Percutaneous coronary intervention of an anomalous right coronary artery originating from the left coronary artery

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 Anomalies - State of the Art Review

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

A Single Coronary Artery From the Left Coronary Sinus: The Continuing Conundrum

It is extremely rare to come across a single coronary artery during routine interventional cardiology practice. The incidence of single coronary arteries increases across congenital heart diseases. We report an extremely rare case of a single coronary artery arising from the left coronary sinus in an octogenarian presenting with anterior wall non-ST elevated myocardial infarction (NSTEMI) secondary to atherosclerotic occlusion of the proximal left main coronary artery (LMCA). It is often difficult to selectively engage a single coronary artery due to anomalous origin from the sinus; nonselective coronary sinus injection often suffices in visualizing the single coronary trunk dividing into left and right coronary arteries besides demonstrating the associated route and atherosclerotic anomalies.

Single coronary artery presenting dilated cardiomyopathy and hyperlipidemia with the SCN5A and APOA5 gene mutation: A case report and review of the literature

We present a 55-year-old man with chest tightness and dyspnoea after activity lasting for 2 months who was diagnosed with single coronary artery (SCA) and presented with dilated cardiomyopathy (DCM) with the c.1858C > T mutation in the SCN5A gene. The computed tomography coronary angiogram (CTCA) showed congenital absence of the right coronary artery (RCA), and the right heart was nourished by the left coronary artery branch with no apparent stenosis. Transthoracic echocardiography (TTE) revealed enlargement of the left heart and cardiomyopathy. Cardiac magnetic resonance imaging (CMR) revealed DCM. Genetic testing showed that the c.1858C > T variant of the SCN5A gene could lead to Brugada syndrome and DCM. SCA is a rare congenital anomaly of the coronary anatomy, and this case reported as SCA accompanied by DCM is even rarer. We present a rare case of a 55-year-old man with DCM with the c.1858C > T (p. Arg620Cys)/c.1008G > A (p.(Pro336=) variant of the SCN5A gene, congenital absence of RCA, and c.990_993delAACA (p. Asp332Valfs*5) variant of the APOA5 gene. To our knowledge, this is the first report of DCM combined with the SCN5A gene mutation in SCA after searching the PubMed, CNKI and Wanfang databases.

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.

Congenital absence of the right coronary artery with acute myocardial infarction: report of two cases and review of the literature

Congenital absence of the right coronary artery (RCA) is a rare coronary anomaly. Few cases of this condition have been reported. Congenital absence of the RCA is considered as a benign anomaly. However, in certain cases, these patients may develop life-threatening clinical complications that include acute myocardial infarction, stroke, or sudden death. We report two patients who were diagnosed with congenital absence of the RCA and presented with acute myocardial infarction. We discuss our experience in diagnosis and treatment of this disease. Congenital absence of the RCA with acute myocardial infarction is an uncommon clinical emergency. Therefore, early detection, correct diagnosis, and appropriate treatment are important.

Percutaneous coronary intervention for congenital absence of the right coronary artery with acute myocardial infarction: A case report and literature review

RATIONALE

Congenital absence of the right coronary artery with acute myocardial infarction (AMI) is a rare clinical situation that may lead to death. We report a case of successful percutaneous coronary intervention for congenital absence of the right coronary artery with AMI.

PATIENT CONCERNS

A 53-year-old woman had a 7-day history of chest discomfort that had worsened over 10 hours. She was diagnosed as having myocardial infarction and was admitted to hospital.

DIAGNOSIS

Coronary angiography showed absence of the right coronary artery; the left anterior descending (LAD) branch sent out the right ventricular branch and the posterior descending branch. The LAD branch was occluded and there was diffuse stenosis of the middle right ventricular branch and severe stenosis of the distal circumflex branch.

INTERVENTIONS

Percutaneous coronary intervention was performed. One stent was implanted in the LAD branch and another implanted in the right ventricular branch.

OUTCOMES

The patient was discharged 3 weeks after surgery. The follow-up showed that the patient was asymptomatic without recurrence.

LESSONS

Although absence of the right coronary artery with AMI is a fatal condition, percutaneous coronary intervention remains an effective treatment.

Technical success and long-term outcomes after anomalous right coronary artery stenting with cardiac computed tomography angiography correlation

INTRODUCTION

Anomalous origin of coronary arteries has been observed in about 0.35-2.10% of the population. Patients with anomalous right coronary artery (ARCA) may present with significant symptoms, arrhythmias or ACS, and at times sudden death. Traditionally, surgical correction has been the recommended treatment. However, these may be technically challenging, and bypass grafting for such anomalies has the potential for graft failure because of competitive flow. We sought to determine the intermediate and long-term outcomes of drug-eluting stent placement for patients with symptomatic ARCA. We also looked at angiographic findings suggestive of interarterial course as confirmed by subsequent computed tomography (CT) findings.

METHODS

Between January 2005 and December 2012, we enrolled 11 patients for elective percutaneous coronary intervention (PCI) of ARCA in a single center, prospective, nonrandomized fashion. Patients were followed up in clinic at 1 week, 3 months, 6 months, and 1 year, and then annually or more frequently if needed. All patients underwent a cardiac CT, as well as functional stress testing when needed to assess for recurrence of disease.

RESULTS

All 11 of our patients, who presented with significant symptomatic stenosis with an ARCA, were successfully treated with PCI. Mean follow-up duration was 8.5 years. The only two deaths during follow-up were related to noncardiac causes (sepsis), with a mortality rate of 18.2%. Two patients had a positive functional study and on subsequent coronary angiography, one of them had significant in-stent restenosis (target lesion revascularization of 9.1%) and one distal to the stent (target vessel revascularization 9.1%). We found the observation of a "slit-like lesion" on angiography to have a sensitivity of 100% and specificity of 86% for the diagnosis of interarterial course of the anomalous vessel seen on subsequent CT.

CONCLUSIONS

Our study results suggest that PCI of ARCA is an effective and low-risk alternative to surgical correction, with good procedural success and long-term outcomes. It can provide symptomatic relief in such patients and may reduce the risk of sudden death in younger patients, without the inherent risks associated with surgical repair.

Single Coronary Artery Anomaly: A Case Report and Review of Literature

INTRODUCTION

Single coronary artery is a rare anomaly, which is usually associated with other cardiac congenital abnormalities.

CASE REPORT

A 56-year-old female presented with unstable angina. The patient reported complaints of typical chest pain on exertion few months prior to presentation, which progressed to become at rest. The pain was associated palpitations and dizziness. Past medical history was significant for hypertension and hyperlipidemia. Vital signs were stable. Physical examination was non-remarkable. Electrocardiogram showed normal sinus rhythm, with intermittent episodes of sinus bradycardia, and non-specific T-wave changes. Trans-thoracic echocardiogram showed normal left ventricular function and no segmental wall-motion abnormalities. Selective coronary angiography showed a normal left main coronary artery arising from left coronary cusp. The left main branched to a normal left anterior descending artery and to the left circumflex artery; a large vessel which supplied also the territory of the right coronary artery (RCA) through its terminal extension. Aortography showed absence of RCA with no other vessels arising from the right or non-coronary cusps. The patient was managed conservatively and discharged home with resolution of symptoms.

CONCLUSIONS

We report a rare case of isolated single coronary artery with absent RCA. The patient presented with unstable angina, and was managed conservatively. Cardiologists should be aware of this rare condition, which carries a potential risk of sudden cardiac death.

A case of stent thrombosis presenting as acute myocardial infarction related to right coronary artery originating from the left coronary system

Right coronary artery (RCA) originating from the left coronary system is a subtype of single coronary artery (SCA) anomaly, and the origin of RCA as a branch from the left anterior descending artery (LAD) is a very rare variant. A 55-year-old male who had a percutaneous coronary intervention (PCI) history was hospitalized due to acute coronary syndrome. Coronary angiography revealed an aberrant RCA originating from the mid-LAD as well as stent thrombosis. A successful PCI was performed and he was discharged from the hospital three days after the PCI. It is known that there is an increased incidence of atherosclerosis and stent thrombosis in coronary anomaly patients. Therefore, interventional cardiologists should consider the most suitable PCI strategy before stenting and avoid complex techniques.

Successful percutaneous intervention of proximal left anterior descending artery in a case of single coronary artery trunk

Congenital coronary anomalies are mostly asymptomatic, detected accidentally during invasive or non-invasive imaging. One of the least encountered of such anomalies is single coronary ostium. Considering the fact that the whole myocardium is perfused by a single coronary vessel, performing percutaneous coronary stenting is a challenge for interventional cardiologists with some authors even considering it as a contraindication. Here we present a rare case of single coronary artery as a result of terminal extension of right coronary artery from left circumflex artery, for whom successful balloon angioplasty and stenting of left anterior descending artery after myocardial infarction was done. <Learning objective: Single coronary artery is a rare congenital anomaly which poses a challenge for an interventional cardiologist in the event of complications during intervention and is even considered to be a contraindication for percutaneous intervention by some authors. Hereby we present a successful left anterior descending stenting after acute myocardial infarction in a case of single coronary artery.>.

Three different situations and approaches in the management for anomalous origin of the right coronary artery from the left coronary sinus: case report

Anomalous origin of the right coronary artery from the left coronary sinus is rare but potentially dangerous if any ischemic signs are present. Multiple therapeutic options were advocated so far. We experienced three different situations and surgical approaches to these anomalies, and reviewed retrospectively. For the first case, we made a neo-ostium on the right sinus of Valsalva and anastomosed with the right coronary artery after arteriotomy. For the second and third cases, we applied coronary artery bypasses emergently: patient 2 the gastroepiploic artery during off-pump coronary artery bypass and patient 3 the left internal thoracic artery during surgery for acute aortic dissection. For the better outcomes, it is important to understand anatomic and hemodynamic characteristics of each patient and select the surgical options considering each characteristic.

Anomalous aortic origin of coronary arteries from the opposite sinus: a critical appraisal of risk

Background

Anomalous aortic origin of the coronary artery (AAOCA) from the opposite sinus of Valsalva with an interarterial course has received much attention due to its association with sudden death in otherwise healthy individuals. AAOCA is relatively common and may have significant public health implications. While our knowledge of its pathophysiology and natural history remains incomplete, an emphasis has been placed on surgical correction.

Discussion

In 2005 we published a review examining the rates of sudden death with AAOCA, as well as complications of surgical management. Evidence now points even more strongly to lower rates of sudden death, while surgical outcomes data now better documents associated risks.

Summary

Armed with this updated information, we agree with the need for a national registry to better track patients with AAOCA. We submit that the risks of surgical management outweigh any benefits in the asymptomatic patient with anomalous right coronary artery, and expectant management should also be strongly considered even in asymptomatic patients with anomalous left coronary artery.

Successful primary percutaneous coronary intervention in a patient with acute myocardial infarction and single coronary artery ostium

One of the single anomalous origins of coronary artery that has rarely been reported is a congenital anomaly of coronary circulation that occurs in the left coronary artery originating from the right coronary sinus of valsalva. We report a 49-year-old male patient with non-ST segment elevated myocardial infarction that was identified to have an anomalous origin of the left coronary artery from the right coronary artery (RCA) with thrombotic total occlusion of RCA by coronary angiography and cardiac computed tomography. The patient underwent successful percutaneous coronary intervention in total occlusion of the RCA and was discharged after uneventful recovery.