Anomalous origin of the right coronary artery from the left sinus of Valsalva: echocardiographic-angiographic correlations

Anomalous Aortic Origin of a Coronary Artery: Preoperative Diagnosis and Surgical Planning

Background: Anomalous aortic origin of a coronary artery (AAOCA), the anomalous coronary artery arises from an inappropriate coronary sinus and travels between the aorta and pulmonary artery. Proper surgical management depends upon correct diagnosis and accurate characterization of the origin and course of the coronary artery. Transthoracic echocardiography (TTE) has been the mainstay for diagnosis, but magnetic resonance imaging (MRI) and computed tomographic angiography (CTA) have been increasingly utilized. In this study, we report the largest series of surgically repaired AAOCA and accuracy of preoperative diagnostic studies. Methods: A review of 53 consecutive patients (mean age 13.9 years, range 4-65 years) undergoing repair of an AAOCA from 1995 to 2009 was performed. In all, 40 patients were identified with an anomalous right coronary artery (ARCA) from the left sinus of Valsalva, 13 patients had an anomalous left coronary artery (ALCA) arising from the opposite sinus. Symptoms of angina or syncope were present in 58% and 46% of cases with ARCA and ALCA, respectively. Results of preoperative diagnostic testing were compared to actual surgical findings to determine the accuracy of the tests. Results: Lack of an intramural course was observed intraoperatively in 7 cases (5 ARCA and 2 ALCA). Preoperative TTE accurately predicted whether the AAOCA was intramural or extramural in 49 (92.5%) of 53 cases. Magnetic resonance imaging was predictive in 5 (83.3%) of 6 patients and CTA in 11 (64.7%) of 17. Survival was 100%. Complications occurred in 4 (7.5%) of 53 patients (mean follow-up 29 months). Patency was confirmed in 97.7% with TTE, and 23 (95.8%) of 24 patients had a negative postoperative functional study. Conclusions: Transthoracic echocardiography was found to be very accurate at defining the presence or absence of an intramural course in AAOCA. Both MRI and CTA can provide additional information but may not be as accurate as TTE.

Prospective echocardiographic diagnosis and surgical repair of anomalous origin of a coronary artery from the opposite sinus with an interarterial course

OBJECTIVES

In this study, we sought to describe the mode of presentation, anatomic features, diagnostic techniques, and surgical outcome in a group of patients with anomalous origin of a coronary artery from the opposite sinus with an interarterial course between the great arteries (AOCA).

BACKGROUND

Anomalous origin of a coronary artery from the opposite sinus with an interarterial course is associated with myocardial ischemia and sudden cardiac death, particularly in adolescents and young adults.

METHODS

The cardiology database at Children's Hospital of Wisconsin was reviewed to identify all patients diagnosed with AOCA.

RESULTS

From September 1997 to August 2002, 10 patients were identified with AOCA; all were children/adolescents (age range, 3 months to 20 years; weight range, 4.7 to 72 kg), and nine were diagnosed prospectively by transthoracic echocardiography (TTE). Symptoms of cardiac ischemia initiated investigation in 4/10 patients at a mean age of 16 +/- 2.8 years; the other six had TTE for suspected congenital heart disease/musculoskeletal chest pain. The left coronary artery originated from the right sinus in six patients, and the right coronary artery originated from the left sinus in four patients. An intramural course of the AOCA within the anterior aortic wall was found in 9/10 patients and was reliably identified by TTE; the other patient had an intramyocardial course of the anomalous coronary. Surgical repair was performed in 8/10 patients at a mean age of 13 +/- 4.7 years. Unroofing of the intramural portion of the AOCA to relocate the ostia in the appropriate sinus was successfully performed in seven patients. All patients status post unroofing were asymptomatic with patent coronary flow by Doppler and normal exercise treadmill testing at a median follow-up interval of 1.5 years.

CONCLUSIONS

Anomalous origin of a coronary artery from the opposite sinus with an interarterial course is frequently characterized by an intramural course, which can be prospectively identified by TTE. Unroofing the intramural segment without bypass grafting can reliably repair the intramural form of AOCA.

Utility of magnetic resonance imaging in a patient with anomalous origin of the right coronary artery, acute myocardial infarction, and near-sudden cardiac death

A 46-year-old female presented with an acute myocardial infarction and cardiac arrest. Coronary angiography revealed an anomalous origin of the right coronary artery coursing between the aorta and pulmonary artery. Magnetic resonance imaging confirmed the life-threatening nature of this anomaly and led to referral for surgical revascularization.

Magnetic resonance angiography of anomalous coronary arteries. A new gold standard for delineating the proximal course?

BACKGROUND

The clinical significance of anomalously originating coronary arteries depends on their proximal course. Diagnosis of this course by conventional x-ray coronary angiography alone may be equivocal. We postulated that with fast magnetic resonance (MR) angiography, accurate detection of anomalous coronary arteries and unambiguous delineation of their proximal course is feasible.

METHODS AND RESULTS

In a selected group of 38 patients, 19 of them having an anomalously originating coronary artery, a fast MR angiographic technique was used to study the proximal coronary anatomy. Blinded analysis of randomly ordered MR studies was performed independently by two observers. Both origin and proximal course of the coronary arteries were defined. Two cardiologists reviewed all x-ray coronary angiograms. After the separate analyses, a final consensus result was defined for each patient. In 37 patients, successful MR coronary angiography could be performed. Interobserver agreement for determining both origin and proximal course was 100%. An x-ray coronary angiogram was available in 36 patients. In 3 patients (all with an anomalous left main coronary artery originating from the right aortic sinus), there was disagreement about the proximal course between the results of MR and x-ray coronary angiography. Review of these cases demonstrated that MR angiography had unambiguously visualized the proximal coronary artery course, whereas the results of x-ray angiography had been equivocal. Thus, sensitivity and specificity for detecting anomalous coronary arteries and delineating their proximal course were 100%.

CONCLUSIONS

These data suggest that fast MR angiography is highly accurate in determining the origin and delineating the proximal course of anomalous coronary arteries, even in those cases in which x-ray coronary angiographic diagnosis is difficult or even erroneous.

Congenital heart disease and sudden death in the young

Sudden death is a frequent mode of fatal outcome in cardiac disease and does not exclude young people. The aim of this investigation was to establish whether and to what extent sudden death in the young may be ascribable to the substrate of underlying congenital heart disease. Among 182 young people (< or = 35 years) who died of cardiac sudden death and underwent postmortem examination, 58 (32%) had congenital heart disease. Seven showed an intrapericardial rupture of aortic dissection, in the setting of Marfan syndrome in two, isolated bicuspid aortic valve in two, and bicuspid aortic valve and isthmic coarctation in three; all exhibited equally severe degeneration of the aortic wall. Sixteen cases had conduction system anomalies, mostly bypass tracts; 15 coronary artery anomalies (three ostial valve-like stenosis, five origin from the wrong aortic sinus, and seven deep intramyocardial course); 12 hypertrophic cardiomyopathy; five postoperative congenital heart disease including scar following ventriculotomy, conduction system injury, and defects left unrepaired; and three congenital aortic valve stenosis. One third of sudden deaths in the young was ascribable to structural defects present since birth. A large spectrum of congenital heart disease involves the risk of sudden death, but most structural defects are usually not considered to be life threatening. Some of these concealed defects are potentially detectable in life by clinical imaging techniques.

Echocardiographic visualization of anomalous left main coronary arteries originating from the right sinus of Valsalva

We report on two patients in whom the anomalous left main coronary artery arising from the right sinus of Valsalva with a septal course could be visualized by transthoracic echocardiography. It appeared as a small echo-free space, anterior to the aorta in the short parasternal axis. If the left main coronary artery arises anomalously from the right sinus of Valsalva, it can take four different courses until it branches into the left anterior descending and the circumflex coronary artery. The course between aorta and pulmonary trunk can be differentiated into an interarterial and a septal course using angiographic criteria. The interarterial course is a potentially life-threatening anomaly due to a high rate of myocardial infarction and sudden cardiac death. Echocardiography alone seems not to be able to distinguish between the potentially life-threatening interarterial and the benign septal course, as in our patients.

Anomalous origin and course of coronary arteries in adults: identification and improved imaging utilizing transesophageal echocardiography

Anomalous origin of a coronary artery is rare, but may represent a clinically significant abnormality, since some anomalies are associated with myocardial ischemia, infarction, and sudden death. Diagnosis may elude routine screening procedures, and even when an anomalous vessel is identified angiographically, it may be difficult to delineate its true course on the basis of angiography alone. The purpose of this study was to determine whether transesophageal echocardiography (TEE) is of value in making the diagnosis and outlining the course of anomalous coronary arteries. Five adult patients with anomalous origin of a coronary artery were studied by monoplane TEE and selective coronary angiography. Transthoracic echocardiography (TTE) was also performed in four of these five patients. Anomalous coronary ostia were visualized in four of five patients utilizing TEE, but in none of four patients by TTE. A proximal segment of the anomalous coronary vessel was identified in all five patients by TEE, and in only two of four patients by TTE. TEE images were consistently of superior diagnostic quality. TEE is a valuable tool for the echocardiographic identification of anomalous coronary arteries, and is superior to TTE in adult patients.