Major variations in anatomical origin of the coronary arteries: angiographic observations in 4,250 patients without associated congenital heart disease

Anomalous circumflex artery: a benign variant generating a malignant potential after valve surgery

Coronary artery anomalies are a diverse group of congenital disorders presenting with highly variable clinical manifestations. The anomalous origin of left circumflex artery from the right coronary sinus following a retro-aortic trajectory is a well-recognized anatomic variation. Despite its benign course, it can prove lethal in association with valvular surgery. When single aortic valve replacement or combined with mitral valve replacement is performed, the aberrant coronary vessel may be compressed by or between the prosthetic rings triggering postoperative lateral myocardial ischemia. If left untreated, the patient is at risk of sudden death or myocardial infarction with its detrimental complications. Skeletonization and mobilization of the aberrant coronary artery is the most widely accepted intervention, but valve downsizing or concomitant surgical or transcatheter revascularization have also been described. However, large series are lacking from the literature. Therefore, no guidelines exist. This study is a thorough review of the literature concerning the aforementioned anomaly in association with valvular surgery.

Morphological importance of coronary ostia in equine

The position of the coronary ostia was investigated in 70 segments of the aorta from young adult crossbred horses. After fixation with a 4% buffered aqueous formaldehyde solution and cautious dissection of the aortic bulb, the morphometric relationships between the coronary ostium and the aortic valvar elements were digitally analysed with the support of Image-Pro Plus® software. In horses, the left coronary ostium was near to the right valvular commissure in all cases (100%) analysed in this study. The left coronary ostium was at the level of the intercommissural line in 57.1% and below it in 42.9%. The right coronary ostium was near to the left valvular commissure in 58.6% (2.14 ± 0.32 cm) and close to the right valvular commissure in 41.4% (2.27 ± 0.40 cm). Concerning the intercommissural line, the right coronary ostia was at its level in 24.3% and below it in 75.7%. Accessory coronary ostia were observed in 8.6% of the specimens. In view of the results, it was possible to assume that the positions of the coronary ostia in equines tend towards a standard morphological disposition. Thus, perfusion of the left coronary artery occurs partly more frequently in ventricular systole and complete perfusion occurs less frequently in ventricular diastole. For the right coronary artery, perfusion is mostly complete in diastole and partially in ventricular systole.

Morphological importance of coronary ostia in sheep and swine

The aortic valve was investigated in 58 sheep and 60 swine without heart disease. After fixation in 4% formalin, the distance between the ostia and the elements of the right/left aortic sinuses was measured. For the left coronary ostium (LCO), it was found that in sheep 81% were below and 19% at the level of intercomissural line (IL). In pigs, 88.3% were below and 11.7% at the IL level. In sheep, the OCL was close to the right valve commissure (CVR) in 98.3% and close to the left valve commissure (CVV) in 1.7%. In pigs, it was close to RVC at 83.3% and close to LVC at 16.7%. Regarding to RCO, it was found that in sheep 69% was below, 1.7% was above and 29.3% at the IL level. In pigs, 20% were below, 15% above and 65% at the IL level. The distance of the RCO in relation to the valve commissures was 56.9% close to LVC and 43.1% close to RVC in sheep. In pigs, 81.7% were close to LVC and 18.3% close to RVC. The position of LCO was balanced between sheep and swine, while the RCO in swine was closer to CVE when compared with sheep. The accessory coronary ostium was observed in 18.6% of sheep and 10% of pigs. Thus, it is concluded that in sheep and swine the left coronary artery is perfused only in ventricular diastole. Perfusion of the right coronary artery occurs more frequently in diastole and less frequently in ventricular systole.

Anomalous aortic origin of coronary arteries: an alternative to the unroofing strategy

OBJECTIVES

Anomalous aortic origin of a coronary artery (AAOCA) is the second leading cause of sudden death in children and young adults. The most threatening anatomy is an interarterial and an intramural course, both probably involved in ischaemic phenomena and sudden death. The treatment of interarterial AAOCA remains controversial. Most of the published studies describe the results of the unroofing technique. Our study aims to evaluate the results of a different surgical approach.

METHODS

From 2005 to 2019, 61 patients were operated on for an interarterial AAOCA (median age 14.7 years). Forty patients had a right AAOCA, and 21 patients had a left AAOCA including 5 patients with intraseptal course. Seventy percent of patients were symptomatic. Five patients had an aborted sudden cardiac death. Two surgical techniques were used: an 'anatomical' repair for 35 patients (15 left and 22 right AAOCA) or a coronary translocation with creation of a neo-ostia in 19 patients (1 left and 18 right AAOCA). The 5 left AAOCA patients with an intra-septal course required a complete release of the coronary artery from the septum.

RESULTS

There was no early or late postoperative death. Three patients had an acute postoperative ischaemic event. Two patients required immediate angioplasty and stenting: 1 patient (7 years) with a hypoplastic right AAOCA and 1 patient (66 years) for inadequate tailoring after septal release. The third patient required an immediate surgical revision (H-2) for left AAOCA thrombosis at the level of the pericardial patch with full myocardial recovery at discharge. During follow-up, 1 patient with right AAOCA translocation and chronic chest pain required subsequent stenting and finally a coronary artery bypass grafting 2 years after initial surgery. One patient who had an asymptomatic mild right coronary stenosis 1 year after anatomical repair was successfully treated by angioplasty alone. All patients but 1 who underwent coronary translocation are totally asymptomatic. All patients with anatomical repair or septal release are free from ischaemic symptoms.

CONCLUSIONS

Anatomical repair might provide a better protective option for these patients. Unlike unroofing, it treats the entire intramural segment, relocates the ostium at the appropriate sinus level and corrects any acute take-off angle.

Congenital combined atresia of the left main coronary with supravalvar aortic stenosis

Congenital atresia of the left main coronary artery (LMCA) is an exceedingly rare phenomenon, and in the most of them, coronary artery bypass graft is required. We here describe a rare case of this anomaly that concomitantly was associated with supravalvar aortic stenosis and coronary–pulmonary fistula without the presence of conventional collateral circulation in a 16-year-old boy. The patient was admitted to our center with chest pain and dyspnea. Echocardiographic examinations showed supravalvar aortic stenosis with normal function of the aortic valve. Coronary angiography revealed atresia of LMCA with poorly developed left anterior descending coronary artery and well-developed circumflex coronary artery and diagonal artery that perfused by dominant and lengthy right coronary artery. The patient underwent coronary artery bypass grafting with repair of supravalvar aortic stenosis. The postoperative course was uneventful. The 6-month follow-up revealed normal diameter of the ascending aorta with symptomatic relief of preoperative chest complaint.

Case report: a common trunk of the coronary arteries

We describe the heart from a 79-year-old woman with no medical history of cardiac complaints. Her heart shows a regular right coronary artery (RCA) and a variant left coronary artery (LCA) arising from the right sinus of Valsalva. The common stem of the RCA and the LCA is extremely short. The LCA depicts a preinfundibular course with a cranial-anterior loop and reaches the intersection of the anterior interventricular sulcus and the left coronary sulcus, where it divides into the regular branches, the anterior interventricular branch (left anterior descending, LAD) and the circumflex branch (left circumflex, LCx). All further branching resembles a normal distribution with the posterior interventricular branch coming for the RCA. Such a variant LCA is extremely rare with a reported incidence of 0.17 %. However, recognition and angiographic demonstration of such a variation assume the highest priority in a patient undergoing, for instance, direct coronary artery surgery or prosthetic valve replacement.

Associated Coronary Anomalies in 135 Iranian Patients with Tetralogy of Fallot

Coronary artery anomalies are common among patients with tetralogy of Fallot. One hundred and thirty-five patients (80 males and 55 females) with tetralogy of Fallot who underwent repair between 1995 and 2002 were studied to determine the incidence of coronary anomalies in Iranian patients. Eight (5.9%) patients (4 males and 4 females) had a surgically relevant coronary artery anomaly: single coronary ostium in 5, origin of the left anterior descending artery from the right coronary artery in 2, and origin of the right coronary artery from the left coronary artery in 1. The surgical technique in 3 of these patients was repair of the ventricular septal defect with a transverse incision on the right ventricle, without damage to the coronary arteries. In another patient, an allograft aortic valve cylinder was inserted. In the other 4 patients with a single coronary ostium, placement of a limited transannular patch was adequate. Consideration of these anomalies during primary repair could decrease the risk of operation in such patients. However, it seems that the presence of anomalous coronary arteries does not affect incremental risk after surgical repair.

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.

Aborted sudden cardiac death associated with an anomalous right coronary artery

Coronary artery anomalies arising from the opposite sinus of Valsalva and having an interarterial course between the aorta (AO) and pulmonary artery (PA) are the second most common cause of sudden cardiac death among young athletes, after hypertrophic cardiomyopathy. The right coronary artery (RCA) originating from the AO above the left sinus of Valsalva (LSV) is an extremely rare anomaly. We report the first case of a RCA arising from the AO above the LSV that subsequently runs between the AO and the PA, discovered by a 64-slice multidetector coronary CT, in a patient who was successfully resuscitated from ventricular fibrillation (VF) cardiac arrest while running in a marathon race.

Anomalous origin of the right coronary artery from the posterior, non-coronary sinus of Valsalva diagnosed by cardiac magnetic resonance imaging

Anomalous origin of the right coronary artery from the posterior, non-coronary sinus is extremely rare and has never been reported in a paediatric-age competitive athlete. We report this very rare case of the right coronary artery arising from the posterior sinus. In the anomalous right coronary from the posterior sinus, the proximal right coronary artery appears widely patent and has no interarterial course.

Incidence and clinical relevance of primary congenital anomalies of the coronary arteries in children and adults

OBJECTIVES

To describe our experience in the management of coronary artery anomalies both in an adult and in a paediatric population and to compare the two groups for finding out differences in terms of angiographic incidence and treatment.

PATIENTS AND METHODS

Databases at the Department of Cardiology of San Martino Adult's Hospital and of Gaslini Children's Hospital were searched for all patients with a diagnosis of coronary artery anomaly who underwent coronary angiography between 1994 and 2006.

RESULTS

Coronary anomalies were diagnosed in 76 (1%) adult patients. Anomalous left circumflex artery was the commonest coronary anomaly (25%). Anomalous left coronary artery from pulmonary artery and myocardial bridges were the only anomalies responsible for angina-like symptoms. No patients except the one with anomalous left coronary artery from pulmonary artery needed surgical intervention. In the paediatric population, we found 28 (0.9%) patients with coronary anomalies. Anomalous left coronary artery from pulmonary artery was the most common anomaly (48%) and always required emergency surgical treatment; in addition there were two patients with stenosis of the left main coronary artery.

CONCLUSION

Coronary artery anomalies may be associated with very acute, even life-threatening symptoms in children, whereas they are usually clinically silent and detected by accident on coronary angiography in adults. Recognition of coronary artery anomalies enables early treatment or close follow-up in children, whereas it could be useful in case of cardiac surgery in adults.

Origin of all three coronaries separately from right sinus of valsalva - A rare anomaly

Anomalous coronary artery origin from opposite sinus is uncommon and separate origin of all three coronary arteries from right sinus of valsalva is exceptionally rare. The anomaly may cause ischemia due to atherosclerosis or due to altered ostial configuration, its exit angulations from the aorta, route of the artery, and intussuception. Various imaging modalities such as echocardiography, coronary angiography, computed tomography, and magnetic resonance imaging have been used to diagnose origin and course of anomalous coronary arteries. Management includes medical treatment and percutaneous or surgical revascularization. Percutaneous coronary intervention is technically challenging and needs judicious selection of guide catheters. We report a patient who presented with inferior wall myocardial infarction and separate origin of all three coronaries from right sinus of valsalva with successful percutaneous revascularization.

Anomalous origin of the coronary arteries in children: diagnostic role of three-dimensional coronary MR angiography

When the anomalous origin of coronary arteries (AOCA) is suspected in children (especially athletes), due to signs and symptoms of myocardial ischemia or on the basis of echocardiographic assessment, three-dimensional coronary magnetic resonance angiography (3D-CMRA) can be proposed for the fine morphological evaluation of coronary branches anatomy and course. We tested the diagnostic potential of CMRA angiography in a prospective study on AOCA in young patients. Between July 2005 and June 2008, 15 patients aged 6-29 years (mean age, 13.5 years+/-5.6 S.D.; median, 14) with clinical and echocardiographic suspicion of AOCA underwent CMRA (1.5 T), 3D whole-heart, free-breathing technique, without the use of contrast medium and beta-blockers, with a mean examination time of 30 min. We acquired a second scan of all patients to ameliorate the quality of the acquisition and to improve our experience. AOCA was confirmed by 3D-CMRA in 8 out of 15 cases (53%) and three different anatomical variants were demonstrated, that is, ectopic origin of the left circumflex artery arising from the right coronary artery with retro-aortic course in four cases, single coronary artery arising from the right sinus of Valsalva with interarterial course in one case, ectopic right coronary artery arising from the left sinus of Valsalva with interarterial course in one case; in two patients without anomalies of origin of the coronary arteries, elongated LMCA with angulation of the proximal segment of the left circumflex artery was present. When AOCA is suspected particularly in children (especially athletes), CMRA without the use of contrast medium is an effective diagnostic technique, which is useful to clarify the spatial position of the anomalous course of the main coronary branches in order to suggest the most convenient management of the disease. CMRA does not need contrast medium, needles, and beta-blockers; is repeatable in the same examination without the exposure to X-rays; allows a parent to stay near the child; and needs low collaboration in low-stress conditions.

Anomalous origin and retropulmonary course of an atherosclerotic stenosed left circumflex coronary artery

We here present the case of a rarely seen anomalous origin and retropulmonary course of the left circumflex artery from the proximal right coronary artery. The patient suffered from coronary ischemia due to stenotic lesions both in the aberrant circumflex coronary artery and in the first and second diagonal branches. Coronary bypass operation was performed.

Detection of coronary artery anomalies by dual-source CT coronary angiography

AIM

To retrospectively evaluate the clinical value of dual-source computed tomography (DSCT) coronary angiography in the diagnosis of coronary artery anomalies.

MATERIALS AND METHODS

A large cohort of 3625 consecutive patients, who underwent DSCT coronary angiography in our institute, was reviewed for coronary artery anomalies. All images were evaluated by two experienced readers using axial source images, multi-planar reformations (MPR), maximum intensity projections (MIP) and volume rendering (VR). Coronary artery anomalies were found in 36 patients (male 20, female 16, mean age 48 years, range 15-76 years). Of the 36 patients, 19 patients also underwent conventional coronary angiography (CCA).

RESULTS

The incidence of coronary artery anomalies was 0.99% (36/3625). Six different types of coronary artery anomalies were diagnosed by DSCT coronary angiography: (1) 11 anomalies of the right coronary artery; (2) five anomalies of the left coronary artery; (3) 10 anomalies of the left circumflex artery; (4) two single coronary artery; (5) one anomalous pulmonary origin of the coronary artery; (6) seven coronary artery fistula. Evaluation of the CCA resulted in a precise diagnosis in 53% (10/19) patients.

CONCLUSION

DSCT coronary angiography is a good diagnostic tool to examine coronary artery anomalies.

Origins of the coronary arteries and their significance

OBJECTIVE

To describe the normal and variant anatomy of the coronary artery ostia in Indian subjects.

INTRODUCTION

Anomalous coronary origins may cause potentially dangerous symptoms, and even sudden death during strenuous activity. A cadaveric study in an unsuspected population provides a basis for understanding the normal variants, which may facilitate determination of the prevalence of anomalies and evaluation of the value of screening for such anomalies.

METHODS

One hundred and five heart specimens were dissected. The number of ostia and their positions within the respective sinuses were observed. Vertical and circumferential deviations of the ostia were observed. The heights of the cusps and the ostia from the bottom of the sinus were measured.

RESULTS

No openings were present in the pulmonary artery or the non-coronary sinus. The number of openings in the aortic sinuses varied from 2-5 in the present series; multiple ostia were mostly seen in the anterior sinus. The majority of the ostia lay below the sinutubular ridge (89%) and at or above the level of the upper margin of the cusps (84%). Left ostial openings were mainly centrally located (80%), whereas the right coronary ostia were often shifted towards the right posterior aortic sinus (59%).

DISCUSSION

The preferential location of the ostia was within the sinus and above the cusps, but below the sinutubular ridge. On occasion, normal variants like multiple ostia, vertical or circumferential shift in the position, and slit-like ostia may create confusion in interpreting the images and pose a difficulty during procedures like angiography, angioplasty, and coronary artery bypass grafting.

Visualization of anomalous origin and course of coronary arteries in 748 consecutive symptomatic patients by 64-slice computed tomography angiography

Background

Coronary artery anomalies (CAAs) are currently undergoing profound changes in understanding potentially pathophysiological mechanisms of disease. Aim of this study was to investigate the prevalence of anomalous origin and course of coronary arteries in consecutive symptomatic patients, who underwent cardiac 64-slice multidetector-row computed tomography angiography (MDCTA).

Methods

Imaging datasets of 748 consecutive symptomatic patients referred for cardiac MDCTA were analyzed and CAAs of origin and further vessel course were grouped according to a recently suggested classification scheme by Angelini et al.

Results

An overall of 17/748 patients (2.3%) showed CAA of origin and further vessel course. According to aforementioned classification scheme no Subgroup 1- (absent left main trunk) and Subgroup 2- (anomalous location of coronary ostium within aortic root or near proper aortic sinus of Valsalva) CAA were found. Subgroup 3 (anomalous location of coronary ostium outside normal "coronary" aortic sinuses) consisted of one patient with high anterior origin of both coronary arteries. The remaining 16 patients showed a coronary ostium at improper sinus (Subgroup 4). Latter group was subdivided into a right coronary artery arising from left anterior sinus with separate ostium (subgroup 4a; n = 7) and common ostium with left main coronary artery (subgroup 4b; n = 1). Subgroup 4c consisted of one patient with a single coronary artery arising from the right anterior sinus (RAS) without left circumflex coronary artery (LCX). In subgroup 4d, LCX arose from RAS (n = 7).

Conclusions

Prevalence of CAA of origin and further vessel course in a symptomatic consecutive patient population was similar to large angiographic series, although these patients do not reflect general population. However, our study supports the use of 64-slice MDCTA for the identification and definition of CAA.

Coil embolization of coronary artery fistulas. A single-centre experience

BACKGROUND AND PURPOSE

Congenital coronary artery fistula (CAF) is an uncommon anomaly. It can become symptomatic, associated with significant morbidity and mortality. We report our experience in percutaneous treatment of CAF.

METHODS AND RESULTS

Four patients with five CAFs were treated. All were symptomatic at admission. Four fistulas rose from the left anterior descending coronary artery. The fifth originated from the right coronary sinus. All drained into the pulmonary artery. Percutaneous treatment was performed using microcoils in two cases and Hydrocoils in the last two patients (three fistulas). A complete occlusion was achieved in all. There was no complication related with the procedure, and all were asymptomatic at the follow-up.

CONCLUSIONS

Transcatheter closure of CAFs with microcoils/Hydrocoils is feasible and safe in the anatomically suitable vessels, with low rates of complications. Percutaneous treatment with microcoils/Hydrocoils is a valid option in symptomatic patients.

Imaging of coronary artery anomalies: the role of multidetector computed tomography

BACKGROUND

Coronary artery anomalies are evaluated by using catheter-based angiography. Multidetector row-computed tomography (MDCT) is a new noninvasive imaging technique that has excellent spatial resolution for detecting the origin and course of a coronary anomalous vessel.

OBJECTIVE

To determine the sensitivity of multidetector computed tomography in patients who had coronary artery anomaly demonstrated by conventional coronary angiography.

MATERIAL AND METHODS

A retrospective evaluation to identify 23 patients, who underwent retrospective electrocardiographic (ECG)-gated MDCT, was done and in whom an anomalous coronary vessel was found at a single center. Metoprolol (50-100 mg) was given orally to all patients to reduce heart rate so as to get high-quality MDCT images. After performing MDCT, the CT scans of each patient were analysed and compared with their coronary angiograms by two experienced radiologists and one cardiologist who were unaware about the study, and the sensitivity of MDCT was determined.

RESULTS

Twenty-three patients (age range 28-73) with seven different coronary arteries of the anomalous type were evaluated. Nineteen patients had an anomalous left coronary artery; three patients had an anomalous single coronary artery; and one patient had an anomalous right coronary artery. The most common anomaly type was the left circumflex coronary artery (52%). The origin and course of all anomalous vessels were detected by ECG-gated MDCT (Lightspeed 16, GE Medical Systems, Milwaukee, Wisconsin, USA). The sensitivity of 100% of MDCT was detected in patients who had anomalous coronary vessels.

CONCLUSION

We suggest that MDCT could be a non-invasive alternative imaging technique to conventional coronary angiography for screening the anomalous vessels of coronary arteries because of its excellent spatial resolution, which is very important for detecting the relationship of anomalous vessels with great arteries and cardiac structures.

Exercise-induced myocardial ischemia in a patient with dislocated right coronary artery orifice in the right sinus of Valsalva

Anomalous origin of the right coronary artery (RCA) is a rare congenital anomaly, which may cause myocardial ischemia and sudden death. In most cases, the RCA orifice is located in the left sinus of Valsalva and the RCA courses between the great arteries. We report a case in whom the RCA orifice is located in the right sinus of Valsalva but myocardial ischemia in the territory of the RCA was induced by exercise. Multidetector-row computed tomography showed that the RCA orifice was located in the right sinus of Valsalva adjacent to the left sinus of Valsalva and the RCA coursed between the great arteries. Compression of the RCA by the great arteries during exercise was thought to be the major cause of myocardial ischemia.

Demonstration of an anomalous connection between the left coronary artery and the pulmonary artery using a multislice CT 64

In this article, we describe two cases of anomalous connection of the left coronary artery. The first case is an infant of 4 years with an anomalous origin of the left anterior descending (LAD) artery and the diagonal branches and a circumflex artery which originated from the pulmonary artery. The second case is an adult of 50 years with the coronary artery originating from the pulmonary artery. Anomalous origin of the left coronary artery from the pulmonary artery is an uncommon congenital cardiac anomaly with an incidence of 0.25% among all congenital heart defects (Parale and Pawar [2006], J Assoc Physicians India 54:397-399). The originality of this communication consists in the use of a multislice CT scanner as a support for the angiography. The result is an original image with three dimensional details; in the case of the infant, it was determinant in the choice of the surgical approach.

Coronary artery anomalies

Coronary artery anomalies are uncommon findings but can be of significant clinical importance in a small number of individuals. Clinical presentation depends on the specific anomaly. Most coronary artery anomalies are benign and clinically insignificant, however, some anomalies are potentially significant and can lead to heart failure and even death. Noninvasive imaging has emerged as the preferred way to image coronary anomalies. Both electron beam computed tomography (EBCT) and magnetic resonance angiography (MRA) are useful for the diagnosis of anomalous coronary arteries. Recently, MDCT has also proven to be very useful in the detection and characterization of anomalous coronary arteries. This chapter will review the appearance of the most commonly encountered coronary anomalies on MDCT.

Origin of all three major coronary arteries from the right sinus of Valsalva: clinical, angiographic, and magnetic resonance imaging findings and incidence in a select referral population

OBJECTIVE

We sought to determine the incidence and imaging features by coronary angiography and cardiac magnetic resonance imaging (MRI) of anomalies in which the right, circumflex, and left anterior descending coronary arteries arise separately from the right sinus of Valsalva.

BACKGROUND

The anomalous origin of all major coronary arteries from separate ostia in the right sinus of Valsalva has been reported as exceedingly rare, with mainly isolated cases reported. A knowledge of the origin and proximal courses of aberrant arteries is critical for patient management.

METHODS

42 consecutive patients without other congenital heart disease referred to our institution for MRI evaluation of anomalous coronary artery over a six year period were evaluated. Analysis of angiograms and MRI was done to determine the anatomic origin and proximal pathway of coronary arteries (determined by conventional angiography and MRI) and degree of any stenosis (by angiography).

RESULTS

Seven of the 42 patients (17%) in this referral population had the described anatomy. Both conventional angiography and MRI depicted the origin and proximal courses of these arteries. In all patients, the circumflex passed behind the aorta. In three, the left anterior descending passed through the ventricular septum; in four, it passed anterior to the pulmonary trunk.

CONCLUSIONS

This series is the largest ever reported on this complex anatomical variant and the first to give a systematic analysis of the anatomy by angiography and MRI. This constellation of multiple anomalous coronary arterial origins and proximal courses may not be as rare as previously reported.

Double Right Coronary Artery Arising From the Left Main Stem and Right Coronary Sinus Associated with Ventricular Septal Defect in an Adult: An Extremely Rare Case

Anomalies of the coronary arteries are often asymptomatic and uncommon in general population. In this report we describe a case of a 48-year-old male patient with ventricular septal defect and double right coronary artery originating from the left main coronary artery and the right coronary sinus.

Multi-slice cardiac computed tomography reveals anomalous origin of the right coronary artery between the great arteries

We report a case of a 72-year-old man whose multi-slice cardiac computed tomography revealed an anomalous origin of the right coronary artery between the great arteries.

Echocardiographic diagnosis of clinically silent congenital coronary artery anomalies

BACKGROUND

The incidence of congenital coronary anomalies is mainly derived from autopsy series and pre-participation exams in athletes. Limited data exist regarding the spectrum of coronary anomalies that can be detected in asymptomatic patients. We sought to describe echocardiographically detected congenital coronary artery anomalies in asymptomatic children after implementing a screening protocol mandating identification of coronary artery origin and proximal course in all initial studies.

METHODS

Our database was searched from 1/1/1993 to 3/31/2006 and all echocardiograms coded for coronary anomalies were identified. Clinically "silent" congenital coronary anomalies were culled from that group.

RESULTS

Of the 168 "silent" coronary anomalies detected, 111 were anomalies of aortic origin, including 59 patients with "high coronary takeoff" and 30 patients with "wrong sinus" origin of either the left or right coronary artery. Small coronary fistulas were seen in 57. Associated congenital heart defects were found in 53% of individuals with coronary anomalies.

CONCLUSIONS

This study comprises the largest group of echocardiographically detected, "silent" but potentially clinically significant, congenital coronary anomalies in children. Prospective echocardiographic diagnosis of "high coronary takeoff", a risk factor for injury during cardio-pulmonary bypass, and asymptomatic intraseptal coronary stenosis are described for the first time.

Congenital Left Circumflex Coronary Artery Atresia Detected by 64-Slice Computed Tomography: A Case Report

A variety of coronary artery disorders, including intramyocardial coronary segments and coronary artery anomalies, can result in sudden cardiac death, especially in young adults. The detection of structural coronary artery abnormalities is important in the management of patients at risk of sudden cardiac death. Coronary artery anomalies occur in about 1% of the population. Congenital absence of left circumflex coronary artery (LCX) is a very rare vascular anomaly, and few cases have been reported in the literature, with a frequency of only 0.003% in all patients who underwent coronary angiography. Although coronary catheterization is the gold standard for the evaluation of coronary arterial patency disease, noninvasive computed tomography (CT) is considered the diagnostic method of choice for the detection and evaluation of coronary artery anomaly. Herein, we report the case of a 17-year-old girl who presented with exertional dyspnea and chest pain and who was studied at our emergency department with the final diagnosis of LCX atresia detected by 64-slice CT. She may be the first case of congenital LCX atresia proved by multislice CT.

Coronary Magnetic Resonance Imaging

This article highlights the technical challenges and general imaging strategies for coronary MRI. This is followed by a review of the clinical results for the assessment of anomalous CAD, coronary artery aneurysms, native vessel integrity, and coronary artery bypass graft disease using the more commonly applied MRI methods. It concludes with a brief discussion of the advantages/disadvantages and clinical results comparing coronary MRI with multidetector CT (MDCT) coronary angiography.

Remarkable anatomic anomalies of coronary arteries and their clinical importance: a multidetector computed tomography angiographic study

OBJECTIVE

An anomalous origin and course of the coronary arteries can be benign or life threatening. Recently, because of new advances in computed tomography technology, radiologists have begun to interpret the diseases of coronary arteries. We aimed to demonstrate some remarkable anomalies of coronary arteries, some of which were not shown by multidetector computed tomography (MDCT) coronary angiography previously, and to discuss the clinical importance of these anomalies.

MATERIALS AND METHODS

Seven hundred twenty-five consequent patients referred to Florence Nightingale Hospital and Atatürk University Hospital for MDCT coronary angiography were included in this study. The patients were between the ages of 33 and 78 years (mean +/- SD, 59 +/- 13.86 years). Four hundred ninety-seven patients (68.6%) were men, and 228 (31.4%) were women. All the examinations were evaluated by both a radiologist and a cardiologist.

RESULTS

The incidence of anomalous anatomical origin and course of the coronaries found in our study group was 5.79% (n = 42). The anomalies found in our study are absence of the right coronary artery (RCA; n = 1, 0.13%), ectopic origin of RCA from the left anterior descending (LAD) artery (n = 1, 0.13%), absence of the left main coronary artery (n = 4, 0.52%), ectopic origin of the left main coronary artery from the right sinus of Valsalva (n = 1, 0.13%), double LAD and ectopic origin of LAD from RCA (n = 1, 0.13%), ectopic origin of the left circumflex artery from the right sinus of Valsalva (n = 3, 0.39%), ectopic origin of the left circumflex artery from RCA (n = 2, 0.26%), and myocardial bridging (n = 29, 4%).

CONCLUSIONS

An anomalous origin of the coronary anatomy must be present in the interpretations because of its importance for patients, cardiologists, and surgeons. As a conclusion, our study showed that MDCT, especially volume rendering and maximum intensity projection techniques, may be useful for assessment of complex variations, when the conventional angiography may not be sufficient.