Prevalence of coronary artery anomalies in 12,457 adult patients who underwent coronary angiography

Congenital anomalies of coronary artery misdiagnosed as coronary dilatations in Kawasaki disease: A clinical predicament

BACKGROUND

2D-echocardiography (2DE) has been the primary imaging modality in children with Kawasaki disease (KD) to assess coronary arteries.

AIM

To report the presence and implications of incidental congenital coronary artery anomalies that had been misinterpreted as coronary artery abnormalities (CAAs) on 2DE.

METHODS

Records of children diagnosed with KD, who underwent computed tomography coronary angiography (CTCA) at our center between 2013-2023 were reviewed. We identified 3 children with congenital coronary artery anomalies in this cohort on CTCA. Findings of CTCA and 2DE were compared in these 3 children.

RESULTS

Of the 241 patients with KD who underwent CTCA, 3 (1.24%) had congenital coronary artery anomalies on CTCA detected incidentally. In all 3 patients, baseline 2DE had identified CAAs. CTCA was then performed for detailed evaluation as per our unit protocol. One (11-year-boy) amongst the 3 patients had complete KD, while the other two (3.3-year-boy; 4-month-girl) had incomplete KD. CTCA revealed separate origins of left anterior descending artery and left circumflex from left sinus [misinterpreted as dilated left main coronary artery (LCA) on 2DE], single coronary artery (interpreted as dilated LCA on 2DE) and dilated right coronary artery on 2DE in case of anomalous origin of LCA from the main pulmonary artery. The latter one was subsequently operated upon.

CONCLUSION

CTCA is essential for detailed assessment of coronary arteries in children with KD especially in cases where there is suspicion of congenital coronary artery anomalies. Relying solely on 2DE may not be sufficient in such cases, and findings from CTCA can significantly impact therapeutic decision-making.

Quadriostial Origin of the Coronary Arteries: A Case Report

A 75-year-old male, with a history of hypertension and peripheral vascular disease, presented to the cardiac catheterization lab for an elective coronary angiogram after an abnormal cardiac stress test. The coronary angiogram results showed a total of four separate coronary artery ostia. Within the right coronary cusp, there were two separate ostia as opposed to a single ostia that supplies the right coronary artery (RCA). The additional ostia gave rise to the left anterior descending artery (LAD). Further, as opposed to the single ostia in the left coronary cusp, there were two separate ostia creating a left circumflex (LCX) and marginal artery. Despite this anomalous anatomy, the patient was asymptomatic and instructed to continue to follow up with outpatient cardiology. Our case report discusses this unique quadriostial coronary anatomy, the complications that can arise from anomalous coronary arteries, diagnoses, and management of such cases.

Prevalence of anomalies and variants of coronary arteries: A single center study by coronary CT angiography

PURPOSE

It has been demonstrated that the coronary artery anomalies (CAAs) are generally asymptomatic. However, some cases can cause severe life threatening events. As coronary computed tomography angiography (CCTA) has emerged as a non-invasive alternative to invasive coronary angiography for the evaluation of coronary anatomy, the prevalence of CAAs in CCTA may more closely reflect the true prevalence in the general population. So we aimed to review and determine the prevalence of CAAs and variants retrospectively in patients who underwent CCTA at our center.

METHODS

Reports of 1802 patients who underwent CCTA at the radiology department of our university hospital were traced for CAAs. At least two independent investigators reviewed the images, which were selected for further assessment prior to final classification.

RESULTS

One hundred and fifty two anomalies in 152 patients (8.44 %) were encountered. Origin of any coronary artery from the pulmonary trunk in 1 (0.06 %), origin of LMCA from right sinus in 1 (0.06 %), origin of right coronary artery (RCA) from left sinus in 5 (0.28 %), origin of left anterior descending artery (LAD) from right sinus in 2 (0.11 %), origin of circumflex branch (RCx) of LMCA from right sinus in 6 (0.33 %), origin of RCx from RCA in 4 (0.22 %), origin of any coronary artery from the ascending aorta in 2 (0.11 %), split RCA in 5 (0.28 %), RCx and left marginal artery from the first diagonal artery in 1 (0.06 %), myocardial bridging in 123 (6.83 %) and fistula in 2 (0.11 %) were detected as CAAs.

CONCLUSION

The prevalence of CAAs observed in this study was similar to the literature. CCTA can clearly visualize the anomalous origin, course and termination of the coronary artery.

A Survey on the Management of Anomalous Aortic Origins of the Coronary Arteries

The management of patients with an anomalous aortic origin of a coronary artery (AAOCA) remains controversial despite the publication of the 2017 American Association for Thoracic Surgery (AATS) expert guidelines. We surveyed the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery and the Pediheart.net online community regarding their care of patients with anomalous origins of the right or left coronary from the opposite cusp with inter-arterial courses and compared them to the AATS guidelines. We received 111 complete responses. Four notable variations from the AATS recommendations were identified. Respondents were more likely to use ECG exercise testing than the stress imaging recommended in the AATS guidelines. For a 16-year-old with AAOCA, recommendations for surgery generally followed the AATS guidelines. However, for asymptomatic left AAOCA without signs of ischemia on stress imaging, only 69.4% felt surgery was appropriate or somewhat appropriate. In the setting of a 16-year-old with right AAOCA free from signs or symptoms of ischemia, respondents were more likely to recommend surgery if the patient was a competitive athlete, a topic not directly addressed in the AATS guidelines. After surgical treatment of AAOCA, only 24% of respondents recommended lifelong antiplatelet therapy despite recommendations for this in the AATS guidelines. Respondents recommendations were generally consistent with the 2017 AATS guidelines but with important variations in the use of stress imaging, indications for surgery in asymptomatic left AAOCA, the impact of identification as a competitive athlete and duration of postoperative antiplatelet therapy.

The functional impact on donor vessel following transcatheter closure of coronary artery fistulas-a retrospective study using QFR analysis

Background

The impact of transcatheter closure of coronary artery fistula (CAF) and residual shunt after occlusion on improving blood flow in the donor vessel remains uncertain.

Objectives

To evaluate the functional impact on the donor vessel following CAFs closure using QFR (Quantitative Flow Ratio) analysis.

Methods

A total of 46 patients with 48 CAFs who underwent transcatheter closure at Shanghai Chest Hospital and Shuguang Hospital between March 2015 and August 2023 were included in the review. The clinical, angiographic details, and QFR data were subjected to analysis. The size of the fistulae was defined according to the ratio between the diameters of the fistulae and the largest diameter of the coronary vessel not feeding the coronary fistula.

Results

Among 48 CAFs, the average diameter of the fistulae ostium was 3.19 ± 1.04 mm, while the mean diameter of the donor vessel segment following fistulae was 3.45 ± 1.01 mm. The mean QFR value of the donor vessels with medium CAFs was found to be significantly lower than those with small CAFs (0.93 ± 0.10 vs. 0.98 ± 0.03; p < 0.05). Furthermore, the mean QFR value of donor vessels with medium CAFs was observed to be significantly improved after occlusion (0.99 ± 0.01 vs. 0.93 ± 0.10; p = 0.01). However, there was no statistical difference in the mean QFR value of donor vessels with small CAFs before and after occlusion (0.98 ± 0.03 vs. 0.98 ± 0.02; p > 0.05). Moreover, the changes in QFR were more pronounced in donor vessels with medium CAFs compared to those with small CAFs after occlusion (0.06 ± 0.10 vs. 0.005 ± 0.012; p = 0.01). There is no statistical difference in the mean QFR variation and QFR variation rate between donor vessels with CAFs that occurred residual shunt and those without residual shunt after occlusion (p > 0.05).

Conclusions

The presence of medium CAFs has a significant impact on the blood flow of the donor vessel, as compared to small CAFs, and may benefit from occlusion. A small residual shunt has no significant impact on the effectiveness of CAFs occlusion in enhancing donor blood flow.

Anatomical Variants of the Origin of the Coronary Arteries: A Systematic Review and Meta-Analysis of Prevalence

PURPOSE

The most common anomaly is an anomalous left coronary artery originating from the pulmonary artery. These variants can be different and depend on the location as well as how they present themselves in their anatomical distribution and their symptomatological relationship. For these reasons, this review aims to identify the variants of the coronary artery and how they are associated with different clinical conditions.

METHODS

The databases Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS were researched until January 2024. Two authors independently performed the search, study selection, and data extraction. Methodological quality was evaluated using an assurance tool for anatomical studies (AQUA). Pooled prevalence was estimated using a random effects model.

RESULTS

A total of 39 studies met the established selection criteria. In this study, 21 articles with a total of 578,868 subjects were included in the meta-analysis. The coronary artery origin variant was 1% (CI = 0.8-1.2%). For this third sample, the funnel plot graph showed an important asymmetry, with a p-value of 0.162, which is directly associated with this asymmetry.

CONCLUSIONS

It is recommended that patients whose diagnosis was made incidentally and in the absence of symptoms undergo periodic controls to prevent future complications, including death. Finally, we believe that further studies could improve the anatomical, embryological, and physiological understanding of this variant in the heart.

A Rare Case of Symptomatic Anomalous Origin of the Right Coronary Artery With a High Interarterial Course Between the Pulmonary Artery and the Aorta

The congenital anomalous origin of the right coronary artery (AORCA) with an incongruous course is a rare malformation that can manifest as exertional chest pain, syncope, arrhythmias, heart failure, and sudden cardiac death. We present a case of a 42-year-old male with a history of hypercholesterolemia who presented with chest pain and dizziness upon exertion for two weeks. The physical examination was unremarkable, and the patient was hemodynamically stable. Initial blood tests were normal. Electrocardiogram (ECG) showed sinus bradycardia at 56 bpm without ST or T wave changes. A cardiac stress test indicated antero-apical inducible ischemia with a moderate probability of stress-induced ischemia. Computed tomography angiography (CTA) revealed an AORCA with a high interarterial course between the pulmonary artery and the aorta. Subsequent left heart catheterization confirmed the anomalous origin and revealed atherosclerotic disease. This anomaly was identified as the cause of the patient's symptoms due to the compression of the right coronary artery (RCA). The patient was treated with aspirin and statin and underwent successful internal mammary artery-RCA bypass grafting. Postoperatively, the patient's symptoms resolved, and there were no further episodes of chest pain.

Management of a Rare Case of Multiple Coronary Artery Fistulas Associated with Ascending Aortic and Root Aneurysm: Case Report and Review of Literature

Coronary artery fistulas draining into the left ventricle is a rare finding. They can be associated with other congenital cardiac anomalies like ventricular septal defect or tetralogy of Fallot. While most of them are asymptomatic, they can lead to severe cardiac complications like infective endocarditis, heart failure, or myocardial ischemia. Symptomatic coronary artery fistulas can be managed surgically or percutaneously. We present a case of a 61-year-old male patient with both left anterior descending artery and right coronary artery fistulas draining into the left ventricle associated with ascending aorta and root aneurysm. Preoperative assessment for myocardial ischemia and the size and location of the fistulas was performed. The echocardiography stress test was negative. Surgery consisted of replacement of the ascending aorta and reconstruction of the noncoronary sinus with a Dacron patch with aortic valve preservation and no intervention for the coronary artery fistulas. The surgical strategy was adapted for cardioplegia administration to compensate for the volume of coronary blood drained into the left ventricle and for better protection of the distal myocardium.

Prevalence and characteristics of coronary artery fistulas among 20 259 patients undergoing invasive coronary angiography

BACKGROUND

Coronary artery fistula (CAF) is a rare coronary anomaly. This study aimed to investigate the prevalence, clinical features, and imaging characteristics of CAF among patients undergoing coronary angiography (CAG).

METHOD

This was a retrospective study including 20 259 consecutive patients (12 458 were male) who underwent CAG at our institution from September 2018 to March 2023. Electronic angiography records were reviewed, and a total of 86 (0.42%) CAF patients were enrolled and analyzed.

RESULT

Of the 86 CAF patients, 42 (49%) were male. Thus, the prevalence of CAF for males and females was 0.34% and 0.56%, respectively. Arrhythmia, left ventricular (LV) hypertrophy, LV dilation, and LV systolic dysfunction were observed in 38, 25, 10 and 5 cases, respectively. Among the 86 CAF patients, a total of 117 CAFs were detected. 61 (71%) patients had a single CAF, and the remaining 25 (29%) patients had multiple CAFs. Of the 117 CAFs, the most common origins and terminations were the left anterior descending artery (n = 50) and the pulmonary artery (n = 73), respectively. The CAF diameters were greatly varied, ranging from unmeasurable to 7.8 mm, and 22 (18%) CAFs were larger than 3 mm.

CONCLUSION

In the present study, the prevalence of CAF was 0.42% with a female predilection. Arrhythmia, LV remodeling and dysfunction were common. Seventy-one percent of patients had a single CAF. The left anterior descending artery and the pulmonary artery were the most common origin and termination of CAFs, respectively. Most CAFs were small, and 18% of CAFs were larger than 3 mm.

Image and Clinical Characteristics of the Right Coronary Artery Originating From the Left Coronary Sinus: A Database Review

This article systematically explores the imaging and clinical characteristics of a relatively rare cardiac anomaly: the right coronary artery originating from the left coronary sinus. Through a comprehensive analysis of existing literature, this study aims to provide a comprehensive understanding of the prevalence, diagnostic methods, and potential clinical implications of this anatomical variation. Anatomical classification is introduced, along with clinical imaging diagnostic methods, including coronary angiography, computed tomography, and magnetic resonance imaging. Additionally, the review delves into the clinical significance of this anomaly, including its potential associations with myocardial ischemia, arrhythmias, and acute cardiac events, outlining clinical approaches to diagnosing myocardial ischemia. The study results consolidate current knowledge about this cardiac variation, emphasizing the importance of recognizing and appropriately managing it in clinical practice.

Coronary Artery Fistula: A Diagnostic Dilemma

Coronary artery fistula (CAF), although one of the rare coronary anomalies, is becoming increasingly more detectable in the recent years due to advancements in cardiac diagnostic imaging. Its long-term prognostic implications and importance for the cardiovascular system remain a dilemma for cardiologists and patients. Based on a variety of haemodynamic symptoms and complications, cardiologists must be aware of the characteristics of CAF and the diagnostic importance of multi-slice CT in evaluation, pre-procedural management and follow-up. Both surgical and percutaneous options are available for symptomatic patients or those with complications, while management of asymptomatic CAF remains a viable alternative.

Cinematic rendering of the coronary-pulmonary arterial fistula

Coronary-pulmonary arterial fistula is a rare coronary artery abnormality disease, which refers to a coronary fistula that terminates at the pulmonary artery. Coronary-pulmonary fistulas are much less common in children than in adults, and the small fistulas are easily missed. We report the case of a 9-year-old girl who presented with coronary-pulmonary arterial fistula. She underwent multimodal imaging, including chest X-ray, echocardiography, computed tomography with 3-dimensional cinematic rendering. We found that the cinematic rendering images clearly showed the small-caliber fistulous connections. The combination of CT and echocardiography can effectively help doctors understand the anatomical details and hemodynamic information.

Successful surgical management of a single coronary artery with giant coronary artery aneurysm with fistula to the right ventricle

A giant coronary artery aneurysm (GCAA) concurrent with coronary artery fistula is a rare condition, and it becomes even more unusual when combined with a single coronary artery (SCA) anomaly. Here, we report such an extremely rare case, who is a 35-year-old woman presenting with severe chest distress. A GCAA with fistula to the right ventricle was noted, occurring in a single coronary artery, diagnosed by multimodality cardiovascular imaging techniques. Both GCAA and coronary artery fistula can cause severe cardiac complications, which jeopardize life. While an SCA is mostly asymptomatic, it may also lead to sudden cardiac death as well. Therefore, surgical intervention was recommended. We chose a novel thrombus-inducing strategy to eliminate the GCAA and repair the fistula. Symptoms were relieved after the surgery, and the patient remained asymptomatic over 8 months of follow-up.

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.

An Anomalous Left Main Coronary Artery Arising From the Right Sinus of Valsalva With Anginal Chest Pain

An anomalous coronary artery (ACA) is a congenital malformation or variation where one or both coronary arteries have an abnormal origin. This condition has been associated with a high risk of adverse cardiac events, including sudden cardiac death. Our patient initially presented nine years before the diagnosis of the ACA with anginal chest pain on exertion. The patient had positive nuclear stress with both ST depressions and ST elevations, as well as transient ischemic dilatation of 1.36. A coronary artery angiogram revealed an anomalous left coronary artery originating from the right coronary sinus. The distal anatomy was determined with coronary computed tomography angiography (CCTA), which showed an interarterial course. The patient underwent coronary artery bypass surgery following CCTA.

3D Printed Model-Guided Neonatal Transcatheter Closure of Left Main Coronary Artery-to-Right Ventricle Fistula

We report on a 2-week-old infant with huge left main coronary artery-to-right ventricular outflow tract fistula causing myocardial ischemia due to global coronary steal who was successfully submitted to percutaneous closure guided by a 3-dimensional-printed model using a duct-occluder vascular plug. (Level of Difficulty: Advanced.).

Coronary Artery Anomalies: A Short Case Series and Current Review

Coronary artery anomalies (CAAs) are rare congenital cardiovascular defects that can present in various ways depending on the origin, course, and termination of the abnormal coronary artery fistula. It is sometimes detected incidentally during procedures such as coronary angiography or autopsies. While adults with this condition are often asymptomatic, some may experience angina, congestive heart failure, myocardial infarction, cardiomyopathy, ventricular aneurysms, or sudden cardiac death (SCD). In fact, it is the second leading cause of SCD among young athletes and requires more studies to handle such patients efficiently. To illustrate the many possible manifestations of this unusual diagnosis, we present a series of five cases. We have also reviewed the different varieties of this rare congenital anomaly and discussed the latest diagnostic tests and treatment plans.

Transcatheter Closure of a Coronary Artery Fistula in a Neonate with Tetralogy of Fallot

Coronary artery-to-pulmonary artery fistulae are a not uncommon finding in patients with Tetralogy of Fallot (TOF) and collateral-dependent pulmonary blood flow. Management for these fistulae is often primary surgical ligation or unifocalization at the time of complete repair, dependent on the presence of dual blood flow to the involved areas. We present the case of a 32-week premature boy weighing 1.79 kg with TOF, confluent branch pulmonary arteries, major aortopulmonary collaterals, and right coronary artery to main pulmonary artery fistula. The patient demonstrated evidence of coronary steal into the pulmonary vasculature with an elevation in the troponin level without hemodynamic instability, and subsequently underwent successful transcatheter occlusion of the fistula via right common carotid access using a Medtronic 3Q microvascular plug. This case demonstrates the realistic potential for early coronary steal in this physiology and possibility of transcatheter therapy even in a small neonate.

Acute Ischemic Stroke and Transient Ischemic Attack in ST-Segment Elevation Myocardial Infarction Patients Who Underwent Primary Percutaneous Coronary Intervention

BACKGROUND

Acute ischemic stroke (AIS) is a rare but critical complication following ST-elevation myocardial infarction (STEMI). The risk of AIS or transient ischemic attack (TIA) may be amplified by invasive procedures, including primary percutaneous coronary intervention (PCI). This study aimed to investigate the factors associated with in-hospital AIS/TIA in patients with STEMI who required primary PCI.

METHODS

We included 941 STEMI patients who underwent primary PCI and divided them into an AIS/TIA group (n = 39) and a non-AIS/TIA group (n = 902), according to new-onset AIS/TIA. The primary interest was to find the factors associated with AIS/TIA by multivariate logistic regression analysis. We also compared clinical outcomes between the AIS/TIA and non-AIS/TIA groups.

RESULTS

The incidence of in-hospital deaths was significantly higher in the AIS/TIA group (46.2%) than in the non-AIS/TIA group (6.3%) (p < 0.001). Multivariate analysis revealed that cardiogenic shock (OR 3.228, 95% CI 1.492-6.986, p = 0.003), new-onset atrial fibrillation (AF) (OR 2.280, 95% CI 1.033-5.031, p = 0.041), trans-femoral approach (OR 2.336, 95% CI 1.093-4.992, p = 0.029), use of ≥4 catheters (OR 3.715, 95% CI 1.831-7.537, p < 0.001), and bleeding academic research consortium (BARC) type 3 or 5 bleeding (OR 2.932, 95% CI 1.256-6.846, p = 0.013) were significantly associated with AIS/TIA.

CONCLUSION

In STEMI patients with primary PCI, new-onset AIS/TIA was significantly associated with cardiogenic shock, new-onset AF, trans-femoral approach, the use of ≥4 catheters, and BARC type 3 or 5 bleeding. We should recognize these modifiable and unmodifiable risk factors for AIS/TIA in the treatment of STEMI.

Origin of all Three Coronaries from Single Ostium: A Rare Case Report

Origin of coronary arteries from the opposite sinus of Valsalva is rare and origin from a single ostium is extremely rare. Patients with these anomalies may have myocardial ischemia because of altered ostial configuration, exit angulation from the aorta, the course between great arteries, and atherosclerosis. Usually, these anomalies are diagnosed during coronary angiography either by computed tomography or catheter-based. Management depends upon the coronary anomaly and associated clinical condition.

COVID-19-induced myocarditis in patient with anomalous origin of the left circumflex artery from the right coronary artery: a case report

The prevalence of coronary artery anomalies has been increasing due to the increasing usage of coronary angiography. There is a paucity of literature concerning management of viral-induced myocarditis in patients with anomalous coronary artery. We present a very unusual case of a 44-year-old man with anomalous origin of the left circumflex artery from the proximal ostium of the right coronary artery who was admitted for COVID-19-induced myocarditis. He presented with signs of heart failure and coronary angiography revealed the left circumflex artery with a separate ostium originating from the proximal right coronary artery. He was treated medically with Bisoprolol, Perindopril Arginine, Rivaroxaban, and Furosemide. His condition improved rapidly and he resumed regular life within 1 month. Coexistence of cardiac disease such as viral-induced myocarditis with an underlying anomalous origin of the coronary artery is challenging to spot and can lead to worse outcomes in case of misdiagnosis and inaccurate management.

Challenging Diagnosis of Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery

Anomalous origin of the right coronary artery (RCA) from the pulmonary artery, ARCAPA, is an extremely rare congenital heart disease. Only 200 cases were reported from 1885 to the present. Patients diagnosed with ARCAPA can be either asymptomatic or can experience symptoms, such as heart murmur, dyspnea, or angina, shortly after birth or around 40-60 years of life. Usually, those with isolated ARCAPA are diagnosed later in life compared to those who associate other structural cardiac defects. We report two cases of anomalous origin of the right coronary artery at the level of the pulmonary artery trunk (ARCAPA) that were diagnosed by invasive coronary angiography. Although asymptomatic, general recommendations suggest an early corrective intervention to prevent complications such as myocardial ischemia and cardiac dysfunction, which can lead to sudden cardiac death.

Left vs. right radial approach for coronary catheterization: Relation to age and severe aortic stenosis

Background

Old age and the presence of aortic stenosis are associated with the unfolding of the intrathoracic aorta. This may result in increased difficulties navigating catheters from the right compared to the left radial approach.

Objective

To investigate whether increasing age or presence of severe aortic stenosis was associated with increased catheterization success rates from left (LRA) compared to right radial artery approach (RRA).

Methods

We compared coronary angiography success rates of RRA and LRA according to different age groups and in a subgroup of patients with severe aortic stenosis.

Results

A total of 21,259 coronary angiographies were evaluated. With increasing age, the first pass success rate from either radial access decreased significantly (p < 0.001). In patients aged <85 years, there was no difference between LRA and RRA. However, in patients aged ≥85 years, LRA was associated with significantly higher success rates compared to RRA (90.1 vs. 82.8%, p = 0.003). Patients aged ≥85 years received less contrast agent and had shorter fluoroscopy time when LRA was used [86.6 ± 41.1 vs. 99.6 ± 48.7 ml (p < 0.001) and 4.5 ± 4.1 min vs. 6.2 ± 5.7 min (p < 0.001), mean (±SD)]. In patients with severe aortic stenosis (n = 589) better first pass success rates were observed via LRA compared to the RRA route (91.9 vs. 85.1%, p = 0.037).

Conclusion

LRA, compared to RRA, is associated with a higher first-pass catheter success rate for coronary artery angiography in patients aged ≥85 years and those with severe aortic stenosis.

Case report: Multimodal imaging diagnosis of a giant coronary artery fistula: A report of two cases

Being a very rare cardiac disease, most cases of coronary artery fistula (CAF) are genetic. Complications such as coronary steal syndrome, myocardial infarction, heart failure, or tamponade can manifest following the abnormal communication that the fistula creates between the coronary arteries and cardiac chambers or major vessels and the subsequent shunt. Most CAFs are small and asymptomatic, making diagnosis difficult. In symptomatic patients, the initial diagnostic workup is generally made with chest radiography and electrocardiography. Other imaging modalities have also been suggested to improve diagnostic accuracy. Cardiac catheterization and coronary angiography are currently the gold standard for diagnosis and planning the intervention, as they can recognize the quantum of the shunt as well as complications of a fistulous track (e.g., aneurysm formation, thrombus, leak, and the number of openings to the receiving chamber/vessel); however, this invasive method may be associated with risk. Herein, we report two patients with giant CAFs, one from the left circumflex artery to the coronary sinus and the other to the superior vena cava. Moreover, we describe how multimodal imaging, including two- and three-dimensional transesophageal echocardiography, coronary cineangiography, coronary computed tomography angiography, and enhanced chest computed tomography, can facilitate diagnosis and estimate the disease course in such patients. We believe that using multimodal imaging cannot only help the initial diagnosis regarding the presence of a CAF and the accurate anatomical site of the fistula in the patient but can also help predict the disease course and choose the most suitable treatment modality. Therefore, we suggest multimodal imaging be done to diagnose patients suspected of CAF. However, invasive cineangiography should be necessarily followed, regardless of whether an intervention is planned or not.

Anomalous Origin of the Right Coronary Artery From the Left Coronary Cusp Presenting as a Non-ST-Elevation Myocardial Infarction (NSTEMI)

Coronary artery anomalies are relatively uncommon in the general population with a roughly 1% incidence. Though oftentimes asymptomatic, these anomalies can be detrimental, resulting in myocardial infarction and even sudden cardiac death. Here, we present a case in which a 65-year-old male presented to the emergency room with substernal chest pain that radiated into his left arm. The patient's cardiac enzyme panel revealed a troponin of 10.14 ng/mL and a creatine kinase-myocardial band (CK-MB) of 78.8 ng/mL. Furthermore, the patient's electrocardiogram demonstrated normal sinus rhythm with no significant changes. Upon cardiac catheterization, his right coronary artery was found to originate from the left coronary cusp. Moreover, the anomalous artery demonstrated significant stenosis in its middle portion, which was presumably causing his elevated cardiac enzymes and anginal chest pain. The patient underwent successful percutaneous coronary intervention and was discharged the following day.

Concomitant cardiovascular malformations in isolated bicuspid aortic valve disease: a retrospective cross-sectional study and meta-analysis

Background

Congenital bicuspid aortic valve affects up to 2% of the general population. It occurs in complex congenital heart defects or in syndromes such as Turner, Marfan, or Loeys-Dietz. However, the majority of bicuspid aortic valves are considered to manifest as isolated malformations.

Methods

We aimed to assess retrospectively associated cardiovascular malformations in 200 individuals with bicuspid aortic valve considered to occur as an isolated manifestation. All individuals underwent transthoracic echocardiography, 164 thoracoabdominal tomographic imaging, and 84 coronary artery imaging. In addition, we also performed a meta-analysis of data from the literature to assess the occurrence of associate malformations.

Results

In our retrospective cross-sectional study collective, the mean age was 45±15 years, 154 (77%) individuals were male. Anatomy of bicuspid aortic valve according to Schaefer was type 1 in 142 (71%), type 2 in 35 (18%), type 3 in 2 (1%), unicuspid in 6 (3%), and unclassified in 15 (8%) individuals. Coarctation of the aorta had 4.2% of individuals, 3.6% had coronary anomalies. No individual had a patent ductus arteriosus, 0.5% had atrial and ventricular septal defect each, 1.5% mitral valve prolapse. No individual had a tricuspid valve prolapse. Our meta-analysis identified in cohorts with isolated bicuspid aortic valve 11.8% (95% CI: 7.7–16.0%) individuals with aortic coarctation, 3.7% (95% CI: 1.2–6.1%) with coronary anomalies, 3.3% (95% CI: 0.0–6.7%) with patent ductus arteriosus, 5.9% (95% CI: 1.3–10.5%) with ventricular septal defect and 1.6% (95% CI: 1.1–2.1%) with mitral valve prolapse.

Conclusions

Individuals with isolated bicuspid aortic valve may exhibit a variety of associated cardiovascular malformations and therefore screening for associated malformations may be warranted.

A Case of Takotsubo Cardiomyopathy in a Patient With Coronary Artery Fistula

Takotsubo cardiomyopathy (TTC) is also known as stress-induced cardiomyopathy and mimics acute coronary syndrome in the setting of non-obstructive coronary artery disease. It is associated with reversible left ventricular apical, mid, and/or basal wall motion abnormalities. A coronary artery fistula (CAF) is a connection between one or more of the coronary arteries and the cardiac chamber or great vessel. We present a case of an elderly woman who presented with chest pain and was found to have non-obstructive coronary artery disease with wall motion abnormality pattern consistent with TTC and multiple CAF involving the left circumflex coronary artery and pulmonary artery. This case highlights a rare association between two uncommon entities.

Coronary artery bypass grafting for coronary artery anomalies in infants and young children

OBJECTIVES

Coronary artery bypass grafting (CABG) has been reported for coronary artery diseases in patients with Kawasaki disease and coronary artery complications after arterial switch operations for transposition of the great arteries. However, only a few studies have explored this modality for congenital coronary artery anomalies. As congenital coronary artery anomalies, particularly left coronary artery atresia and stenosis, are one of the reasons for sudden death, coronary revascularization is often required in infants and young children. Therefore, we aimed to investigate the outcome of CABG for such anomalies in infants and young children.

METHODS

From 2014 to 2018, 3 infants and 2 children (median age: 10 months; range: 6-40 months) with coronary artery anomalies underwent CABG at our hospital. The indications for the procedure included left main coronary artery atresia and stenosis in 2 and 3 patients, respectively. Graft patency was evaluated postoperatively by contrast-enhanced computed tomography or coronary angiography, and postoperative outcomes (including death and cardiac events) were assessed during the follow-up period.

RESULTS

No 30-day or in-hospital mortalities were noted. Postoperative examinations revealed patent grafts in all patients. They were discharged without any cardiac complications. Regarding the outcomes at the follow-up period, the graft patency rate was 80.0% (4/5 grafts), with no deaths or cardiac events.

CONCLUSIONS

CABG is a useful strategy for coronary revascularization in infants and young children with coronary artery anomalies. Although the mid-term outcomes and patency are satisfactory, careful follow-up is necessary because the long-term outcomes remain unknown.

Investigation of the Frequency of Coronary Artery Anomalies in MDCT Coronary Angiography and Comparison of Atherosclerotic Involvement between Anomaly Types

Coronary artery anomalies (CAAs) are rare anatomical variations characterized by abnormal origin, course, or termination of the coronary arteries. This study aims to identify incidental CAAs in patients who underwent multidetector computed tomography coronary angiography (MDCTCA) to determine their incidence and to evaluate whether there is a difference between CAA types in terms of coronary atherosclerotic involvement. For this purpose, patients who underwent MDCTCA between December 2018 and January 2022 were retrospectively assessed. Of the 5200 MDCTCAs analyzed, CAAs were detected in 136 patients (2.61%). Of these 136 patients, 37 (27.2%) patients had an origin anomaly, 97 (71.3%) had a course anomaly, and 2 (1.5%) had a termination anomaly. There was no statistically significant difference between CAA types in terms of atherosclerotic involvement (p = 0.220). However, atherosclerotic involvement was high in vessels with anomalies when normal vessels with and without anomalies were compared (p = 0.005). Accurate detection of CAAs is vital for endovascular treatment or surgical intervention. MDCTCA is helpful both in the diagnosis of CAA and in the early detection and development of prevention strategies for coronary atherosclerosis.

Oldukça nadir bir koroner arter anomalisi: Non-koroner sinüsten çıkan sol ana koroner arter

Although they are rare, left coronary artery anomalies can cause complications with high mortality, including arrhythmia and cardiac arrest. Left main coronary artery originates from the non-coronary sinus abnormality is rarely observed. This abnormality has been defined as a benign pathology in the past, although it is described in the literature to cause morbidity and mortality in some cases. We present very rare case of the left main coronary artery arising from non-coronary sinus detected on CCTA.

Clinical Characteristics of Congenital Atresia of the Left Main Coronary Artery in 12 Children

BACKGROUND

Left main coronary artery atresia (LMCAA) is an extremely rare abnormality and only <100 cases have been reported worldwide. We describe the clinical manifestations, imaging features, prognosis, and treatments of LMCAA who were admitted in our department, which aimed to improve the clinical diagnosis and treatments of LMCAA in children.

METHODS

A retrospective study identified 12 patients diagnosed with congenital left coronary artery atresia at Pediatric Heart Center of Beijing Anzhen Hospital from June 2010 to June 2019. The clinical characteristics, imaging data, and treatment follow-up were analyzed.

RESULTS

Among the 12 cases, 8 were boys and 4 were girls; the age of onset was 2 months to 2 years old (median age 7 months); the age of diagnosis was 7 months to 6 years old (median age 2 years and 11 months). At the initial diagnosis, there were 4 cases of respiratory tract infection with cardiac murmur, 3 cases of cardiac shadow enlargement, 1 case of recurrent syncope, 2 cases of feeding difficulty with cardiac enlargement, and 2 cases of simple cardiac murmur. In 12 cases of electrocardiogram examination, 7 cases showed pathological Q waves of lead I, AVL and v4-v6; in 12 cases of chest X-ray examination, 8 cases showed cardiac shadow enlargement; in 12 cases of our hospital's first cardiac ultrasound examination, 4 cases were definitely diagnosed, and 8 cases showed the possibility of left coronary artery abnormality; in 5 cases of cardiac coronary CT angiography examination, 2 cases were confirmed, 2 cases reported suspected left coronary artery abnormality, and 1 case did not report abnormality; All cases were definitely diagnosed in 8 cases of angiography. Follow-up was performed from 1 to 8 years; one case died suddenly, one case of syncope after activity was treated by oral medication, 3 cases received open coronary angioplasty and mitral valvuloplasty, recovered well after operation, the rest of the children were treated by oral medication, and the symptoms are stable at present.

CONCLUSIONS

Left main coronary artery atresia is difficult to diagnose and can result in heart failure early in life. Timely diagnosis and reasonable treatment are the keys to improve the prognosis.

Coronary Artery Anomaly, What Radiologist Should Know?

심장 전산화단층촬영(이하 CT)은 현재 관상동맥기형을 진단하고, 평가하는 가장 정확한 진단 도구로 자리매김하였으며, 심장 CT 촬영 건수가 증가함에 따라 관상동맥기형을 종종 관찰할 수 있다. 본 종설은 관상동맥기형에서 영상의학과 의사들이 꼭 알아야 할 대표적인 기형의 CT 소견들에 대해 다루었다. 관상동맥기형의 종류를 3부분 즉, 기시부, 동맥 내, 그리고 연결 부위로 나누어 설명하였으며, 임상에서 볼 수 있는 대표적인 기형들 중심으로 다루었다. 특히 혈역학적 이상을 유발하거나, 급사의 위험이 있는 기형들의 CT상 위험한 해부학적 소견에 대해서는 자세히 기술하였다.

Coronary artery-to-pulmonary artery fistula in adults: evaluation with 320-row detector computed tomography coronary angiography

Background

To analyze the imaging features of coronary artery-to-pulmonary artery fistula (CPAF) on coronary computed tomography angiography (CCTA).

Methods

This was a retrospective study of 3,975 patients who underwent 320 row detector CCTA examinations in our hospital from May 2015 to July 2020. A total of 22 patients who diagnosed with CPAF were reviewed for CCTA imaging characteristics, including the origin, number, blood volume, opening size, and course of fistula vessels, and the drainage site, size, and imaging features of the fistula. All cases were analyzed for the presence of coronary atherosclerotic plaque and that of deficient left ventricular myocardial perfusion.

Results

A total of 22 CPAF cases detected by CCTA were collected (men, 11; women, 11; median age, 59.6±10.1 years). There were 7, 10, and 5 cases detected with 1, 2, and 3 fistula vessels, respectively, among which 4 originated from the left coronary artery, 4 from the right coronary artery, and 14 had bilateral origins. There were 10 cases in which the fistula vessels presented as a worm-like tortuous dilation with (n=5) or without (n=5) aneurysm, while 12 cases showed malformed vascular networks with (n=8) or without (n=4) aneurysm, respectively. The calculated incidence of aneurysm formation was 59.09%, and fistula vessels with an aneurysm had larger blood volume than those without. All fistula showed a single drainage site, with an average diameter of 2.81±1.48 mm where the diameter of fistula with aneurysm was larger than that without. The fistula vessels drained into the left anterolateral and anterior walls of main pulmonary artery and the proximal left inferior PA, respectively. Typical jet sign, smoke sign, and isodensity sign were presented in 22, 14 and 1 case, respectively. For the coexistent abnormalities analyzed in 22 cases, 17 participants with CPAF demonstrated hypoperfusion of the fistula vessels, and 11 demonstrated calcified plaque accompanied with luminal stenosis to different degrees.

Conclusions

The 320-row detector CCTA can comprehensively characterize the morphological features of CPAF, which is an optimal choice for physicians to make an accurate assessment before formulating patient management strategies.

Association between coronary dominance pattern and left ventricular mass index: Is there a gender disparity?

BACKGROUND

Increased left ventricular mass index (LVMI) and left ventricular hypertrophy (LVH) are independent predictors of adverse cardiovascular events. However, little is known regarding the association between coronary circulation and LVMI. We aimed to investigate the association between coronary dominance and LVMI, and to demonstrate the impact of coronary dominance pattern on the emergence of LVH.

METHODS

In total, 367 consecutive patients without known cardiovascular disease and significant obstructive coronary artery disease who underwent diagnostic coronary angiography were prospectively included in the study. Patients were divided into three groups according to coronary dominance pattern. Patients with right dominance (RD), co-dominance (CD) and left dominance (LD) patterns were compared regarding echocardiographically detected LVMI. Additionally, the association between coronary dominance pattern and LVH was investigated.

RESULTS

The frequency of RD, CD and LD patterns was 70.3%, 19.1% and 10.6%, respectively. LVMI was significantly higher in patients with CD pattern compared with those with RD and LD patterns (P < .001, for both comparisons). LVH was present in 71 (19.3%) patients. Importantly, the CD pattern was more frequent in patients with LVH compared with those without LVH (P < .001). No significant difference was found between women and men regarding the type of coronary dominance pattern. However, while the presence of CD pattern was found to be an independent predictor of LVH in women (OR:1.221, 95%CI:1.048-1.872, P < .001), no association was observed between coronary dominance pattern and LVH in men.

CONCLUSIONS

Coronary dominance pattern may significantly affect the LVMI, and it may be useful in the further risk stratification of female patients.

Case report of an acute coronary syndrome in a patient with artery coronary fistulae

Background

Coronary artery fistulae are rare vascular anomalies. Although they are usually asymptomatic, the presence of symptoms might present a challenge in the diagnostic and therapeutic management.

Case summary

We present a patient with chest pain whose initial tests were normal, but coronary artery fistulae were found. Single-photon emission computed tomography test showed ischaemia due to coronary artery fistulae and cardiac computed tomography helped in the planning of the percutaneous closure.

Discussion

CCT is emerging as an optimal non-invasive tool to characterise the morphology and course of coronary artery fistulae and may be essential for its accurate diagnosis and planning for percutaneous closure.

High Risk Features of an Anomalous Origin of the Right Coronary Artery

Anomalous aortic origin of the coronary arteries (AAOCA) is a rare congenital abnormality. It is usually asymptomatic and often found incidentally during coronary angiography. However, it can also be discovered during the autopsy of young healthy adults who have suffered from sudden cardiac death (SCD). AAOCA represents the second most common cause of SCD in young athletes. Herein, we report a case of a 39-year-old patient with left-sided right coronary anomaly with multiple high-risk features who presented with life-threatening symptoms for SCD but normal electrocardiography, echocardiography, and cardiac markers. The coronary computed tomography revealed an anomalous coronary artery from the left sinus of Valsalva with a hypoplasic origin and a high-risk path between the aorta and the pulmonary artery with a short intramural path. He was surgically managed with a coronary artery bypass with an uneventful follow-up.

A case of right ventricular infarction due to acute type A aortic dissection with anomalous aortic origin of the right coronary artery from the left sinus of Valsalva

Anomalous aortic origin of a coronary artery from the opposite sinus is a rare congenital condition that can cause sudden death in young people. When it is associated with acute aortic dissection, acute myocardial infarction can occur due to enlargement of the sinus of Valsalva. We report the case of a 71-year-old man with anomalous origin of the right coronary artery from the left sinus of Valsalva, who developed right ventricular infarction due to the compression of the right coronary artery between the aorta and pulmonary artery trunk.

Congenital Coronary Artery-to-Pulmonary Artery Fistula with Anomalous Origin of Right Coronary Artery from Pulmonary Artery: A Case of "Double Trouble"

Congenital coronary artery fistula is a rare coronary anomaly. Its clinical significance focuses mainly on the mechanism of coronary steal phenomenon. A combination of left main (LM) coronary artery-to-main pulmonary artery (MPA) fistula with anomalous origin of right coronary artery from the pulmonary artery (ARCAPA) was encountered in a 3-month-old infant who presented with tachypnea. Evaluation with echocardiography and CT confirmed the diagnosis. The patient underwent surgical ligation of LM-to-MPA fistula with direct reimplantation of ARCAPA to aortic root. Keywords: Pediatrics, CT, CT-Angiography, Echocardiography © RSNA, 2021.

Coronary Artery Fistulas: Indications, Techniques, Outcomes, and Complications of Transcatheter Fistula Closure

Coronary artery fistulas (CAFs) are rare coronary anomalies that are usually diagnosed incidentally with cardiac imaging. Small CAFs are generally asymptomatic and can close over time, while some untreated medium or large CAFs can enlarge, leading to clinical sequelae such as cardiac chamber enlargement or myocardial ischemia. With the advancement of transcatheter equipment and techniques, CAFs have been increasingly closed using a percutaneous approach. However, the procedure is not free of limitations given the risk for myocardial infarction, device embolization, and fistula recanalization. In this review, the authors illustrate the contemporary procedural considerations, techniques, and outcomes of transcatheter CAF closure.

Prevalence and Pattern of Congenital Coronary Artery Anomalies in Patients Undergoing Coronary Angiography at a Tertiary Care Hospital of Northern India

Objectives: To evaluate the prevalence and pattern of congenital coronary artery anomalies (CAAs) in the adult population undergoing catheter coronary angiography.

Methods: The coronary angiograms done between October 2015 and September 2020 were reviewed for the presence of coronary anomalies based upon Angelini's classification. The medical record of patients with anomalies was reviewed for symptomatology and indication of angiography.

Results: CAAs were found in 129 (87 males and 42 females) of 6,258 patients giving a prevalence of 2.06%. The mean age was 57.8 ± 11.8 (range 32-81) years. Among these, the anomalous origin and course of the coronaries were the most common anomaly seen in 81 (1.29%) patients, followed by intrinsic anomalies of the coronary arterial system in 44 (0.7%) patients and anomalies of coronary termination and anomalous anastomotic vessels in 2 (0.03%) patients each. Overall, the absence of the left main trunk with a separate origin of the left anterior descending (LAD) and the circumflex artery was the commonest anomaly seen in 46 (0.74%) patients, followed by dual LAD in 35 (0.56%) patients. The anomalous origin of the right coronary artery (RCA) from the left sinus was seen in 14 patients (0.22%) and that of the circumflex artery from the right sinus or right coronary artery was seen in 11 patients (0.17%). The origin of the left main and RCA from ascending aorta was found in eight (0.13%) patients. One (0.02%) patient had a single coronary artery, and another one (0.02%) had all the three coronary arteries arising from the right sinus; however, with separate ostia. The split RCA was seen in nine (0.14%) patients and there were two (0.03%) patients each of coronary artery fistulae, and of anomalous anastomotic vessels.

Conclusions: The prevalence of congenital coronary anomalies in this study was 2.06%. The commonest anomaly was that of origin and courses of the vessels, however, the pattern of anomalies is different from previous studies.

Anomalous Origin of the Right Coronary Artery Causing Myocardial Ischemia: A Case for a Multimodality Imaging Approach

A 46-year-old man was admitted with non-ST elevation myocardial infarction and newly diagnosed acutely decompensated heart failure. Echocardiogram demonstrated left ventricular ejection fraction of 30% with basal inferior and inferolateral akinesis. Coronary angiography showed mild diffuse coronary artery disease and an anomalous right coronary artery arising from the left coronary cusp. Further imaging was consistent with ischemia in the right coronary distribution. Etiology of ischemia was thought to be the anomalous right coronary artery, and surgical unroofing of the right coronary ostium was performed. Here, we report a multimodality imaging approach, including cardiac magnetic resonance, cardiac computed tomographic angiography, and single-photon emission computed tomography, to support the diagnosis and management of a patient with anomalous right coronary artery arising from the left coronary cusp.

Anomalous Origin of the Right Coronary Artery From the Ascending Aorta Above the Left Sinus of Valsalva

Congenital anomalous origin of the coronary arteries is a rare but well-described cause of myocardial ischemia and sudden cardiac death. Anomalous origin of the right coronary artery from the ascending aorta is an extraordinarily rare occurrence. We report a case of anomalous origin of the right coronary artery from the ascending aorta posteriorly above the left sinus of Valsalva found during coronary angiography for evaluation of newly diagnosed cardiomyopathy.

Anomalous Coronary Origin and Malignant Course in a Young Patient With Palpitation and Demand Ischemia: A Serendipity or a Syndrome Without a Name?

Anomalous coronary artery remains the second most common cause for sudden cardiac death (SCD) in young athletes. The anomaly most commonly associated with SCD is the one that courses between the aorta and pulmonary artery, the malignant course. We present a case of a young gentleman who presented with symptomatic palpitations and was found to have anomalous right coronary artery from ostial left main coronary artery coursing between the aorta and pulmonary artery.

Echocardiographic Screening of Anomalous Origin of Coronary Arteries in Athletes with a Focus on High Take-Off

Anomalous aortic origin of coronary arteries (AAOCA) represents a rare congenital heart disease. However, this disease is the second most common cause of sudden cardiac death in apparently healthy athletes. The aim of this systematic review is to analyze the feasibility and the detection rate of AAOCA by echocardiography in children and adults. A literature search was performed within the National Library of Medicine using the following keywords: coronary artery origin anomalies and echocardiography; then, the search was redefined by adding the keywords: athletes, children, and high take-off. Nine echocardiographic studies investigating AAOCA and a total of 33,592 children and adults (age range: 12–49 years) were included in this review. Of these, 6599 were athletes (12–49 years). All studies demonstrated a high feasibility and accuracy of echocardiography for the evaluation of coronary arteries origin as well as their proximal tracts. However, some limitations exist: the incidence of AAOCA varied from 0.09% to 0.39% (up to 0.76%) and was lower than described in computed tomography series (0.3–1.8%). Furthermore, echocardiographic views for the evaluation of AAOCA and the definition of “minor” defects (e.g., high take-off coronary arteries) have not been standardized. An echocardiographic protocol to diagnose the high take-off of coronary arteries is proposed in this article. In conclusion, the screening of AAOCA by echocardiography is feasible and accurate when appropriate examinations are performed; however, specific acoustic windows and definitions of defects other than AAOCA need to be standardized to improve sensitivity and specificity.