Origin of the right coronary artery from the pulmonary trunk: diagnosis by two-dimensional echocardiography

Anomalous origin of the right coronary artery from the main pulmonary artery: diagnosis and management

Anomalous origin of the right coronary artery (ARCA) from the main pulmonary artery (MPA) is a rare congenital anomaly, with only 18 reported cases in the pediatric age group. More than half of these had associated cardiac anomalies that masked the presence of ARCA. Conversely, in many patients with ARCA as an isolated anomaly, the diagnosis has been missed during lifetime. The only patient with an isolated ARCA who was diagnosed in infancy presented with congestive heart failure. Asymptomatic infants with ARCA from the MPA have not been previously reported. Three additional cases, two infants and a child with ARCA from the MPA, are reported in this paper. The diagnostic dilemmas and the prognosis are discussed and management is recommended.

Right coronary artery arising from the pulmonary trunk

The right coronary artery (RCA) abnormally originating from the pulmonary trunk (PT) is a rare congenital anomaly. Our patient is a 62-year-old woman with longstanding systemic arterial hypertension and angina pectoris. Angiographic images documented the RCA arising from the PT, and coronary angiography showed severe stenosis (70%) on the distal tract of the left anterior descending artery. The primary treatment of the anomalous origin of RCA from the pulmonary artery is surgical technique. Our surgeons opted for coronary reimplantation; 6-month follow-up has shown very good results, with complete disappearance of symptoms.

Anomalous right coronary artery arising from the pulmonary artery: a report of 7 cases and a review of the literature

OBJECTIVE

To determine the experience with anomalous right coronary artery arising from the pulmonary artery (ARCAPA) at our institution.

BACKGROUND

Anomalous right coronary artery from the pulmonary artery is a rare congenital defect affecting 0.002% of the population. Unlike anomalous left coronary artery from the pulmonary artery (ALCAPA), ARCAPA generally has not been considered to be a lethal defect in infancy or childhood, although case reports of sudden death exist. The natural history of ARCAPA is difficult to describe because of the relatively small number of cases reported. Medical knowledge of this defect has been collected from case reports alone. No pediatric series of ARCAPA has been published.

METHODS

Hospital databases were retrospectively searched for cases of ARCAPA diagnosed at the New York Presbyterian Hospital over the past 25 years. A comprehensive literature search for case reports of ARCAPA was performed.

RESULTS

Seven pediatric cases are described. The cases range in clinical presentation from a young infant with tetralogy of Fallot to an adolescent with chest pain on exertion. Only 1 patient came to medical attention because of chest pain; 6 patients were asymptomatic. In these 6, ARCAPA was diagnosed upon evaluation of either a murmur (3) or associated congenital heart disease (3). All 7 patients have undergone repair. One patient died after repair of complex tetralogy of Fallot/pulmonary atresia. One patient developed a thrombus in the dilated right coronary artery years after repair. The thrombus resolved with anticoagulation.

CONCLUSIONS

Anomalous right coronary artery from the pulmonary artery is an uncommon coronary anomaly that, unlike ALCAPA, rarely leads to sudden death. Surgical correction is low risk and should be considered for all patients.

Right coronary artery arising from the pulmonary trunk in a 63-year-old man

Unlike anomalous origin of the left coronary artery (CA) from the pulmonary trunk (PT), right CA from the PT, a rare congenital malformation, may present in adulthood. We herein describe a man with anomalous origin of the right CA from the PT who presented with angina and syncope at age 63.

Anomalous origin of the right coronary artery: preoperative and postoperative hemodynamics

Anomalous origin of the right coronary artery from the main pulmonary artery is a rare congenital cardiac malformation. Most patients remain asymptomatic. However, there are cases of sudden cardiac death described in the literature, indicating a potentially malign course of the disease. To establish a double-ostium coronary system, correction of the aberrant vessel is recommended. Despite surgical reconstitution of normal coronary anatomy, the postoperative clinical presentation of some patients does not improve substantially, raising the question of the functional outcome of reinserted coronary vessels. This report of a patient with anomalous origin of the right coronary artery from the pulmonary trunk, in whom a complete hemodynamic assessment including intracoronary Doppler flow measurements was performed before and after reimplantation, very strongly supports the concept of an anatomically corrective operation.

Anomalous origin of the right coronary artery from the pulmonary artery: an unusual cause of angina

Origin of the right coronary artery from the pulmonary trunk rather than the aorta is a rare congenital anomaly. Only five cases of this anomaly have presented with signs and symptoms of ischemia. One of these cases, along with objective evidence for the cause of the ischemia and recommendations regarding surgical repair, is presented here.

Anomalous origin of right coronary artery from pulmonary artery

A 67-year-old female was incidentally found to have an anomalous right coronary artery (RCA) arising from the pulmonary artery during evaluation of her aortic valve disease. The left main, left anterior descending, and circumflex coronary arteries were mildly dilated. Large collaterals from the left filled the RCA retrogradely. During surgery, a circumferential web was found at the ostia of the RCA. The patient underwent an aortic valve replacement, resection of the web, and translocation of the anomalous RCA into the aorta.

Early congestive heart failure due to origin of the right coronary artery from the pulmonary artery

We describe a two-month-old infant with early congestive heart failure due to anomalous origin of the right coronary artery from the pulmonary artery. The diagnosis was made by two-dimensional and color flow Doppler echocardiography, confirmed by angiocardiography, and the case was successfully corrected at surgery. As opposed to the more frequent anomalous origin of the left coronary artery from the pulmonary trunk, this anomaly generally does not cause any typical clinical finding, often becoming an autoptic or surgical surprise after infancy or in adult age.

Coronary artery abnormalities in children

Although coronary artery abnormalities are somewhat rare in children, they constitute a population at significant risk for morbidity and/or mortality. The expeditious and accurate diagnosis of these lesions is imperative for optimum management. The ability of two-dimensional and Doppler echocardiography to accurately evaluate coronary artery abnormalities in children will be discussed under three headings: (1) major congenital coronary artery anomalies, (2) coronary artery anomalies associated with specific congenital heart lesions, and (3) acquired coronary artery abnormalities.

Normal and anomalous coronary arteries: definitions and classification

Results of a comprehensive survey of the literature concerning coronary artery anatomy, embryology, and pathophysiology show the lack of an adequate definition of normal coronary arteries. To fill this gap, the present review considers the available data concerning the embryogenesis of the coronary arteries and proposes a new definition of normality that refers to essential anatomic features. The concepts of normal variant versus anomaly are introduced, based on a statistical definition of the normal range (99% of the presentations observed in a normal, unselected population). Coronary anomalies are defined as those patterns found in less than 1% of the cases. The wide spectrum of coronary abnormalities is then organized according to a comprehensive classification scheme. For clinical purposes the conceptual difference between anatomic and pathophysiologic anomalies is stressed. The current paucity of experimental studies concerning normal and abnormal embryogenesis of the coronary arteries is found to be the major limitation to an understanding of this subject.

Anomalous origin of the right coronary artery from the left sinus of Valsalva: echocardiographic diagnosis--a case report

Anomalous origin of the right coronary artery from the left sinus of Valsalva is a rare congenital abnormality diagnosed by coronary angiography. This is the first report of an echocardiographic diagnosis of a patient with this anomaly, as far as is known.