Coronary artery anomalies: classification and ECG-gated multi-detector row CT findings with angiographic correlation

Anatomical and radiological angiographic study of the coronary ostia in the adult human hearts and their clinical significance

This study was carried out to investigate the morphometric parameters and variations of coronary ostia in the hearts of adult human cadavers and coronary angiographs. The hearts of 60 adult human cadavers and 400 coronary angiographs were used in this study. The root of the aorta was carefully dissected to clear aortic sinuses, coronary ostia, and sinutubular junction (STJ). Number, locations, internal diameter distance between coronary ostia and their corresponding STJ, sinus bottom, and valve commissures were investigated. The anterior aortic sinus (AAS) revealed a single ostium for right coronary artery (RCA) in 77.5% of male and 80% of female hearts. This ostium gave a common origin for RCA and third coronary artery (TCA) in 15% of male and 20% of female hearts. However, two separate ostia for RCA and TCA origin were seen in 20% of male and 15% of female hearts. Moreover, three ostia were seen in one male and one female hearts within AAS. Meanwhile, the left posterior aortic sinus showed a single ostium for left coronary artery (LCA) in 97.5% of male and 95% of female hearts and two ostia in one male and one female hearts. The ostia were commonly seen below STJ and less commonly were observed above STJ. The distance between the bottom of aortic sinus and LCA ostium was longer than that of RCA. The internal diameter of RCA ostium was significantly (P<0.05) narrower than that of LCA but with no significant sex difference. Moreover, anomalous of coronary ostia was observed in seven out 400 angiographs and in two cadaveric hearts. Knowledge the morphometric parameters and anatomical variations of coronary ostia helps the cardiac surgeons to overcome the possible difficulties that could occur during surgical and radiological coronary interventions.

Aortic expansion induces lumen narrrowing in anomalous coronary arteries: a parametric structural finite element analysis

Anomalous aortic origin of coronary arteries (AAOCA) is a congenital disease that can lead to cardiac ischemia during intense physical activity. Although AAOCA is responsible for sudden cardiac death (SCD) among young athletes and soldiers, the mechanisms underlying the coronary occlusion during physical effort still have to be clarified. The present study investigates the correlation between geometric features of the anomaly and coronary lumen narrowing under aortic root dilatations. Idealized parametric computer-aided designed (CAD) models of the aortic root with anomalous and normal coronary are created and static finite element (FE) simulations of increasing aortic root expansions are carried out. Different coronary take-off angles and intramural penetrations are investigated to assess their role on coronary lumen narrowing. Results show that increasing aortic and coronary pressures lead to lumen expansions in normal coronaries, particularly in the proximal tract, while the expansion of anomalous coronary is impaired especially at the ostium. Concerning the geometric features of the anomaly, acute take-off angles cause elongated coronary ostia, with an eccentricity increasing with aortic expansion; the impact of intramural penetration of coronary on its luminal narrowing is limited. The present study provides a proof of concept of the biomechanical reasons underlying the lumen narrowing in AAOCA during aortic expansion, promoting the role of computational simulations as a tool to assess the mechanisms of this pathology.

A Rare Cause of Supraventricular Ectopic Beats and Angina in a Young Patient

Introduction: We present the case of a young man with multiple atherosclerotic risk factors and a rare cause of angina and supraventricular ectopic beats.

Case presentation: A 35-year-old man with one-year history of stable angina pectoris and supraventricular ectopic beats, without any medication, presented to the emergency room complaining of anterior chest pain that occurs at moderate physical exertion. The rest electrocardiogram, transthoracic echocardiography, and chest X-ray were normal; the exertion stress test was also normal, except for supraventricular ectopic beats (trigeminal rhythm). Due to the intermediate pre-test probability of coronary artery disease, he was evaluated using coronary computed tomography angiography. An anomalous origin of the right coronary artery from the left coronary sinus, with an inter-arterial course and without any atheroma plaques, was observed. During hospitalization the evolution was stable, without complications. The patient was further referred to a cardiac surgery clinic to evaluate the possibility of surgical treatment of this anomaly.

Conclusions: Coronary artery anomalies are very rare; however, they present multiple implications in current practice. The most severe complication of this condition is represented by sudden death in young patients due to malignant ventricular arrhythmias. Imaging diagnostic techniques allow for a rapid, noninvasive diagnosis of this rare cause of angina.

Coronary Artery Development: Origin, Malformations, and Translational Vascular Reparative Therapy

After thickening of the cardiac chamber walls during embryogenesis, oxygen and nutrients can no longer be adequately supplied to cardiac cells via passive diffusion; therefore, a primitive vascular network develops to supply these vital structures. This plexus further matures into coronary arteries and veins, which ensures continued development of the heart. Various models have been proposed to account for the growth of the coronary arteries. However, lineage-tracing studies in the last decade have identified 3 major sources, namely, the proepicardium, the sinus venosus, and endocardium. Although the exact contribution of each source remains unknown, the emerging model depicts alternative pathways and progenitor cells, which ensure successful coronary angiogenesis. We aim to explore the current trends in coronary artery development, the cellular and molecular signals regulating heart vascularization, and its implications for heart disease and vascular regeneration.

Sports Behavior in Middle-Aged Individuals with Anomalous Coronary Artery from the Opposite Sinus of Valsalva

Objectives: Recommendations regarding sports restriction are lacking for middle-aged athletes with anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). Methods: Sixty-three patients with ACAOS were subdivided into ACAOS with (n = 38) or without (n = 25) an interarterial course (IAC). Sports behavior, either competitive (COMP) or recreational (REC), was evaluated at the time of diagnosis and after a median follow-up of 4.2 years. Results: Mean age was 56 ± 11 years and 48 (76.2%) patients were engaged in sports. Three individuals (4.8%) were surgically corrected after diagnosis. Thirty-eight (60.3%) patients were aware of their diagnosis at follow-up and 12 (19.0%) were counseled by their physician about sports restrictions. Sports behavior at the time of diagnosis and at follow-up did not differ significantly, neither in patients engaged in COMP (17.5 vs. 12.7%, p = 0.619) nor those engaged in REC (58.7 vs. 61.9%, p = 0.856). Sport-related symptoms were not significantly different between ACAOS patients with and without IAC. No athlete had died at follow-up. Conclusions: The majority of middle-aged individuals with ACAOS were involved in sports activities at the time of diagnosis and at follow-up. Awareness and counseling about ACAOS diagnosis had no significant effect on sports behavior. IAC did not have an impact on sport-related symptoms, and outcomes were favorable in all athletes, regardless of surgical correction.

Myocardial bridging with left ventricular hypertrophy presenting as Wellens pattern

The course of epicardial coronary arteries into a muscular tunnel under a bridge of myocardium is known as myocardial bridging (MB). This could be a benign anomaly, nevertheless, it could have a great impact on the quality of life in the setting of severe anginal symptoms. The clinical presentation and diagnosis could be challenging in those patients. The treatment options start from simple medical therapy to surgical intervention in refractory cases, the role of percutaneous coronary intervention (PCI) is limited in MB. We are describing a case of severe MB presenting as Wellens pattern with underlying left ventricular hypertrophy (LVH).

Imaging of Cardiovascular Disease in Pregnancy and the Peripartum Period

OPINION STATEMENT

Cardiovascular disease is an important cause of morbidity and mortality during pregnancy and the postpartum period. During pregnancy, the cardiovascular system undergoes extensive hemodynamic, hormonal, and microstructural changes which may exacerbate a preexisting underlying cardiovascular condition or predispose to cardiovascular complications not typically seen in young healthy women. Such conditions include spontaneous coronary artery dissection, atherosclerotic coronary artery disease, and peripartum cardiomyopathy. When evaluating this patient population, the diagnostic strategy should be tailored to specifically assess this distinct disease spectrum. The choice of imaging techniques must also consider potential risks to both the mother and child; a unique challenge of diagnostic imaging during pregnancy. The risk of radiation from radiography, computed tomography, and nuclear medicine imaging; iodinated and gadolinium-based contrast media for computed tomography and magnetic resonance imaging respectively; and heat deposition from sonography are of special importance during pregnancy. A thorough understanding of pregnancy-specific cardiovascular complications and the capabilities and risks of available diagnostic imaging modalities is crucial to appropriately manage the pregnant patient.

Anomalous origin of coronary arteries from the "wrong" sinus in athletes: Diagnosis and management strategies

AIMS

Although anomalous origin of left (AOLCA) and right coronary artery (AORCA) from the wrong sinus may cause sudden death (SD) in athletes, early diagnosis and management of these anomalies are still challenging. We analysed clinical/instrumental profiles of athletes identified with AOLCA/AORCA focusing our attention on diagnosis, management and follow-up.

METHODS AND RESULTS

We report 23 athletes (17 males, mean age 27±17yrs.), 6 with AOLCA and 17 with AORCA. Diagnosis was made by trans-thoracic echocardiography (TTE) in 21/23(91%). Symptoms were present only in 10(41%). Only 3 had an abnormal rest-ECG and 9(39%) an abnormal stress test ECG (3 ST-depression, 4 ventricular arrhythmias, 1 supraventricular arrhythmias, 1 rate-dependent left-bundle-branch-block). Anatomy of the anomalous coronary artery showed no significant correlation with clinical presentation, except for a tendency to higher occurrence of proximal hypoplasia in symptomatic athletes (83% vs 40%, p=0.09). All athletes were disqualified from competitive-sports and advised to avoid strenuous effort. Surgery was recommended to all athletes with AOLCA and 6 with AORCA, but only 6 underwent surgery. No major cardiac events or ischemic symptoms/signs occurred during a mean follow-up of 65±70months.

CONCLUSIONS

Early diagnosis of AOLCA/AORCA in athletes is feasible by TTE. Typical symptoms/signs of myocardial ischemia are present only in one third of cases thus underlying the need of a high index of clinical suspicion to achieve the diagnosis. After exercise restriction, none had major cardiac events or ischemia symptoms/signs recurrence. There was no correlation between anatomical characteristics and clinical presentation with the possible exception of coronary hypoplasia.

Aneurysmal coronary artery disease: An overview

Aneurysmal coronary artery disease (ACAD) comprises both coronary artery aneurysms (CAA) and coronary artery ectasia (CAE). The reported prevalence of ACAD varies widely from 0.2 to 10%, with male predominance and a predilection for the right coronary artery (RCA). Atherosclerosis is the commonest cause of ACAD in adults, while Kawasaki disease is the commonest cause in children and adolescents, as well as in the Far East. Most patients are asymptomatic, but when symptoms do exist, they are usually related to myocardial ischemia. Coronary angiography is the mainstay of diagnosis, but follow up is best achieved using noninvasive imaging that does not involve exposure to radiation. The optimal management strategy in patients with ACAD remains controversial. Medical therapy is indicated for the vast majority of patients and includes antiplatelets and/or anticoagulants. Covered stents effectively limit further expansion of the affected coronary segments. Surgical ligation, resection, and coronary artery bypass grafting are appropriate for large lesions and for associated obstructive coronary artery disease.

Abnormalities of the Coronary Arteries in Children: Looking beyond the Origins

Coronary arterial abnormalities are uncommon findings in children that have profound clinical implications. Although anomalies of the coronary origins are well described, there are many other disease processes that affect the coronary arteries. Immune system-mediated diseases (eg, Kawasaki disease, polyarteritis nodosa, and other vasculiditides) can result in coronary arterial aneurysms, strictures, and abnormal tapering of the vessels. Because findings at imaging are an important component of diagnosis in these diseases, the radiologist's understanding of them is essential. Congenital anomalies may present at varying ages, and findings in hemodynamically significant anomalies, such as fistulas, are key for both diagnosis and preoperative planning. Pediatric heart surgery can result in wide-ranging postoperative imaging appearances of the coronary arteries and also predisposes patients to a multitude of complications affecting the heart and coronary arteries. In addition, although rare, accidental trauma can lead to injury of the coronary arteries, and awareness and detection of these conditions are important for diagnosis in the acute setting. Patients with coronary arterial conditions at presentation may range from being asymptomatic to having findings of myocardial infarction. Recognition of the imaging findings is essential to direct appropriate treatment. ^©RSNA, 2017.

The prevalence of coronary artery anomalies in Qassim Province detected by cardiac computed tomography angiography

BACKGROUND

Coronary artery anomalies (CAAs) affect about 1% of the general population based on invasive coronary angiography (ICA) data, computed tomography angiography (CTA) enables better visualization of the origin, course, relation to the adjacent structures, and termination of CAAs compared to ICA.

OBJECTIVE

The aim of our work is to estimate the frequency of CAAs in Qassim province among patients underwent cardiac CTA at Prince Sultan Cardiac Center.

METHODS

Retrospective analysis of the CTA data of 2235 patients between 2009 and 2015.

RESULTS

The prevalence of CAAs in our study was 1.029%. Among the 2235 patients, 241 (10.78%) had CAAs or coronary variants, 198 (8.85%) had myocardial bridging, 34 (1.52%) had a variable location of the Coronary Ostia, Twenty two (0.98%) had a separate origin of left anterior descending (LAD) and left circumflex coronary (LCX) arteries, ten (0.447%) had a separate origin of the RCA and the Conus artery. Seventeen (0.76%) had an anomalous origin of the coronaries. Six (0.268%) had a coronary artery fistula, which is connected mainly to the right heart chambers, one of these fistulas was complicated by acute myocardial infarction.

CONCLUSIONS

The incidence of CAAs in our patient population was similar to the former studies, CTA is an excellent tool for diagnosis and guiding the management of the CAAs.

Hybrid CCTA/SPECT myocardial perfusion imaging findings in patients with anomalous origin of coronary arteries from the opposite sinus and suspected concomitant coronary artery disease

BACKGROUND

Anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) are associated with adverse cardiac events. Discrimination between ACAOS and coronary artery disease (CAD)-related perfusion defects may be difficult. The aim of the present study was to investigate the value of hybrid coronary computed tomography angiography (CCTA)/SPECT-MPI in patients with ACAOS and possible concomitant CAD.

METHODS

We retrospectively identified 46 patients (mean age 56 ± 12 years) with ACAOS revealed by CCTA who underwent additional SPECT-MPI. ACAOS with an interarterial course were classified as malignant, whereas all other variants were considered benign. CCTA/SPECT-MPI hybrid imaging findings (ischemia or scar) were analyzed according to the territory subtended by an anomalous vessel or a stenotic coronary artery.

RESULTS

Twenty-six (57%) patients presented with malignant ACAOS. Myocardial ischemia or scar was found only in patients who had concomitant obstructive CAD in the vessel matching the perfusion defect as evidenced by hybrid CCTA/SPECT imaging.

CONCLUSION

Hybrid CCTA/SPECT-MPI represents a valuable non-invasive tool to discriminate the impact of ACAOS from concomitant CAD on myocardial ischemia. Our results suggest that in a middle-aged population myocardial ischemia due to ACAOS per se may be exceedingly rare and is more likely attributable to concomitant CAD.

Characteristics of Coronary Artery to Pulmonary Artery Fistula on Coronary Computed Tomography Angiography

OBJECTIVE

The aim of the study was to evaluate the characteristics of coronary artery-to-pulmonary artery fistula (CPAF) found by coronary computed tomography (CT) angiography.

METHODS

Among 10,121 cases of coronary CT angiography performed for 7 years, we found 32 cases of CPAF. We retrospectively evaluated the demographics, clinical symptoms, and anatomical characteristics such as the origin, number of origins, course, opening site of the fistula, and the presence of aneurysmal changes (defined as dilatation 1.5 times the diameter of the origin). We also categorized the fistula openings according to size compared with that of the proximal left anterior descending coronary artery.

RESULTS

The patients were 14 men and 18 women with a mean (range) age of 56.5 (34-86) years. Nineteen patients had no related symptoms, and the other 13 patients had symptoms such as angina, chest discomfort, palpitations, or shoulder pain. Among these patients, 2 patients were diagnosed with coronary artery disease. The origins of CPAF were single (n = 15, 46.9%) or multiple (n = 17, 53.1%). The CPAFs arose most commonly from the conus branch of the right coronary artery (n = 20, 62.5%) and proximal left anterior descending (n = 17, 53.1%). All CPAFs coursed anteriorly to the main pulmonary artery and drained into the anterolateral aspect. Twenty-five patients (78.1%) exhibited aneurysmal changes. The openings were small in 13 (40.6%), medium in 13 (40.6%), and large in 6 (18.8%) patients.

CONCLUSIONS

More than half of patients with CPAF had no related symptoms. Coronary artery-to-pulmonary artery fistula may have a single origin or multiple origins. All of the CPAFs coursed anteriorly to the main pulmonary artery and drained into the anterolateral aspect; the CPAFs identified here frequently exhibited aneurysmal changes.

Anomalous right coronary artery in a middle-aged patient: A case report and review of the literature

BACKGROUND

An anomalous right coronary artery originating from the left sinus of Valsalva is a rare, but often incidental, finding in middle-aged to elderly people. Prevalence is difficult to define, as well as determining potential harmful hemodynamic consequences. Moreover, the optimal treatment remains debatable.

CASE SUMMARY

The authors present a case of a middle-aged patient diagnosed with an anomalous right coronary artery causing ischemia, who was treated surgically.

CONCLUSION

By reviewing literature, the authors conclude that choice of treatment depends on age, symptoms, and certain anatomic features of this anomaly. However, there are no randomized trials available in this field.

Variant origin and course of left circumflex coronary artery

Variant origin of left circumflex coronary artery (LCx) from right aortic sinus is a well-recognized coronary variation, usually without any clinical consequences. However, the variant origin and trajectory of the artery may have major implications during percutaneous coronary intervention, coronary artery surgery, aortic and mitral valve replacement procedures. We observed a variant LCx in a heart specimen belonging to 45-year-female with no history of hypertension, diabetes mellitus and coronary artery disease. The artery arose along with the right coronary artery from a common ostium in right aortic sinus and depicted a retroaortic course. The vessel was located at the level of aortic annulus and 6.6 mm above mitral valve annulus. The degree of luminal stenosis in variant LCx was higher than that in right coronary artery (RCA) and left anterior descending artery (LAD). Appropriate anatomical knowledge of the location and course of variant LCx is important for successful coronary interventions and valve replacement procedures.

Single coronary artery with a pre-pulmonic dual left anterior descending artery and a retro-aortic left circumflex artery

We present two cases of an unusual coronary artery anomaly, namely, a single coronary artery with retro-aortic course of the left circumflex artery and pre-pulmonic course of the left anterior descending artery, and one of which showed a dual left anterior descending artery as well - a combination that has not yet been reported in the literature.

Sudden cardiac death from structural heart diseases in adults: imaging findings with cardiovascular computed tomography and magnetic resonance

Sudden cardiac death (SCD) is defined as the unexpected natural death from a cardiac cause within an hour of the onset of symptoms in the absence of any other cause. Although such a rapid course of death is mainly attributed to a cardiac arrhythmia, identification of structural heart disease by cardiovascular computed tomography (CCT) and cardiovascular magnetic resonance (CMR) imaging is important to predict the long-term risk of SCD. In adults, SCD most commonly results from coronary artery diseases, coronary artery anomalies, inherited cardiomyopathies, valvular heart diseases, myocarditis, and aortic dissection with coronary artery involvement or acute aortic regurgitation. This review describes the CCT and CMR findings of structural heart diseases related to SCD, which are essential for radiologists to diagnose or predict.

The clinical anatomy of high take-off coronary arteries

A number of criteria are used in the literature to describe high take-off coronary arteries, which can in part, explain the divide in the literature on the pathological significance of this anomaly. This study presents the anatomical variations of high take-off coronary arteries to draw attention to the possible clinical implications they may cause during angiography and other surgical procedures. The English Literature was searched to review high take-off coronary arteries. A high take-off coronary artery arising at least 1 cm in adults or 20% the depth of the sinus in children above the sinutubular junction, is considered of greater clinical relevance and was included in our meta-analysis. High take-off coronaries by other criteria was also included as part of the comprehensive review. Exclusion criteria were reports made in case studies or case reviews. The prevalence of high take-off coronary arteries in our study was 26 of 12,899 (0.202%). High take-off coronary arteries were found to originate up to 5 cm above the sinutubular junction. Right coronary arteries made up 84.46% of high take-off coronary arteries reported in the literature. Three (0.023%) cases that originated more than one centimeter above the sinutubular junction was associated with sudden cardiac death. This is a higher reported association than in studies that used other criteria for classification. It is important for clinicians to recognize the importance of correctly diagnosing high take-off coronary arteries in patients with coexisting cardiac morbidities so that suitable management plans can be developed.

Prevalence and characteristics of coronary artery anomalies in an adult population undergoing multidetector-row computed tomography for the evaluation of coronary artery disease

Background

Congenital coronary anomalies are uncommon with an incidence ranging from 0.17 % in autopsy cases to 1.2 % in angiographically evaluated cases. The recent development of ECG–gated multi–detector row computed tomography (MDCT) coronary angiography allows accurate and noninvasive depiction of coronary artery anomalies.

Methods

This retrospective study included 2572 patients who underwent coronary 64-slice MDCT coronary angiography from January 2008 to March 2012. Coronary angiographic scans were obtained with injection of 80 ml nonionic contrast medium. Retrospective gating technique was used to synchronize data reconstruction with the ECG signal. Maximum intensity projection, multi-planar reformatted, and volume rendering images were derived from axial scans.

Results

Of the 2572 patients, sixty (2.33 %) were diagnosed with coronary artery anomalies (CAAs), with a mean age of 53.6 ± 11.8 years (range 29–80 years). High take-off of the RCA was seen in 16 patients (0.62 %), of the left main coronary artery (LMCA) in 2 patients (0.08 %) and both of them in 2 patients (0.08 %). Separate origin of the left anterior descending artery (LAD) and left circumflex artery (LCx) from left sinus of Valsalva (LSV) was found in 15 patients (an incidence of 0.58 %). In 9 patients (0.35 %) the right coronary artery (RCA) arose from the opposite sinus of Valsalva with a separate ostium. In 6 patients (0.23 %) an abnormal origin of LCX from the right sinus of Valsalva (RSV) was found with a further posterior course within the atrioventricular groove. A single coronary artery was seen in 3 patients (0.12 %). It originated from the right sinus of Valsalva in one patient and from LSV in two patients. In two other patients (0.08 %) the left coronary trunk originated from the RSV with separate ostium from the RCA. LCA originating from the pulmonary artery was found in one patient (0.04 %). A coronary artery fistula, which is a termination anomaly, was detected in 4 patients (0.15 %).

Discussion

Although these anomalies, which are remarkably different from the normal structure, exist as early as birth, they are incidentally encountered during selective angiography or at autopsy. The incidence in reported angiographic series ranges from 0.6 % to 1.3 %. Variations in the frequency of primary congenital coronary anomalies may possibly have a genetic background. The largest angiographic series of 126595 patients, by Yamanaka and Hobbs, reported a 1.3 % incidence of anomalous coronary artery.

Conclusion

The results of this study support the use MDCT coronary angiography as a safe and effective noninvasive imaging modality for defining CAAs in an appropriate clinical setting, providing detailed three-dimensional anatomic information that may be difficult to obtain with invasive angiography.

Anomalous Coronary Artery: Run of a Lifetime

The anatomy of the coronary circulation is well described with incidence of congenital anomalies of approximately 0.3% to 1.0%. Although often incidental, 20% are life-threatening. A 25-year-old woman with syncopal episodes collapsed following a 10-km run. Coronary anatomy evaluation showed an anomalous left main coronary artery originating from the right sinus of valsalva and following a course between the aorta and the pulmonary outflow tract. Percutaneous coronary intervention was followed by eventual surgical revascularization. Abnormal course of coronary arteries plays a role in the pathogenesis of sudden death on exertion. Origin of the left main coronary from the right sinus of valsalva is a rare congenital anomaly. The expansion of the roots of the aorta and pulmonary trunk with exertion lead to compression of the coronary artery and syncope. Our patient raises awareness of a potentially fatal coronary artery path. Intraoperative identification of anomalous coronaries by utilizing intraoperative transesophageal echocardiography was critical.

Coronary anomalies: what the radiologist should know

Coronary anomalies comprise a diverse group of malformations, some of them asymptomatic with a benign course, and the others related to symptoms as chest pain and sudden death. Such anomalies may be classified as follows: 1) anomalies of origination and course; 2) anomalies of intrinsic coronary arterial anatomy; 3) anomalies of coronary termination. The origin and the proximal course of anomalous coronary arteries are the main prognostic factors, and interarterial course or a coronary artery is considered to be malignant due its association with increased risk of sudden death. Coronary computed tomography angiography has become the reference method for such an assessment as it detects not only anomalies in origination of these arteries, but also its course in relation to other mediastinal structures, which plays a relevant role in the definition of the therapeutic management. Finally, it is essential for radiologists to recognize and characterize such anomalies.

A rare coronary artery anomaly: origin of all three coronary arteries from the right sinus of valsalva

Left anterior descending (LAD) artery and left circumflex (LCx) coronary artery originating separately from the right sinus of valsalva is exceptionally rare and very few cases have been reported in the literature. Congenital coronary artery anomalies are generally incidental, uncommon, and asymptomatic. Some can cause severe potentially life-threatening symptoms such as myocardial ischemia and sudden cardiac death. The aberrant vessels that pass between the aorta and the pulmonary trunk pose a risk of sudden cardiac death, particularly if the vessel supplies the left coronary artery network. The electrocardiographically gated multi-detector computed tomography (MDCT) allows accurate and non-invasive depiction of coronary artery anomalies including origin, course, and termination. We report here a rare case of all three coronary arteries separately originating from the right coronary sinus, which was detected with MDCT.

Korean guidelines for the appropriate use of cardiac CT

The development of cardiac CT has provided a non-invasive alternative to echocardiography, exercise electrocardiogram, and invasive angiography and cardiac CT continues to develop at an exponential speed even now. The appropriate use of cardiac CT may lead to improvements in the medical performances of physicians and can reduce medical costs which eventually contribute to better public health. However, until now, there has been no guideline regarding the appropriate use of cardiac CT in Korea. We intend to provide guidelines for the appropriate use of cardiac CT in heart diseases based on scientific data. The purpose of this guideline is to assist clinicians and other health professionals in the use of cardiac CT for diagnosis and treatment of heart diseases, especially in patients at high risk or suspected of heart disease.

Anomalous origin of the right coronary artery with concomitant myxomatous mitral valve disease: a rare coexistence

A 45-year-old man previously diagnosed with myxomatous mitral valve disease was admitted to our hospital with chest pain at rest and on effort. Contrast-enhanced CT revealed that the patient's right coronary artery originated from the left sinus Valsalva, which was compressed between the aortic and pulmonary roots. This anatomical abnormality can be associated with sudden death, syncope and chest pain. Ultrasonography showed mitral valve prolapse with severe regurgitation. Surgical repair was performed, which included coronary artery bypass graft and mitral valvoplasty with tricuspid annuloplasty. The postoperative course was uneventful and the patient remains asymptomatic. This is the first description of the coexistence of an anomalous origin of the right coronary artery with myxomatous mitral valve disease.

Coronary cameral fistula treated by the Amplatzer vascular plug

Coronary artery anomalies occur in less than 1 % of the general population. With the advent of multidetector rows and 3D reconstruction, multidetector computed tomography has emerged as the modality of choice in the delineation of the complex coronary anatomy and diagnosis of coronary artery anomalies, helping in the institution of appropriate therapy. We report a case of coronary cameral fistula of the left anterior descending artery to the right ventricle, which was closed by an Amplatzer vascular plug. Coronary CT angiography was used to evaluate the patient prior to the procedure to locate the placement site for the vascular plug.

A rare case of ALCAPA and rheumatic mitral valve regurgitation in an adult patient

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary artery defect leading to sudden cardiac death. Diagnosis is made after the onset of symptoms, mainly in the pediatric population. We describe an uncommon presentation of ALCAPA and rheumatic mitral valve regurgitation, diagnosed by a coronary 64-CT scan performed before a planned mitral valve repair operation.

Coronary anomalies encountered in the acute setting: an imaging review

A broad spectrum of congenital coronary anomalies may be discovered on imaging and sometimes in the emergency setting on computed tomography (CT). Most coronary artery anomalies are of academic interest; however, a minority can cause morbidity and mortality and symptoms such as angina, myocardial infarction, or arrhythmias. These anomalies are usually discovered as an incidental finding on CT examinations as part of the diagnostic workup for other pathology or on dedicated coronary computed tomography angiography (CCTA) as part of the evaluation for a coronary cause of chest pain. The purpose of this pictorial review is to demonstrate the types of coronary anomalies and to enhance the clinicians' understanding of the imaging classifications and clinical implications.

The prevalence of coronary anomalies in a single center of Korea: origination, course, and termination anomalies of aberrant coronary arteries detected by ECG-gated cardiac MDCT

Background

Coronary anomalies are rare congenital abnormalities often found incidentally on conventional coronary angiography (CCA) or coronary CT angiography (CTA). They may result in various clinical outcomes. CCA is invasive and not able to demonstrate all coronary anomalies in detail, especially those with complex courses. Multidetector computed tomography (MDCT) enables visualization of the origin and course of coronary arteries. The objective of this study was to investigate the prevalence of origin and termination coronary artery anomalies and the course of these anomalies in patients in a single center in Korea.

Methods

To diagnose coronary anomalies, the angiographic data of 8,864 consecutive patients undergoing 64- or 320-MDCT from September 2005 to November 2011 were analyzed retrospectively.

Results

Among the 8,864 patients, 103 (1.16%) had coronary anomalies. Ninety (87.4%) patients had origin and distribution anomalies, and 13 (12.6%) patients had a coronary artery fistula. The most common anomaly (41, 39.8%) was an anomalous origin of the right coronary artery (RCA). Of these, three patients received a coronary artery bypass graft.

Conclusions

The prevalence of coronary anomalies in a single center of Korea was 1.16%. The incidence and patterns of coronary artery anomalies in our patient population were similar to those of previous studies.

Congenital coronary artery anomaly simulating a ventricular septal defect

Anomalous origin of the circumflex artery of the right sinus of Valsalva is a rare finding which may be present with other cardiac malformations. A 19-year-old man presented with syncope. A transthoracic echocardiogram revealed discrete subaortic stenosis with a small defect just below the aortic valve, suggesting a ventricular septal defect. Transesophageal echocardiography showed anomalous origin of the circumflex artery from the right sinus of Valsalva. This was confirmed by coronary angiography. The patient underwent successful web resection without concomitant coronary surgery. Failure to demonstrate a coronary artery anomaly can be misleading for surgeons and perilous for patients.

Absent left main coronary artery with variation in the origin of its branches in a South African population

Coronary artery anomalies are traditionally classified into anomalies of origin, course and termination. One of the anomalies of origin is absence of the left main coronary artery (LMCA), where the left anterior descending (LAD), the circumflex (Cx) and the ramus medianus (RM) (when present) arteries originate directly from the left aortic sinus. The study aimed to document the prevalence of absent LMCA, discuss its possible embryogenesis and clinical relevance. A review of 407 coronary angiograms performed by cardiologists of three private hospitals in the eThekwini Municipality area of KwaZulu-Natal, South Africa, was performed. The LMCA was absent in 9.6% (39/407) of the coronary angiograms. The LAD and Cx arteries originated directly from the left aortic sinus with a single ostium in 8.6% (35/407) and separate ostia in 1% (4/407) of the angiograms. In four of the angiograms with absent LMCA, a RM artery was recorded originating directly from the left aortic sinus in addition to the LAD and the Cx arteries. Angiographic detection of the anomalies of the coronary arteries is essential in the determination of the significance of such findings and their management.

Single coronary artery: spectrum of imaging findings with multidetector CT

Single coronary artery is a rare congenital anomaly in which a single artery arises from the aorta. The anomalous single trunk supplies blood to the entire heart. It is classified according to its origin, branching pattern, and course. The presence of a single coronary artery can be an isolated finding or associated with additional cardiac anomalies. Diagnosis is important because of therapeutic implications, although it is an incidental finding. As with any other coronary anomalies, its recognition is more common today because of increasing use of multidetector CT. The objective of this article is to review the classification of single coronary artery anomaly and its clinical significance and to illustrate the imaging findings on multidetector CT.

Multidetector computed tomography imaging of coronary artery anomalies

PURPOSE

The purpose of the study was to determine the prevalence of coronary artery anomalies and to demonstrate in which cases multidetector computed tomography has an additional clinical value compared with the conventional angiography.

MATERIAL AND METHODS

A total of 2375 multidetector computed tomography studies were retrospectively reviewed to determine the dominance of the coronary artery anomalies. The classification of coronary artery anomalies was made according to anatomical criteria--origin, course, intrinsic anatomy, and termination--and clinical relevance--benign versus malignant.

RESULTS

The coronary artery system was right dominant in 83.99%, left dominant in 8.0%, and co-dominant in 9.01% of the cases. The incidence of the origin and/or course anomalies was 1.76%, that of fistulas was 0.42%, and that of myocardial bridges was 10.82%. Multidetector computed tomography was performed after conventional angiography in 23 cases and it provided additional information regarding its origin and proximal course, as well as its relationship with the aortic root and main pulmonary trunk in 100% of the cases; eight malignant cases were found. In addition, in all of (100%) the six cases with coronary artery fistulas, conventional angiography failed to detect their terminations, which were clearly depicted by multidetector computed tomography.

CONCLUSION

Multidetector computed tomographic angiography is superior to conventional angiography in delineating the ostial origin and proximal course of anomalous coronary arteries. Furthermore, it reveals the exact relationship of anomalous coronary arteries with the aorta and the pulmonary artery. Anomalies of the intrinsic anatomy and the termination of coronary arteries are also better visualised with multidetector computed tomography.

Isolated hypoplastic circumflex coronary artery: a rare cause of haemorrhagic myocardial infarction in a young athlete

Hypoplastic coronary artery disease is a rare condition that may lead to myocardial infarction and sudden death. Here we describe for the first time an isolated hypoplasia of the left circumflex artery (LCX). An otherwise healthy and athletically active 16-year-old boy was admitted to the intensive care unit (ICU) after out-of-hospital cardiac arrest. He died 12 hours after the initial event. Autopsy revealed an isolated hypoplastic LCX and acute haemorrhagic infarction in the posterolateral myocardium. The existence of isolated hypoplasia of the LCX challenges our understanding of coronary artery development. Virtual slides: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1558483061962648.

Can coronary artery anomalies be detected on CT calcium scoring studies?

PURPOSE

To determine whether coronary artery anomalies can be detected on noncontrast computed tomography (CT) coronary artery calcium scoring (CCS) studies.

MATERIALS AND METHODS

A total of 126 patients (mean age 62 years; 35 women) underwent noncontrast CCS and contrast enhanced coronary CT angiography (cCTA). Thirty-three patients were diagnosed with a coronary anomaly on cCTA, whereas coronary anomalies were excluded in 93. Two observers (reader 1 [R1] and reader 2 [R2]), blinded to patient information independently evaluated each CCS study for: 1) visibility of coronary artery origins, 2) detection of coronary anomalies, and 3) benign or malignant (ie, interarterial) course. Using cCTA as the reference standard, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CCS studies for detecting coronary anomalies were calculated.

RESULTS

Of the 33 coronary anomalies, 16 were benign and 17 malignant. Based on noncontrast CCS studies, R1 and R2 correctly identified the left main origin in 123/126 (97.6%) and 121/126 (96%) patients; the left anterior descending origin in 125/126 (99.2%) and 122/126 (96.8%); the circumflex origin in 120/126 (95.2%) and 105/126 (83.3%); and the right coronary artery origin in 117/126 (92.9%) and 103/126 (81.7%), respectively. R1 and R2 identified 34 and 27 coronary anomalies and classified 19 and 15 as malignant, respectively. Interobserver reproducibility for detection of coronary anomalies was good (k = 0.76). Interobserver agreement for detection of malignant variants was even stronger (k = 0.80). On average, coronary artery anomalies were diagnosed with 85.2% sensitivity, 96.4% specificity, 90.5% PPV, and 94.1% NPV on noncontrast CCS studies.

CONCLUSION

Benign and malignant coronary artery anomalies can be detected with relatively high accuracy on noncontrast-enhanced CCS studies. CCS studies should be reviewed for signs of coronary artery anomalies in order to identify malignant variants with possible impact on patient management.

High Take Off Left Main and Abnormal Origin of Right Coronary Artery: A Case Report

Coronary anomalies are rare congenital disorders with mostly benign course. We report a case of 54-year-old white male who was with stable angina scheduled for coronary angiography. Due to the difficulty of catheterization, patient underwent CT angiography and high take off left main and right coronary arteries were revealed. We conclude that anomalous coronary arteries are important and coronary interventions may be difficult in their presence.