventricular Longitudinal Myocardial Shortening

BACKGROUND

The mechanistic basis for tortuosity of the coronary arteries (TCA) is unclear. The aim of this study was to test the hypothesis that the relative degree of systolic longitudinal shortening of the left ventricle that deforms coaxially oriented coronary arteries is associated with TCA.

METHODS

Adult subjects undergoing coronary angiography and comprehensive echocardiography within 3 months were classified dichotomously as with (n = 32) or without (n = 42) TCA defined on the basis of number and severity of coronary angles. Systolic left ventricular (LV) longitudinal deformation was determined by mitral annular plane systolic excursion (MAPSE) from both B-mode displacement and tissue Doppler time-velocity integral; data were indexed to LV diastolic long-axis length.

RESULTS

There were no differences between groups with respect to age, gender, hypertension, or coronary artery disease. Patients with TCA had significantly (P < .01) lower LV mass index and a shorter total LV diastolic long-axis length (mean, 8.3 ± 1.9 vs 9.1 ± 2.2 cm; P < .01). Despite having a shorter length, those with TCA had greater MAPSE by both methods. MAPSE normalized to diastolic length was significantly greater (P < .01) in those with TCA, which remained the case after excluding subjects with reduced LV ejection fraction. Multiple linear regression found that lateral annular MAPSE had the largest effect size, with a 13-fold increase in likelihood for TCA for every 0.1 of normalized MAPSE.

CONCLUSIONS

TCA is not associated with increased LV mass but rather with smaller hearts that have greater relative longitudinal shortening of the left ventricle. This finding suggests that TCA could represent an adaptive response to longitudinal systolic distortion of coaxially oriented coronary arteries that dynamically produce shear stresses associated with expansive coronary remodeling.

Coronary Arteries in Childhood Heart Disease: Implications for Management of Young Adults

Survival of patients with congenital heart defects has improved dramatically. Many will undergo interventional catheter or surgical procedures later in life. Others will develop atherosclerotic or post-surgical coronary heart disease. The coronary artery anatomy in patients with congenital heart disease differs substantially from that seen in the structurally normal heart. This has implications for diagnostic procedures as well as interventions. The unique epicardial course seen in some defects could impair interpretation of coronary angiograms. Interventional procedures, especially at the base of the heart, risk injuring unusually placed coronary arteries so that coronary artery anatomy must be delineated thoroughly prior to the procedure. In this review, we will describe the variants of coronary artery anatomy and their implications for interventional and surgical treatment and for sudden death during late follow-up in several types of congenital heart defects including: tetralogy of Fallot, truncus arteriosus, transposition of the great arteries, double outlet right ventricle, congenitally corrected transposition of the great arteries and defects with functionally one ventricle. We will also discuss the coronary abnormalities seen in Kawasaki disease.