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Alzghari T, Sandner S, Di Franco A, Harik L, Perezgorvas-Olaria R, Soletti G, Dimagli A, Cancelli G, Demetres M, Lau C, Girardi LN, Gaudino M. Coronary Artery Bypass Surgery to Treat Anomalous Origin of Coronary Arteries in Adults: A Systematic Review. Heart Lung Circ 2023; 32:1500-1511. [PMID: 37923692 DOI: 10.1016/j.hlc.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/10/2023] [Accepted: 09/13/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To review the available literature on the use of coronary artery bypass grafting (CABG) as a treatment option for anomalous origin of coronary artery in adults. METHODS A systematic literature search was performed in March 2023 (including Ovid MEDLINE, Ovid Embase, and the Cochrane Library databases) to identify studies reporting the use of CABG in adult patients with anomalous origin of coronary artery. RESULTS A total of 31 studies and 62 patients were included, 32 patients (52%) were women, and the mean age was 45.1±16.1 years. The most common coronary anomaly was the right coronary artery arising from the left coronary sinus in 26 patients (42%), followed by an anomalous left coronary artery from the pulmonary artery in 23 patients (37%). A total of 65 conduits were used in 61 patients, and 1 case report did not report conduit type. Reported grafts included saphenous vein (23 of 65 [35.4%]), left internal thoracic artery (15 of 65 [23.1%]), right internal thoracic artery (23 of 65 [35.4%]), and radial artery (2 of 65 [3.1%]); right gastroepiploic artery and basilic vein were used once (1.5%) each. Ligation of the native coronary artery was performed in 42 (67.7%) patients. Patient follow-up was available in 19 studies with a mean of 31.2 months. Only 1 operative mortality was reported. CONCLUSIONS Based on the limited available data, CABG can be performed with good early results. Use of arterial conduits and ligation of the native coronary artery may improve long-term graft patency.
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Affiliation(s)
- Talal Alzghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA. http://www.twitter.com/talalzghari
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | | | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information Centre, Weill Cornell Medicine, New York, NY, USA
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
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2
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Jacobs JP, DeCampli WM, Karamlou T, Najm HK, Marino BS, Blackstone EH, McCrindle BW, Jegatheeswaran A, St Louis JD, Austin EH, Caldarone CA, Mavroudis C, Overman DM, Dearani JA, Jacobs ML, Tchervenkov CI, Svensson LG, Barron D, Kirklin JK, Williams WG. The Academic Impact of Congenital Heart Surgeons' Society (CHSS) Studies. World J Pediatr Congenit Heart Surg 2023; 14:602-619. [PMID: 37737599 DOI: 10.1177/21501351231190916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
PURPOSE We reviewed all 64 articles ever published by The Congenital Heart Surgeons' Society (CHSS) Data Center to estimate the academic impact of these peer-reviewed articles. MATERIALS AND METHODS The Congenital Heart Surgeons' Society has performed research based on 12 Diagnostic Inception Cohorts. The first cohort (Transposition) began enrolling patients on January 1, 1985. We queried PubMed to determine the number of publications that referenced each of the 64 journal articles generated by the datasets of the 12 Diagnostic Inception Cohorts that comprise the CHSS Database. Descriptive summaries of the data were tabulated using mean with standard deviation and median with range. RESULTS Sixty-four peer-reviewed papers have been published based on the CHSS Database. Fifty-nine peer-reviewed articles have been published based on the 12 Diagnostic Inception Cohorts, and five additional articles have been published based on Data Science. Excluding the recently established Diagnostic Inception Cohort for patients with Ebstein malformation of tricuspid valve, the number of papers published per cohort ranged from 1 for coarctation to 11 for transposition of the great arteries. The 11 articles generated from the CHSS Transposition Cohort were referenced by a total of 111 articles (median number of references per journal article = 9 [range = 0-22, mean = 10.1]). Overall, individual articles were cited by an average of 11 (mean), and a maximum of 41 PubMed-listed publications. Overall, these 64 peer-reviewed articles based on the CHSS Database were cited 692 times in PubMed-listed publications. The first CHSS peer-reviewed article was published in 1987, and during the 35 years from 1987 to 2022, inclusive, the annual number of CHSS publications has ranged from 0 to 7, with a mean of 1.8 publications per year (median = 1, mode = 1). CONCLUSION Congenital Heart Surgeons' Society studies are widely referenced in the pediatric cardiac surgical literature, with over 10 citations per published article. These cohorts provide unique information unavailable in other sources of data. A tool to access this analysis is available at: [https://data-center.chss.org/multimedia/files/2022/CAI.pdf].
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Affiliation(s)
- Jeffrey Phillip Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL, USA
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Tara Karamlou
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Hani K Najm
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Bradley S Marino
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene H Blackstone
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Brian W McCrindle
- Division of Pediatric Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - James D St Louis
- Department of Cardiac Surgery, Inova Fairfax Hospital and Inova L.J Murphy Children's Hospital, Fairfax, VA, USA
- Departments of Surgery and Pediatrics, Children's Hospital of Georgia, Augusta University, Augusta, GA, USA
| | - Erle H Austin
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, USA
- Norton Children's Hospital, Louisville, KY, USA
| | | | - Constantine Mavroudis
- Pediatric Cardiothoracic Surgery, Peyton Manning Children's Hospital, Indianapolis, IN, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David M Overman
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christo I Tchervenkov
- Division of Cardiovascular Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Lars G Svensson
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - David Barron
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, Birmingham, AL, USA
| | - William G Williams
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
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3
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Jegatheeswaran A, Argo MB, Devlin PJ, Callahan CP, Meza JM, Wilder TJ, Hickey EJ, Karamlou T. The Congenital Heart Surgeons' Society Kirklin/Ashburn Fellowship: The Fellows' Perspective. World J Pediatr Congenit Heart Surg 2023; 14:575-586. [PMID: 37737596 DOI: 10.1177/21501351231190087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Since its establishment in 2001, the Congenital Heart Surgeons' Society John W. Kirklin/David Ashburn Fellowship has contributed substantially to the field of congenital heart surgery research while simultaneously training the next generation of surgeon- scientists. To date, ten fellows (and counting) have successfully completed this rigorous training, producing over 40 published articles focused on longitudinal outcomes from the various Congenital Heart Surgeons' Society cohorts. As the Kirklin/Ashburn Fellowship expands and additional fellows matriculate, its legacy, the network of support, and the contribution to congenital heart surgery research will undoubtedly hold strong.
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Affiliation(s)
- Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, UK
- Children's Cardiovascular Disease, Institute of Cardiovascular Science, University College London, London, UK
| | - Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul J Devlin
- Division of Cardiac Surgery and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Connor P Callahan
- Division of Pediatric Cardiothoracic Surgery, University Hospitals Rainbow Babies and Children's, Cleveland, OH, USA
| | - James M Meza
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Travis J Wilder
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Edward J Hickey
- Department of Cardiothoracic Surgery, Texas Children's Hospital, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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4
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Jacobs ML, Backer CL. World Journal for Pediatric and Congenital Heart Surgery-The Official Journal of the Congenital Heart Surgeons' Society. World J Pediatr Congenit Heart Surg 2023; 14:572-574. [PMID: 37737600 DOI: 10.1177/21501351231174815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
The World Journal for Pediatric and Congenital Heart Surgery (WJPCHS) was established in 2009, as a means of advancing the educational and scholarship goals of the World Society for Pediatric and Congenital Heart Surgery. WJPCHS has grown steadily since the first issue was published in April 2010. In 2017, the Congenital Heart Surgeons' Society and the European Congenital Heart Surgeons Association both designated WJPCHS as the official journal of their respective organizations. The CHSS and ECHSA represent the face and the voice of congenital heart surgery in North America (United States and Canada) and in Europe, respectively. Each organization has advanced the science of surgical management of congenital heart disease through multicenter outcomes analyses, which have strongly and positively influenced the care of patients around the world.
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Affiliation(s)
- Marshall L Jacobs
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, KY, USA
- Cardiothoracic Surgery, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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5
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Cabello-Ganem A, Espejel-Guzman A, Aparicio-Ortiz AD, Guerra EC, Luna-Alcala S, Solorzano-Pinot E, Serrano-Roman J, Cano-Zarate R, Criales-Vera S, Espinola-Zavaleta N. Spectrum of the anomalous origin of the coronary arteries. Radiol Case Rep 2023; 18:2929-2934. [PMID: 37383175 PMCID: PMC10293585 DOI: 10.1016/j.radcr.2023.05.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/22/2023] [Accepted: 05/26/2023] [Indexed: 06/30/2023] Open
Abstract
The anomalous origin of the coronary arteries (AOCA) has several patterns. Most are functional and asymptomatic. However, some are associated with persistent chest pain and sudden cardiac death. Multiple imaging techniques are available for the assessment of AOCA. We present a report of 4 cases with AOCA, including the anomalous aortic origin of a coronary artery (AAOCA) of the right coronary artery, AAOCA of the circumflex artery, AAOCA of the left anterior descending artery, and AAOCA of the circumflex artery with retroaortic trajectory, in which the clinical manifestations throughout the cases are discussed, highlighting the similarity among patients despite having different patterns. Multiple imaging techniques are indispensable for assessing AOCA, where transthoracic echocardiogram is the first-line study, and cardiac computed tomography provides detailed cardiac and coronary anatomy.
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Affiliation(s)
- Aldo Cabello-Ganem
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Juan Badiano Nº 1, Colonia Seccion XVI, Tlalpan, Mexico City, 14030, Mexico
| | | | - Alexis D. Aparicio-Ortiz
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Juan Badiano Nº 1, Colonia Seccion XVI, Tlalpan, Mexico City, 14030, Mexico
| | - Enrique C. Guerra
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Juan Badiano Nº 1, Colonia Seccion XVI, Tlalpan, Mexico City, 14030, Mexico
| | - Santiago Luna-Alcala
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Juan Badiano Nº 1, Colonia Seccion XVI, Tlalpan, Mexico City, 14030, Mexico
| | - Enrique Solorzano-Pinot
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Juan Badiano Nº 1, Colonia Seccion XVI, Tlalpan, Mexico City, 14030, Mexico
| | | | - Roberto Cano-Zarate
- Department of Computer Tomography, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
- Department of Magnetic Resonance, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Sergio Criales-Vera
- Department of Computer Tomography, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
- Department of Magnetic Resonance, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Nilda Espinola-Zavaleta
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Juan Badiano Nº 1, Colonia Seccion XVI, Tlalpan, Mexico City, 14030, Mexico
- Department of Echocardiography, ABC Medical Center, IAP, Mexico City, Mexico
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6
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Carreon CK, Sanders SP, Ferraro AM, Gauvreau K, Nathan M, Toba S, Newburger JW, Beroukhim RS, Quinonez LG. Histopathology of resected tissue from repair of anomalous aortic origin of a coronary artery: Potential mechanism of coronary artery compression. JTCVS OPEN 2023; 15:412-423. [PMID: 37808028 PMCID: PMC10556936 DOI: 10.1016/j.xjon.2023.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 06/21/2023] [Accepted: 07/10/2023] [Indexed: 10/10/2023]
Abstract
Objective This study aimed to describe the histomorphologic characteristics of resected (unroofed) common wall tissue from repair of anomalous aortic origin of a coronary artery and to determine whether the histologic features correlate with clinical and imaging findings. Methods The histology of resected tissue was analyzed and reviewed for the presence of fibrointimal hyperplasia, smooth muscle disarray, mucoid extracellular matrix accumulation, mural fibrosis, and elastic fiber disorganization and fragmentation using hematoxylin and eosin and special stains. Clinical, computed tomography imaging, and surgical data were correlated with the histopathologic findings. Results Twenty specimens from 20 patients (age range, 7-18 years; 14 males) were analyzed. Anomalous aortic origin of a coronary artery involved the right coronary in 16 (80%), and a slit-like ostium was noted in 18 (90%). By computed tomography imaging, the median proximal coronary artery eccentricity index was 0.4 (range, 0.20-0.90). The median length of intramural course was 8.2 mm (range, 2.6-15.2 mm). The anomalous vessel was determined to be interarterial in 14 patients (93%, 15 had evaluable images). The median distance from a commissure was 2.5 mm above the sinotubular junction (STJ) (range: 2 mm below the STJ-14 mm above the STJ). Prominent histopathologic findings included elastic fiber alterations, mural fibrosis, and smooth muscle disarray. The shared wall of the aorta and intramural coronary artery is more similar to the aorta histologically. Mural fibrosis and elastic fiber abnormalities tended to be more severe in patients >10 years of age at the time of surgery, but this did not reach statistical significance. The extent of vascular changes did not appear to have a clear relationship with the imaging features. Conclusions The findings confirm the aortic wall-like quality of the intramural segment of the coronary artery and the presence of pathologic alterations in the wall microstructure.
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Affiliation(s)
- Chrystalle Katte Carreon
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Pathology, Harvard Medical School, Boston, Mass
| | - Stephen P. Sanders
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Alessandra M. Ferraro
- Department of Pediatrics, Harvard Medical School, Boston, Mass
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Surgery, Harvard Medical School, Boston, Mass
| | - Shuhei Toba
- The Cardiac Registry, Departments of Cardiology, Pathology, and Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Jane W. Newburger
- Department of Pediatrics, Harvard Medical School, Boston, Mass
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Rebecca S. Beroukhim
- Department of Pediatrics, Harvard Medical School, Boston, Mass
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Luis G. Quinonez
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Surgery, Harvard Medical School, Boston, Mass
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7
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Patlolla SH, Stephens EH, Schaff HV, Anavekar NS, Miranda WR, Julsrud PR, Dearani JA. Outcomes of a protocolized approach for surgical unroofing of intramural anomalous aortic origin of coronary artery in children and adults. J Thorac Cardiovasc Surg 2022; 165:1641-1650. [PMID: 36690526 DOI: 10.1016/j.jtcvs.2022.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 10/09/2022] [Accepted: 11/19/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Management of anomalous aortic origin of coronary arteries has been variable, and limited data are available on early and late outcomes. METHODS We report a single institution's experience with a protocolized approach to 148 consecutive patients who underwent surgical unroofing of intramural anomalous aortic origin of coronary arteries (June 2003 to December 2020). The management algorithm included preoperative and postoperative cross-sectional and echocardiographic imaging, exercise testing, and a standardized operative technique. RESULTS The median age of the cohort was 44.4 years (range, 4 months to 83 years); 130 patients had an anomalous right coronary artery, and 19 patients had an anomalous left coronary artery. Surgical unroofing was an isolated procedure in 118 patients (80%) and a concomitant procedure in 30 patients (20.3%). There were 2 (1%) early deaths; both were reoperations for aortic root or valve replacement. Over a median follow-up of 9.5 (interquartile range, 5-12.3) years, there were 5 late deaths, 3 due to noncardiac causes and 2 due to unknown cause. Late survival after anomalous aortic origin of coronary arteries repair at 10 and 15 years was 94.5% and 94.5%, respectively. There were no early or late deaths in the pediatric cohort with a median follow-up of 10.9 years (interquartile range, 6.9-12.1). At a median clinical follow-up of 3.9 years (interquartile range, 1.1-9.5), 36 patients had chest pain but none with evidence of ischemia related to the unroofing. CONCLUSIONS Surgical unroofing of anomalous aortic origin of coronary arteries can be performed safely with low early mortality, even in the setting of concomitant procedures. Late survival is excellent, with the vast majority being symptom free.
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Affiliation(s)
- Sri Harsha Patlolla
- Department of Cardiovascular Surgery, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Elizabeth H Stephens
- Department of Cardiovascular Surgery, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | | | | | | | - Joseph A Dearani
- Department of Cardiovascular Surgery, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn.
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8
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Bigler MR, Kadner A, Räber L, Ashraf A, Windecker S, Siepe M, Padalino MA, Gräni C. Therapeutic Management of Anomalous Coronary Arteries Originating From the Opposite Sinus of Valsalva: Current Evidence, Proposed Approach, and the Unknowing. J Am Heart Assoc 2022; 11:e027098. [PMID: 36205254 DOI: 10.1161/jaha.122.027098] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) are a challenge because of their various anatomic and clinical presentation. Although the prevalence is low, the absolute numbers of detected ACAOS are increasing because of the growing use of noninvasive anatomical imaging for ruling out coronary artery disease. As evidence-based guidelines are lacking, treating physicians are left in uncertainty for the optimal management of such patients. The sole presence of ACAOS does not justify surgical correction, and therefore a thorough anatomic and hemodynamic assessment is warranted. Invasive and noninvasive multimodality imaging provides information to the clinical question whether the presence of ACAOS is an innocent coincidental finding, is responsible for the patient's symptoms, or even might be a risk for sudden cardiac death. Based on recent clinical data, focusing on the pathophysiology of patients with ACAOS, myocardial ischemia is dependent on both the extent of fixed and dynamic components, represented by anatomic high-risk features. These varying combinations should be considered individually in the decision making for the different therapeutic options. This state-of-the-art review focuses on the advantages and limitations of the common contemporary surgical, interventional, and medical therapy with regard to the anatomy and pathophysiology of ACAOS. Further, we propose a therapeutic management algorithm based on current evidence on multimodality invasive and noninvasive imaging findings and highlight remaining gaps of knowledge.
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Affiliation(s)
- Marius Reto Bigler
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Alexander Kadner
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery Inselspital Bern Switzerland
| | - Lorenz Räber
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Afreed Ashraf
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Stephan Windecker
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Matthias Siepe
- Centre for Congenital Heart Disease, Department of Cardiovascular Surgery Inselspital Bern Switzerland
| | - Massimo Antonio Padalino
- Section of Pediatric and Congenital Cardiac Surgery, Department of Cardio-Thoracic and Vascular Sciences, and Public Health University of Padova, Medical School Padova Italy
| | - Christoph Gräni
- Department of Cardiology Inselspital, Bern University Hospital, University of Bern Bern Switzerland
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9
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D'Abramo M, Saltarocchi S, Saade W, Chourda E, De Orchi P, Miraldi F. Setting things "right": right internal mammary artery on anomalous right coronary artery - a case report. J Int Med Res 2021; 49:3000605211054438. [PMID: 34738476 PMCID: PMC8573513 DOI: 10.1177/03000605211054438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Anomalous aortic origin of a coronary artery (AAOCA) is a rare pathology that may cause episodic ischemia owing to possible vessel compression during systolic expansion of the aortic root. This anomaly can lead to myocardial infarction, malignant arrhythmias and sudden cardiac death (SCD). Several surgical techniques have been described; however, there are no defined guidelines regarding the treatment of AAOCA. We report the case of a 47-year-old woman with ectopic origin of the right coronary artery (RCA) from the left sinus of Valsalva, with an interarterial course of the proximal segment of the artery, running between the aorta and the pulmonary trunk. Revascularization was accomplished by harvesting the right internal mammary artery (RIMA) and anastomosing it to the anomalous RCA, given the small portion of the RCA following an intramural course and our familiarity with the procedure. The RCA was ligated proximal to the anastomosis to avoid the string sign phenomenon. This procedure is safe and fast and can be considered an alternative to coronary reconstruction.
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Affiliation(s)
- M D'Abramo
- Internal, Clinical, Anesthesiological and Cardiovascular Sciences Department, Sapienza University of Rome, Rome, Italy
| | - S Saltarocchi
- Internal, Clinical, Anesthesiological and Cardiovascular Sciences Department, Sapienza University of Rome, Rome, Italy
| | - W Saade
- Internal, Clinical, Anesthesiological and Cardiovascular Sciences Department, Sapienza University of Rome, Rome, Italy
| | - E Chourda
- Internal, Clinical, Anesthesiological and Cardiovascular Sciences Department, Sapienza University of Rome, Rome, Italy
| | - P De Orchi
- Internal, Clinical, Anesthesiological and Cardiovascular Sciences Department, Sapienza University of Rome, Rome, Italy
| | - F Miraldi
- Internal, Clinical, Anesthesiological and Cardiovascular Sciences Department, Sapienza University of Rome, Rome, Italy
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10
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Courand PY, Bozio A, Ninet J, Boussel L, Bakloul M, Galoin-Bertail C, Metton O, Mitchell J, de Montclos TP, Walton C, Di Filippo S. Diagnosis and treatment of anomalous aortic origin of coronary artery: A twenty-year retrospective study of experience and decision-making in children and young adults. Int J Cardiol 2021; 337:54-61. [PMID: 33945804 DOI: 10.1016/j.ijcard.2021.04.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 04/24/2021] [Accepted: 04/29/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Anomalous aortic origin of a coronary artery, particularly in the presence of inter-arterial course between the great arteries, has been found to be associated with sudden death in young people. METHODS This study reports a single-center experience in the management of anomalous aortic origin of a coronary artery, with or without inter-arterial course, by focusing specifically on presentation, diagnosis, and patient outcome. RESULTS From March 1993 to February 2018, 100 patients (70 males) were diagnosed with anomalous aortic origin of a coronary artery, including 27 left coronary artery from the right sinus, 60 right coronary artery from the left sinus, and 13 other anomalies. Patients with inter-arterial course between the great arteries presented more frequently with syncope and/or sudden death compared to patients without (23.4% vs. 0%, p = 0.026). Diagnosis was reached using first-line transthoracic echocardiography in 65% of cases. Surgical repair was performed in 61 patients (61%). All operated patients (60 direct implantations, 1 unroofing) had been diagnosed with inter-arterial course between the great arteries, and were asymptomatic at a mean (±SD) postoperative follow-up of 4.9 ± 5.3 years. CONCLUSIONS An inter-arterial course of the anomalous right or left coronary arteries arising from the opposite sinus is associated with life-threatening events. Direct reimplantation of coronary artery is reliable, and should be discussed even in asymptomatic patients.
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Affiliation(s)
- Pierre-Yves Courand
- Fédération de cardiologie, Hôpital de la Croix-Rousse et Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France; Université de Lyon, CREATIS, CNRS UMR5220, INSERM U1044, INSA-Lyon, Université Claude Bernard Lyon 1, France
| | - Andre Bozio
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France
| | - Jean Ninet
- Service de chirurgie cardiaque, Hôpital Louis Pradel Hospices civils de Lyon, 69317 Lyon cedex 04, France
| | - Loic Boussel
- Service de radiologie, Hôpital de la Croix-Rousse, Hospices civils de Lyon, 69317 Lyon cedex 04, France
| | - Mohamed Bakloul
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France
| | - Claire Galoin-Bertail
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France
| | - Olivier Metton
- Service de chirurgie cardiaque, Hôpital Louis Pradel Hospices civils de Lyon, 69317 Lyon cedex 04, France
| | - Julia Mitchell
- Service de chirurgie cardiaque, Hôpital Louis Pradel Hospices civils de Lyon, 69317 Lyon cedex 04, France
| | - Thomas Perouse de Montclos
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France
| | - Camille Walton
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France
| | - Sylvie Di Filippo
- Service de cardiologie congénitale, Hôpital Louis Pradel, Hospices civils de Lyon, 69317 Lyon cedex 04, France; Université Claude Bernard Lyon I, 69677 Lyon, France.
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11
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Anomalous Aortic Origin of a Coronary Artery in Adults. Ann Thorac Surg 2020; 112:1299-1305. [PMID: 33279536 DOI: 10.1016/j.athoracsur.2020.06.153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 06/04/2020] [Accepted: 06/29/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Anomalous aortic origin of a coronary artery (AAOCA) is the second leading cause of sudden death in youth. However, its significance and optimal management in adults is poorly understood. Our objective is to characterize AAOCA in a large single-center adult cohort based on coronary anatomic variants and surgical management strategies. METHODS We reviewed imaging, clinic, and operative reports for 645 adults with an encounter diagnosis code of congenital coronary anomaly from July 2015 to July 2017. After excluding other congenital heart defects, we characterized 167 patients with AAOCAs by anatomic variant, symptoms at diagnosis, indication for advanced imaging, and if performed, surgical repair. To describe the anatomic variant, we classified the origin and course by following the atomization scheme developed by the Congenital Heart Surgeon's Society's AAOCA registry. RESULTS Among adults with AAOCA, the anomalous origin involved the right coronary artery in 57% (96 of 167), left main coronary artery in 23% (39 of 167), left anterior descending in 2% (4 of 167), circumflex in 16% (26 of 167), and multiple coronaries in 1% (2 of 167). Anomalous right coronary arteries were diagnosed at an older median age than anomalous left main coronary arteries (55 vs 51 years, respectively; P = .026). Surgical repair of AAOCA occurred in 22% (36 of 167) of patients. Concomitant cardiac surgical procedures accompanied 36% (13 of 36) of them. No deaths occurred over a median follow-up of 2.5 years. CONCLUSIONS Most patients in our single-center AAOCA registry were diagnosed in the presence of cardiac symptoms. Concomitant aortic valve disease and coronary atherosclerotic burden complicate both the evaluation and surgical approach to adult AAOCA repair.
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Pontailler M, Demondion P, Lebreton G. Surgical management of an anomalous right coronary artery. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 9:NP1-NP2. [PMID: 26858021 DOI: 10.1177/2048872616632154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Anomalous aortic origin of coronary arteries is a rare congenital heart disease that can be associated with sudden death. We present the case of a young patient who sustained a cardiac arrest revealing an anomalous origin of the right coronary artery. Unroofing and pericardial enlargement of the coronary artery ostia was performed and the patient is actually asymptomatic.
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Affiliation(s)
- Margaux Pontailler
- Department of Thoracic and Cardio-Vascular Surgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Pierre Demondion
- Department of Thoracic and Cardio-Vascular Surgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Guillaume Lebreton
- Department of Thoracic and Cardio-Vascular Surgery, Pitié-Salpêtrière Hospital, Paris, France
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13
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Algahim MF. Commentary: Why Stress It? Modeling of Coronary Wall Shear Stress and Morphology of Anomalous Aortic Origin of Coronary Artery may Help Define Surgical Strategy. Semin Thorac Cardiovasc Surg 2020; 33:170-171. [PMID: 33176196 DOI: 10.1053/j.semtcvs.2020.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 09/25/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Mohamed F Algahim
- University of Rochester School of Medicine and Dentistry, Department of Surgery, Division of Pediatric Cardiac Surgery, Rochester, New York.
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14
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Karangelis D, Mylonas KS, Loggos S, Adreanides E, Tzifa A, Mitropoulos F. Surgical repair of anomalous aortic origin of coronary artery in adults. Asian Cardiovasc Thorac Ann 2020; 29:51-58. [PMID: 32903023 DOI: 10.1177/0218492320957818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Anomalous aortic origin of a coronary artery is a congenital abnormality of the origin or course of a coronary artery that arises from the aorta. The surgical treatment of this anomaly is highly variable and controversial and is achieved by implementing elaborate techniques of anatomic repair or by simple coronary artery bypass grafting. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two independent reviewers determined whether studies met the inclusion criteria. Eligible papers were published in English, clinical studies describing surgical repair of anomalous aortic origin of a coronary artery including coronary artery bypass in adults, and enrolled >5 patients. In the absence of multicentre trials, 7 single-center retrospective series were included, which demonstrated comparable short- and midterm outcomes of anatomic repair and coronary artery bypass in adults with anomalous aortic origin of a coronary artery. Coronary unroofing was the preferred technique when the anomalous artery has an intramural component, but there is a risk of aortic insufficiency. Anatomic repair is technically demanding and should be carried out in experienced centers. Coronary artery bypass with internal thoracic artery or vein grafts is technically straightforward with low operative risk and comparable midterm outcomes, however, long-term outcomes are unknown. Coronary artery bypass grafting is the technique of choice for older patients, in those with concomitant coronary artery disease, as a bailout procedure for failed anatomic repair, or in centers without experience in anatomic repair for anomalous aortic origin of a coronary artery.
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Affiliation(s)
| | | | - Spiros Loggos
- Department of Cardiac Surgery, Mitera Hospital, Athens, Greece
| | - Elias Adreanides
- Department of Cardiology, Medical Institution Military Shareholder Fund, Athens, Greece
| | - Aphrodite Tzifa
- Department of Congenital Cardiology, Mitera Hospital, Athens, Greece
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15
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Najm HK, Karamlou T, Ahmad M, Hassan S, Salam Y, Majdalany D, Ghobrial J, Stewart RD, Unai S, Pettersson G. Early Outcomes of Transconal Repair of Transseptal Anomalous Left Coronary Artery From Right Sinus. Ann Thorac Surg 2020; 112:595-602. [PMID: 32822667 DOI: 10.1016/j.athoracsur.2020.04.149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 03/20/2020] [Accepted: 04/20/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anomalous aortic origin of the left coronary artery (AAOCLA) with an extended transseptal course behind the right ventricular outflow tract (RVOT) is a rare variant that poses challenges not addressed by current surgical techniques. We utilized a novel transconal approach in 7 consecutive patients. METHODS A retrospective review was made of a prospectively collected database for consecutive patients undergoing transconal unroofing of transseptal AAOLCA. Surgical repair entails transection of the RVOT, unroofing the septal course of the AAOLCA, followed by RVOT extension with a rectangular strip of autologous pericardium. Preoperative characteristics, operative details, and postoperative course were abstracted. RESULTS All 7 patients identified were symptomatic. Median age was 48 years (range, 12 to 62). The AAOLCA with transseptal course was confirmed by computed tomography angiography. Three patients had provocative testing demonstrating anterolateral ischemia. Four patients underwent cardiac catheterization with intravascular ultrasound and indexed fractional flow reserve, confirming flow-limiting lesion. Importantly, 3 patients had negative provocative noninvasive testing for ischemia. Median postoperative hospital length of stay was 6 days (range, 4 to 12). No mortality or major complications occurred during a median follow-up of 0.75 years. Postoperative evaluation demonstrated anatomically patent unroofed AAOLCA with improved indexed fractional flow reserve compared with preoperative (0.59 ± 0.16 vs 0.90 ± 0.03, P = .05). CONCLUSIONS Complete unroofing of AAOLCA with transseptal course repaired with posterior extension of RVOT is an effective technique with excellent early outcome. Multimodality provocative testing is critical to evaluate these lesions as individual studies may be misleading. Intravascular ultrasound with indexed fractional flow reserve is clinically useful to confirm the hemodynamic significance of specific lesions.
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Affiliation(s)
- Hani K Najm
- Division of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Tara Karamlou
- Division of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Munir Ahmad
- Division of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Saad Hassan
- Division of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Yezan Salam
- Division of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Division of Cardiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - David Majdalany
- College of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Joanna Ghobrial
- College of Medicine, AlFaisal University, Riyadh, Saudi Arabia
| | - Robert D Stewart
- Division of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Division of Pediatric Cardiac Surgery, Akron Children's Hospital, Akron, Ohio
| | - Shinya Unai
- Division of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Gosta Pettersson
- Division of Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Khan MS, Idris O, Shah J, Sharma R, Singh H. Anomalous Origin of Left Main Coronary Artery from the Right Sinus of Valsalva: A Case Series-based Review. Cureus 2020; 12:e7777. [PMID: 32461852 PMCID: PMC7243662 DOI: 10.7759/cureus.7777] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Congenital anomalies involving the origin of coronary arteries are rare and the most common anomaly is left circumflex (LCX) arising from the right sinus of Valsalva (RSV). Other anomalies include a single coronary artery from the left sinus of Valsalva, both coronary arteries from RSV and left anterior descending coronary artery (LAD) from RSV. Anomalous origin of left main from RSV carries a high risk of sudden cardiac arrest. A retrospective analysis and literature review of three patients admitted to our medical center with the acute coronary syndrome, who underwent coronary angiography and were found to have left main coronary artery (LMCA) originating from the right coronary cusp (RCA). One patient had non-diseased coronaries with symptoms caused by the variant anatomy with possible compression of the LMCA, whereas the other two patients had 100% occluded RCA with variable stenosis in the left coronary system. Eventual surgical re-implantation with bypass grafting was required in all three patients. LMCA from the RSV is a rare, but often fatal anomaly. Due to a lack of data and inability to predict sudden cardiac death, the latest guidelines recommend surgical intervention (class 1 recommendation) for all patients with LMCA from RSV, regardless of ischemia or ischemic symptoms.
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Affiliation(s)
- Muhammad S Khan
- Internal Medicine, Mercy St Vincent Medical Center, Toledo, USA
| | - Owais Idris
- Cardiology, Mercy St Vincent Medical Centre, Toledo, USA
| | - Jay Shah
- Internal Medicine, Mercy St Vincent Medical Centre, Toledo, USA
| | - Ravina Sharma
- Internal Medicine, Mercy St Vincent Medical Centre, Toledo, USA
| | - Hemindermeet Singh
- Interventional Cardiology, Ascension St John Hospital and Medical Centre, Dretroit, USA
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17
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Jegatheeswaran A, Devlin PJ, Williams WG, Brothers JA, Jacobs ML, DeCampli WM, Fleishman CE, Kirklin JK, Mertens L, Mery CM, Molossi S, Caldarone CA, Aghaei N, Lorber RO, McCrindle BW. Outcomes after anomalous aortic origin of a coronary artery repair: A Congenital Heart Surgeons' Society Study. J Thorac Cardiovasc Surg 2020; 160:757-771.e5. [PMID: 32800265 DOI: 10.1016/j.jtcvs.2020.01.114] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 12/31/2019] [Accepted: 01/12/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES It remains unclear when sudden cardiac event risk outweighs surgical risk for patients with anomalous aortic origin of a coronary artery. The Congenital Heart Surgeons' Society sought to characterize the surgical risks by determining the techniques, complications, and outcomes of repair. METHODS Between January 2000 and September 2018, 682 patients with anomalous aortic origin of a coronary artery aged 30 years or less were enrolled. Demographic, morphologic, operative, imaging, and ischemia-related data were analyzed. RESULTS There were 395 of 682 (57%) surgical patients (45 centers, median follow-up 2.8 years). In addition to primary repair (87% unroofing, 26% commissural manipulation), 13 patients had 15 coronary-related reoperations. Of 358 patients with pre/postoperative aortic insufficiency assessment, 27 (8%) developed new mild or greater aortic insufficiency postoperatively, and 7 (2%) developed new moderate or greater aortic insufficiency. Freedom from mild aortic insufficiency differed in those with versus without commissural manipulation (85%/91% at 6 months, 83%/90% at 1 year, and 77%/88% at 3 years, respectively) (P = .05). Of 347 patients with preoperative/postoperative ejection fraction, 6 (2%) developed new abnormal ejection fraction (<50%) within 30 days of surgery which persisted. Although 64 of 395 patients (16%) had preoperative ischemia, after surgery 51 of 64 patients (80%) no longer had ischemia (13 = new postoperative ischemia, P < .0001). Four patients died postoperatively (preoperatively 2 asymptomatic, 1 symptomatic, 1 in extremis). Composite surgical adverse event rates were 7% to 13% in the entire cohort (increasing/decreasing by presentation/anatomy/repair strategy). CONCLUSIONS Anomalous aortic origin of a coronary artery surgery may relieve ischemia with low mortality; however, it can result in a variety of important morbidities, varying by the group evaluated. Strategies avoiding commissural manipulation may decrease the risk of developing aortic insufficiency. Understanding these risks should inform surgical decision-making and support the need for standardized assessment and management.
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Affiliation(s)
- Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Paul J Devlin
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
| | - William G Williams
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Julie A Brothers
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Marshall L Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Md
| | - William M DeCampli
- Division of Cardiac Surgery, Department of Surgery, University of Central Florida, College of Medicine, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Craig E Fleishman
- Division of Cardiology, Department of Pediatrics, University of Central Florida, College of Medicine, Arnold Palmer Hospital for Children, Orlando, Fla
| | - James K Kirklin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama, School of Medicine, Birmingham, Ala
| | - Luc Mertens
- Division of Cardiology, Department of Paediatrics, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Carlos M Mery
- Division of Pediatric and Congenital Heart Surgery, Department of Surgery and Perioperative Care, University of Texas at Austin, Dell Children's Medical Center, Austin, Tex
| | - Silvana Molossi
- Division of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Christopher A Caldarone
- Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Nabi Aghaei
- Congenital Heart Surgeons' Society Data Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Richard O Lorber
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of San Antonio, Baylor College of Medicine, San Antonio, Tex
| | - Brian W McCrindle
- Division of Cardiology, Department of Paediatrics, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
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18
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Diao KY, Zhao Q, Gao Y, Shi K, Ma M, Xu HY, Guo YK, Yang ZG. Prognostic value of dual-source computed tomography (DSCT) angiography characteristics in anomalous coronary artery from the opposite sinus (ACAOS) patients: a large-scale retrospective study. BMC Cardiovasc Disord 2020; 20:25. [PMID: 31952479 PMCID: PMC6966895 DOI: 10.1186/s12872-019-01285-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/27/2019] [Indexed: 02/08/2023] Open
Abstract
Background Most reported cases of right anomalous coronary artery from the opposite sinus (R-ACAOS) have benign clinical outcomes. However, patients with left ACAOS (L-ACAOS) and some of the patients with R-ACAOS are more at risk for arrhythmias and sudden cardiac death, which remains a major concern. Here we report the prevalence and anatomical features of ACAOS patients. Moreover, we explore the high-risk morphological signs and evaluate their mid-term prognostic value in R-ACAOS patients without surgical intervention. Methods Data from coronary computed tomography angiography (CTA) of 30,593 patients, pertaining to a single center over 5 consecutive years, were retrospectively analyzed. The image analysis included stenosis severity ranking and high-risk anatomy evaluation, based on the commercially available image post-processing software OsirX. Patients with R-ACAOS and without evidence of coronary atherosclerosis (CAD) were followed-up, with recording of the cardiovascular clinical events. Cox regression analysis was performed to identify the potential anatomical risk factors of cardiovascular clinical events for non-CAD R-ACAOS patients, using R project. Results The prevalence of ACAOS in the study population was 0.69% (211/30593). Significant differences were found between patients with mild (< 50%) and severe (> 50%) stenosis, in terms of height-to-weight ratio (HW ratio), take-off angle, and proximal stenosis length. A total of 54 cardiovascular clinical events were observed among 108 non-CAD R-ACAOS patients and an average follow-up of 27.8 ± 18.7 months. Among those patients’ anatomical features, stenosis severity was the main risk factor for cardiovascular clinical events during the mid-term follow-up, with a risk ratio of 4.14 (95% CI: 1.78 to 9.63, P < 0.001). Conclusions Among patients referred to coronary CTA, the overall incidence of ACAOS was 0.69%. For patients with R-ACAOS, severe stenosis was the independent risk factor of adverse clinical events in the mid-term follow-up, and positive clinical intervention might be needed to help them avoid the malignant clinical events.
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Affiliation(s)
- Kai-Yue Diao
- Department of Radiology, State Key Laboratory of Biotherapy West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, China
| | - Qin Zhao
- Department of Radiology, State Key Laboratory of Biotherapy West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, China
| | - Yue Gao
- Department of Radiology, State Key Laboratory of Biotherapy West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, China
| | - Ke Shi
- Department of Radiology, State Key Laboratory of Biotherapy West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, China
| | - Min Ma
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hua-Yan Xu
- Department of Radiology, State Key Laboratory of Biotherapy West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, China
| | - Ying-Kun Guo
- Department of Radiology, Key Laboratory of Birth Defects and Related Diseases of Women and Children of Ministry of Education, West China Second University Hospital, Sichuan University, 20# Section 3 South Renmin Road, Chengdu, 610041, China.
| | - Zhi-Gang Yang
- Department of Radiology, State Key Laboratory of Biotherapy West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, China.
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Transconal Unroofing of Anomalous Left Main Coronary Artery From Right Sinus With Trans-septal Course. Ann Thorac Surg 2019; 108:e383-e386. [DOI: 10.1016/j.athoracsur.2019.04.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/26/2019] [Accepted: 04/01/2019] [Indexed: 11/24/2022]
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20
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Jegatheeswaran A, Devlin PJ, McCrindle BW, Williams WG, Jacobs ML, Blackstone EH, DeCampli WM, Caldarone CA, Gaynor JW, Kirklin JK, Lorber RO, Mery CM, St. Louis JD, Molossi S, Brothers JA. Features associated with myocardial ischemia in anomalous aortic origin of a coronary artery: A Congenital Heart Surgeons' Society study. J Thorac Cardiovasc Surg 2019; 158:822-834.e3. [DOI: 10.1016/j.jtcvs.2019.02.122] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 02/05/2019] [Accepted: 02/17/2019] [Indexed: 01/10/2023]
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22
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Commentary: The intercoronary pillar—Not necessarily an innocent bystander. J Thorac Cardiovasc Surg 2019; 158:218-219. [DOI: 10.1016/j.jtcvs.2019.02.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 02/11/2019] [Indexed: 11/21/2022]
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23
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Kostolny M, Kanakis M, Hsia TY. Anomalous origin of both the right and left coronary arteries: a singular anomaly†. Interact Cardiovasc Thorac Surg 2019; 28:640-641. [PMID: 30376066 DOI: 10.1093/icvts/ivy301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/21/2018] [Accepted: 09/29/2018] [Indexed: 11/14/2022] Open
Abstract
Herein, the case of an 8-year-old male child diagnosed with an extremely rare anatomical presentation of a single origin of both the left and right coronary arteries from the non-coronary sinus is presented. The surgical management is also described.
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Affiliation(s)
- Martin Kostolny
- Cardiothoracic Unit, Great Ormond Street Hospital for Children, London, UK.,Slovak Medical University in Bratislava, Bratislava, Slovakia
| | - Meletios Kanakis
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Tain-Yen Hsia
- Pediatric Cardiac Surgery, Yale New Haven Children's Hospital, New Haven, CT, USA
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Yerebakan C, Ozturk M, Mota L, Sinha L, Gordish-Dressman H, Jonas R, Sinha P. Complete unroofing of the intramural coronary artery for anomalous aortic origin of a coronary artery: The role of commissural resuspension? J Thorac Cardiovasc Surg 2019; 158:208-217.e2. [PMID: 30955961 DOI: 10.1016/j.jtcvs.2019.01.140] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 01/12/2019] [Accepted: 01/25/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although surgical repair of an anomalous aortic origin of the coronary artery has low operative mortality, longer-term risk of ischemia and aortic regurgitation remains concerning. We routinely perform aortic commissure resuspension after unroofing and sought to evaluate the outcomes with regard to aortic valve competence, symptoms, and signs of ischemia with this approach. METHODS Twenty-six consecutive patients who received the unroofing procedure for anomalous aortic origin of the coronary artery (10 left; 16 right) between 2004 and 2016 were reviewed. In addition to complete unroofing of the intramural coronary, patients early in the cohort (n = 9) received unroofing only, and aortic commissural resuspension was performed routinely in the subsequent patients (n = 17). Outcomes between commissural resuspension versus no commissural resuspension were compared. The occurrence of mild and greater aortic regurgitation was assessed using a time-to-event analysis after varying lengths of time. Commissural resuspension was considered as the predictor, and the groups were compared using a log-rank test. RESULTS There was no operative mortality. One patient in the no commissural resuspension group died 10 years later of prosthetic aortic valve endocarditis (aortic valve replacement 7 years after unroofing). The follow-up duration was 6.9 years (4.9-9.1) and 3.7 years (2.1-4.3) in the no commissural resuspension and commissural resuspension groups, respectively (P = .001). Available postoperative exercise stress test data (n = 14) revealed that 50% had an endurance level at the 25th percentile or greater for age. After a median follow-up of 1.9 years (3 months to 10.6 years), no patient in the commissural resuspension group had aortic regurgitation, whereas 6 of 9 patients (67%) in the no commissural resuspension group had stable but mild or greater aortic regurgitation. Time-to-event analysis with the primary event of occurrence of mild or greater aortic regurgitation showed significantly higher freedom from the occurrence of aortic regurgitation in the commissural resuspension group (P = .035). CONCLUSIONS Surgical repair of an anomalous aortic origin of the coronary artery can be performed with excellent early and midterm outcomes. Routine commissural resuspension of the aortic valve may lead to a lower rate of aortic valve regurgitation without increasing the risk of ischemia.
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Affiliation(s)
- Can Yerebakan
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Mahmut Ozturk
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Lucas Mota
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Lok Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Heather Gordish-Dressman
- Center for Genetic Medicine Research, Children's Health System, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Richard Jonas
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC
| | - Pranava Sinha
- Department of Cardiovascular Surgery, Children's National Health System, Washington, DC.
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Mavroudis C, Kirklin JK, DeCampli WM. Incremental History of the Congenital Heart Surgeons’ Society (2014-2018). World J Pediatr Congenit Heart Surg 2018; 9:668-676. [DOI: 10.1177/2150135118800305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The history of the first 41 years of the Congenital Heart Surgeons Society (CHSS) was recorded in 2015 which chronicled the metamorphosis of a small informal meeting into a mature organization with bylaws, officers, committees, funded research, the Kirklin-Ashburn Fellowship, and a vision to become the premier organization of congenital heart surgery in North America. Chief among these transformations was the implementation and development of the CHSS Data Center. Member participation, fellowship education, and significant outcomes research have been the hallmark of the CHSS. This incremental historical review highlights continued CHSS sentinel advances. Fifty-three CHSS Data Center manuscripts have been published. Citation scores (number of literature citations that each manuscript has accrued) have been collated and analyzed by cohort study. The average citation score for all manuscripts was 75.4 ± 76.3 (range: 1-333). The Kirklin/Ashburn Fellowship continues to thrive with academic achievements and generous contributions to the endowment. The World Journal of Pediatric and Congenital Heart Surgery has been adopted as the official organ of the CHSS. A Past President’s Dinner has been inaugurated serving as a senior advisory committee to the Executive Council. Toronto Work Weekends continue. Congenital Heart Surgeons Society growth has accrued to 159 active members and 82 institutional members. Future considerations include the size, content, and duration of the annual meeting; the potential for increased membership; and political penetrance into national cardiothoracic governing organizations regarding committee appointments, executive council representation, and education initiatives. Congenital Heart Surgeons Society has achieved numerous advances during this incremental period.
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Affiliation(s)
- Constantine Mavroudis
- Johns Hopkins University School of Medicine, Florida Hospital for Children, Orlando, FL, USA
| | - James K. Kirklin
- Department of Surgery, University of Alabama, Birmingham, AL, USA
| | - William M. DeCampli
- Congenital Heart Surgery, Arnold Palmer Children’s Hospital, Orlando, FL, USA
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Kloesel B, Richtsfeld M, Konia M, Bass JL. Management and Anesthetic Considerations for Patients With Anomalous Aortic Origin of a Coronary Artery. Semin Cardiothorac Vasc Anesth 2018; 22:383-394. [PMID: 30095030 DOI: 10.1177/1089253218793888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The term "coronary artery anomalies" encompasses a large and heterogeneous group of disorders that may affect origin, intrinsic anatomy, course, location, and termination of the coronary arteries. With these different anatomies, presentation, symptoms, and outcomes are heterogeneous as well. While significant efforts are directed toward improving diagnosis and risk-stratification, best evidence-guided practices remain in evolution. Data about anesthetic management of patients with coronary anomalies are lacking as well. This review aims to provide the anesthesiologist with a better understanding of an important subgroup of coronary artery anomalies: anomalous aortic origin of a coronary artery. We will discuss classification, pathophysiology, incidence, evaluation, management, and anesthetic implications of this potentially fatal disease group.
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Affiliation(s)
- Benjamin Kloesel
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - Martina Richtsfeld
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - Mojca Konia
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
| | - John L Bass
- 1 Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, USA
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Anomalous Coronary Artery Origin in a Young Patient with Marfan Syndrome. Case Rep Cardiol 2018; 2017:3861923. [PMID: 29430308 PMCID: PMC5752982 DOI: 10.1155/2017/3861923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 09/13/2017] [Accepted: 11/13/2017] [Indexed: 11/17/2022] Open
Abstract
Marfan syndrome is an autosomal dominant genetic disorder that affects connective tissue and is caused by mutations in the fibrillin 1 gene present at chromosome 15. Aortic aneurysm is its main complication, and along the dilation of the aorta root and its descending portion (60–100%), with secondary aortic insufficiency, it increases risk of acute aortic dissection and death. Coronary artery anomalies affect between 0.3% and 1.6% of the general population and are the second leading cause of sudden death in young adults, especially if the anomalous coronary passes through aorta and pulmonary artery. The anomalous origin of the left main coronary artery in the right Valsalva sinus has a prevalence of 0.02%–0.05% and is commonly related to other congenital cardiac anomalies, such as transposition of great vessels, coronary fistulas, bicuspid aortic valve, and tetralogy of Fallot. Its association with Marfan syndrome is not known, and there is no previous report in the literature. We describe here a case of a female with Marfan syndrome diagnosed with symptomatic anomalous origin of the left coronary artery in the right Valsalva sinus.
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Abstract
PURPOSE OF REVIEW There is a broad spectrum of coronary artery anomalies that cardiologists may encounter either incidentally or during evaluation for cardiac symptoms. These anomalies include anomalous coronary arteries arising from the opposite sinus of Valsalva (ACAOS), coronary fistulae, and coronary artery aneurysms. This manuscript outlines the unique features, diagnostic characteristics, and treatment considerations for these lesions. RECENT FINDINGS Intravenous ultrasound (IVUS), computed tomographic angiography (CTA), and magnetic resonance imaging (MRI) are becoming more sophisticated and will be increasingly used to facilitate the optimal treatment approach for coronary anomalies. There are a wide variety of coronary artery anomalies and their clinical ramifications range from benign to potentially fatal. Coronary anomalies often have complex anatomy and require advanced imaging modalities for comprehensive characterization. Due to the heterogeneity in lesion characteristics and outcomes, physicians should consider clinical and imaging features to create individualized management plans, along with referral to adult congenital heart disease centers.
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Affiliation(s)
- Ajar Kochar
- Duke University Hospital, 2301 Erwin Road, Durham, NC, 27710, USA.
- , 2400 Pratt Street, Durham, NC, 27705, USA.
| | - Todd Kiefer
- Duke University Hospital, 2301 Erwin Road, Durham, NC, 27710, USA
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Aubry P, Halna du Fretay X, Degrell P, Waldmann V, Karam N, Marijon E. [Sudden cardiac death and anomalous connections of the coronary arteries: What is known and what is unknown?]. Ann Cardiol Angeiol (Paris) 2017; 66:309-318. [PMID: 29050742 DOI: 10.1016/j.ancard.2017.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 09/12/2017] [Indexed: 06/07/2023]
Abstract
Some anomalous connections of the coronary arteries may be associated with a risk of sudden cardiac death. In opposite with others cardiac diseases at risk of sudden cardiac death, the relationship between these congenital abnormalities and the risk of sudden cardiac death are not well understood. A correction of the anomaly is generally indicated after an aborted sudden cardiac death. Primary prevention strategy after the discovery of an anomaly at risk is debated. Even if the absolute risk of sudden death is very low, a pre-participation screening in young athletes may be discussed due to a non-rare incidence.
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Affiliation(s)
- P Aubry
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France; Service de cardiologie, centre hospitalier, 95500 Gonesse, France; Groupe ANOCOR : groupe de travail multidisciplinaire sur les anomalies congénitales des artères coronaires, groupe hospitalier Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France.
| | - X Halna du Fretay
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France; Groupe ANOCOR : groupe de travail multidisciplinaire sur les anomalies congénitales des artères coronaires, groupe hospitalier Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; Unité cardiologique de la Reine-Blanche, 45770 Saran, France
| | - P Degrell
- Département de cardiologie, groupe hospitalier Bichat-Claude-Bernard, Assistance Publique-Hôpitaux de Paris, 46, rue Henri-Huchard, 75018 Paris, France
| | - V Waldmann
- Département de cardiologie, hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France; Inserm U970, Centre d'expertise Mort-Subite (CEMS), centre de recherche cardiovasculaire de Paris (PARCC), 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
| | - N Karam
- Département de cardiologie, hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France; Inserm U970, Centre d'expertise Mort-Subite (CEMS), centre de recherche cardiovasculaire de Paris (PARCC), 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
| | - E Marijon
- Département de cardiologie, hôpital Européen Georges-Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France; Inserm U970, Centre d'expertise Mort-Subite (CEMS), centre de recherche cardiovasculaire de Paris (PARCC), 75015 Paris, France; Université Paris Descartes, 75006 Paris, France
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Exercise restriction is not associated with increasing body mass index over time in patients with anomalous aortic origin of the coronary arteries. Cardiol Young 2017; 27:1538-1544. [PMID: 28460658 DOI: 10.1017/s104795111700066x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Anomalous aortic origin of the coronary arteries is associated with exercise-induced ischaemia, leading some physicians to restrict exercise in patients with this condition. We sought to determine whether exercise restriction was associated with increasing body mass index over time. From 1998 to 2015, 440 patients ⩽30 years old were enrolled into an inception cohort. Exercise-restriction status was documented in 143 patients. Using linear mixed model repeated-measures regression, factors associated with increasing body mass index z-score over time, including exercise restriction and surgical intervention as time-varying covariates, were investigated. The 143 patients attended 558 clinic visits for which exercise-restriction status was recorded. The mean number of clinic visits per patient was 4, and the median duration of follow-up was 1.7 years (interquartile range (IQR) 0.5-4.4). The median age at first clinic visit was 10.3 years (IQR 7.1-13.9), and 71% (101/143) were males. All patients were alive at their most recent follow-up. At the first clinic visit, 54% (78/143) were exercise restricted, and restriction status changed in 34% (48/143) during follow-up. The median baseline body mass index z-score was 0.2 (IQR 0.3-0.9). In repeated-measures analysis, neither time-related exercise restriction nor its interaction with time was associated with increasing body mass index z-score. Surgical intervention and its interaction with time were associated with decreasing body mass index z-score. Although exercise restriction was not associated with increasing body mass index over time, surgical intervention was associated with decreasing body mass index z-score over time in patients with anomalous aortic origin of the coronary arteries.
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Cubero A, Crespo A, Hamzeh G, Cortes A, Rivas D, Aramendi JI. Anomalous Origin of Right Coronary Artery From Left Coronary Sinus-13 Cases Treated With the Reimplantation Technique. World J Pediatr Congenit Heart Surg 2017; 8:315-320. [PMID: 28520537 DOI: 10.1177/2150135116688172] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Anomalous aortic origin of a coronary artery is uncommon but potentially clinically significant. Manifestations vary from asymptomatic patients to those who present with angina pectoris, myocardial infarction, heart failure, syncope, arrhythmias, and sudden death. We describe our experience with surgical reimplantation and results at midterm follow-up. METHODS Between February 2003 and July 2016, a total of 13 patients with anomalous origin of the right coronary artery (RCA) from the left sinus underwent surgical reimplantation. RESULTS Mean age was 39 years (range, 11-72 years). Eight patients presented with dyspnea and angina, two with acute myocardial infarction, and the remaining three were studied for atypical chest pain and ventricular premature contractions. Definitive diagnosis was achieved with coronary angiography in eight cases and with computed tomography scan in five. In all cases, the anomalous origin of the RCA from the left sinus had an intramural course except one case with interarterial (but not intramural) course. At operation, the RCA was dissected at the takeoff from the intramural course and reimplanted into the right sinus of Valsalva. There was no mortality. One patient had associated atherosclerotic coronary artery disease that required stent placement postoperatively. After a mean follow-up of 65 months (maximum 12 years), all patients are asymptomatic and have returned to exercise without limitations. CONCLUSIONS The reimplantation technique provides a good physiological and anatomical repair, eliminates a slit-like ostium, avoids compression of the coronary artery between the aorta and the pulmonary artery, and gives similar results to the unroofing technique.
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Affiliation(s)
- Alain Cubero
- 1 Division of Cardiac Surgery, Cruces University Hospital, Barakaldo, Spain
| | - Alejandro Crespo
- 1 Division of Cardiac Surgery, Cruces University Hospital, Barakaldo, Spain
| | - Gadah Hamzeh
- 1 Division of Cardiac Surgery, Cruces University Hospital, Barakaldo, Spain
| | - Andrés Cortes
- 1 Division of Cardiac Surgery, Cruces University Hospital, Barakaldo, Spain
| | - Daniel Rivas
- 1 Division of Cardiac Surgery, Cruces University Hospital, Barakaldo, Spain
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Mery CM, De León LE, Molossi S, Sexson-Tejtel SK, Agrawal H, Krishnamurthy R, Masand P, Qureshi AM, McKenzie ED, Fraser CD. Outcomes of surgical intervention for anomalous aortic origin of a coronary artery: A large contemporary prospective cohort study. J Thorac Cardiovasc Surg 2017; 155:305-319.e4. [PMID: 29074047 DOI: 10.1016/j.jtcvs.2017.08.116] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/26/2017] [Accepted: 08/10/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this study was to prospectively analyze the outcomes of patients with anomalous aortic origin of a coronary artery undergoing surgical intervention according to a standardized management algorithm. METHODS All patients aged 2 to 18 years undergoing surgical intervention for anomalous aortic origin of a coronary artery between December 2012 and April 2017 were prospectively included. Patients underwent stress nuclear perfusion imaging, stress cardiac magnetic resonance imaging, and retrospectively electrocardiogram-gated computed tomography angiography preoperatively. Patients were cleared for exercise at 3 months postoperatively if asymptomatic and repeat stress nuclear perfusion imaging, stress cardiac magnetic resonance imaging, and computed tomography angiography showed normal results. RESULTS A total of 44 patients, with a median age of 14 years (8-18 years), underwent surgical intervention: 9 (20%) for the anomalous left coronary artery and 35 (80%) for the anomalous right coronary artery. Surgical procedures included unroofing in 35 patients (80%), translocation in 7 patients (16%), ostioplasty in 1 patient (2%), and side-side-anastomosis in 1 patient (2%). One patient who presented with aborted sudden cardiac death from an anomalous left coronary and underwent unroofing presented 1 year later with a recurrent episode and was found to have an unrecognized myocardial bridge and persistent compression of the coronary requiring reintervention. At last follow-up, 40 patients (91%) are asymptomatic and 4 patients have nonspecific chest pain; 42 patients (95%) have returned to full activity, and 2 patients are awaiting clearance. CONCLUSIONS Surgical treatment for anomalous aortic origin of a coronary artery is safe and should aim to associate the coronary ostium with the correct sinus, away from the intercoronary pillar. After surgery, the majority of patients are cleared for exercise and remain asymptomatic. Longer follow-up is needed to assess the true efficacy of surgery in the prevention of sudden cardiac death.
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Affiliation(s)
- Carlos M Mery
- Coronary Anomalies Program, Texas Children's Hospital, Houston, Tex; Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex.
| | - Luis E De León
- Coronary Anomalies Program, Texas Children's Hospital, Houston, Tex; Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex
| | - Silvana Molossi
- Coronary Anomalies Program, Texas Children's Hospital, Houston, Tex; The Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex
| | - S Kristen Sexson-Tejtel
- Coronary Anomalies Program, Texas Children's Hospital, Houston, Tex; The Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex
| | - Hitesh Agrawal
- Coronary Anomalies Program, Texas Children's Hospital, Houston, Tex; The Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex
| | | | - Prakash Masand
- Coronary Anomalies Program, Texas Children's Hospital, Houston, Tex; Department of Radiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex
| | - Athar M Qureshi
- Coronary Anomalies Program, Texas Children's Hospital, Houston, Tex; The Lillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex
| | - E Dean McKenzie
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Sibley Heart Center, Children's Healthcare of Atlanta/Emory University School of Medicine, Atlanta, Ga
| | - Charles D Fraser
- Coronary Anomalies Program, Texas Children's Hospital, Houston, Tex; Division of Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Tex
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Balasubramanya S, Mongé MC, Eltayeb OM, Sarwark AE, Costello JM, Rigsby CK, Popescu AR, Backer CL. Anomalous Aortic Origin of a Coronary Artery: Symptoms Do Not Correlate With Intramural Length or Ostial Diameter. World J Pediatr Congenit Heart Surg 2017; 8:445-452. [DOI: 10.1177/2150135117710926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Anomalous aortic origin of a coronary artery (AAOCA) is a known cause of sudden death. Our hypothesis was that longer intramural length and smaller ostial diameter correlate with preoperative symptoms. If true, this would assist in the decision for surgical indications. We also assessed the accuracy of preoperative imaging to predict intramural length. Methods: Retrospective analysis of patients who underwent AAOCA unroofing from 2006 to 2014. Patients had preoperative computed tomography angiography (CTA) or magnetic resonance imaging (MRI). Intramural length was measured. Intramural lengths and ostial diameters were also measured intraoperatively (operating room [OR]). Symptoms were noted. Intramural lengths and ostial diameters were compared between patients with and without preoperative symptoms. The accuracy of intramural length measured by CTA/MRI versus the length measured in the OR was assessed using a Bland-Altman analysis. Results: Sixty-six patients underwent surgical repair of AAOCA. Fifty-two (79%) patients were symptomatic and 14 (21%) were asymptomatic. Mean age was 12.4 ± 4.0 years. There was no mortality. There was strong agreement between intramural length measured by CTA/MRI and measured in the OR. There was no significant difference in AAOCA intramural length in the symptomatic (8.6 ± 3.5 mm) and asymptomatic (8.9 ± 2.8 mm, P = .77) patients, which were measured both by CTA/MRI and intraoperatively (symptomatic 7.3 ± 2.5 mm, asymptomatic 6.9 ± 2.8 mm; P = .62). There was also no significant difference in AAOCA ostial diameters between groups (symptomatic = 1.9 ± 0.5 mm, asymptomatic = 1.6 ± 0.5 mm; P = .09). Conclusion: Preoperative CTA/MRI was very accurate in predicting the length of surgical unroofing. There was no demonstrable correlation between preoperative symptoms and intramural AAOCA length or AAOCA ostial diameter.
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Affiliation(s)
- Shyamasundar Balasubramanya
- Division of Cardiovascular–Thoracic Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Michael C. Mongé
- Division of Cardiovascular–Thoracic Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Osama M. Eltayeb
- Division of Cardiovascular–Thoracic Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anne E. Sarwark
- Division of Cardiovascular–Thoracic Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - John M. Costello
- Division of Cardiology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cynthia K. Rigsby
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andrada R. Popescu
- Division of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Carl L. Backer
- Division of Cardiovascular–Thoracic Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Cheezum MK, Liberthson RR, Shah NR, Villines TC, O'Gara PT, Landzberg MJ, Blankstein R. Anomalous Aortic Origin of a Coronary Artery From the Inappropriate Sinus of Valsalva. J Am Coll Cardiol 2017; 69:1592-1608. [PMID: 28335843 DOI: 10.1016/j.jacc.2017.01.031] [Citation(s) in RCA: 219] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 12/05/2016] [Accepted: 01/03/2017] [Indexed: 02/07/2023]
Abstract
Anomalous aortic origin of a coronary artery (AAOCA) from the inappropriate sinus of Valsalva is increasingly recognized by cardiac imaging. Although most AAOCA subtypes are benign, autopsy studies report an associated risk of sudden death with interarterial anomalous left coronary artery (ALCA) and anomalous right coronary artery (ARCA). Despite efforts to identify high-risk ALCA and ARCA patients who may benefit from surgical repair, debate remains regarding their classification, prevalence, risk stratification, and management. We comprehensively reviewed 77 studies reporting the prevalence of AAOCA among >1 million patients, and 20 studies examining outcomes of interarterial ALCA/ARCA patients. Observational data suggests that interarterial ALCA is rare (weighted prevalence = 0.03%; 95% confidence interval [CI]: 0.01% to 0.04%) compared with interarterial ARCA (weighted prevalence = 0.23%; 95% CI: 0.17% to 0.31%). Recognizing the challenges in managing these patients, we review cardiac tests used to examine AAOCA and knowledge gaps in management.
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Affiliation(s)
- Michael K Cheezum
- Departments of Medicine and Radiology, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Cardiology Service, Fort Belvoir Community Hospital, Ft. Belvoir, Virginia.
| | - Richard R Liberthson
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nishant R Shah
- Lifespan Cardiovascular Institute, Division of Cardiovascular Medicine, Department of Medicine, Brown University Alpert School of Medicine, Providence, Rhode Island
| | - Todd C Villines
- Department of Medicine, Cardiology Service, Walter Reed National Military Medical Center, Bethesda Maryland
| | - Patrick T O'Gara
- Departments of Medicine and Radiology, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Ron Blankstein
- Departments of Medicine and Radiology, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Brothers JA, Frommelt MA, Jaquiss RD, Myerburg RJ, Fraser CD, Tweddell JS. Expert consensus guidelines: Anomalous aortic origin of a coronary artery. J Thorac Cardiovasc Surg 2017; 153:1440-1457. [DOI: 10.1016/j.jtcvs.2016.06.066] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/27/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023]
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Agarwal PP, Dennie C, Pena E, Nguyen E, LaBounty T, Yang B, Patel S. Anomalous Coronary Arteries That Need Intervention: Review of Pre- and Postoperative Imaging Appearances. Radiographics 2017; 37:740-757. [PMID: 28388272 DOI: 10.1148/rg.2017160124] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Coronary artery anomalies constitute a diverse group of abnormalities, ranging from anatomic variants to those having hemodynamic consequences. This review focuses on major anomalies that have clinical implications requiring treatment, including anomalous origin of the coronary artery from the opposite sinus with interarterial course specifically with an intramural course, coronary artery origin from the pulmonary artery, and coronary artery fistula. Comprehensive imaging evaluation is necessary to precisely delineate the anatomy as well as pathophysiologic aspects of the anomaly before determining treatment options for a specific patient. Coronary computed tomographic angiography provides elegant depiction of coronary arterial anatomy and the relationship of the vessel to the adjacent structures, with the ability to perform three-dimensional reconstructions. Magnetic resonance (MR) imaging is emerging as an alternative noninvasive imaging strategy, particularly in young individuals, due to the lack of ionizing radiation and avoidance of iodinated contrast agents. This review describes the roles and recent technical advancements in computed tomography and MR imaging pertinent to coronary artery imaging. Additionally, this article will familiarize readers with the cross-sectional imaging appearance of clinically relevant coronary anomalies, hemodynamic considerations, and complex decision making. The different management strategies used for these anomalies, such as coronary unroofing, reimplantation, bypass grafting, Takeuchi repair, and surgical and interventional closure of fistulas, as well as specific posttreatment complications, are also discussed. ©RSNA, 2017.
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Affiliation(s)
- Prachi P Agarwal
- From the Department of Radiology (P.P.A., S.P.), Department of Internal Medicine, Division of Cardiology (T.L.), and Department of Cardiac Surgery (B.Y.), University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Radiology, University of Ottawa, Ottawa, Ont, Canada (C.D., E.P.); and Department of Radiology, University of Toronto, Toronto, Ont, Canada (E.N.)
| | - Carole Dennie
- From the Department of Radiology (P.P.A., S.P.), Department of Internal Medicine, Division of Cardiology (T.L.), and Department of Cardiac Surgery (B.Y.), University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Radiology, University of Ottawa, Ottawa, Ont, Canada (C.D., E.P.); and Department of Radiology, University of Toronto, Toronto, Ont, Canada (E.N.)
| | - Elena Pena
- From the Department of Radiology (P.P.A., S.P.), Department of Internal Medicine, Division of Cardiology (T.L.), and Department of Cardiac Surgery (B.Y.), University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Radiology, University of Ottawa, Ottawa, Ont, Canada (C.D., E.P.); and Department of Radiology, University of Toronto, Toronto, Ont, Canada (E.N.)
| | - Elsie Nguyen
- From the Department of Radiology (P.P.A., S.P.), Department of Internal Medicine, Division of Cardiology (T.L.), and Department of Cardiac Surgery (B.Y.), University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Radiology, University of Ottawa, Ottawa, Ont, Canada (C.D., E.P.); and Department of Radiology, University of Toronto, Toronto, Ont, Canada (E.N.)
| | - Troy LaBounty
- From the Department of Radiology (P.P.A., S.P.), Department of Internal Medicine, Division of Cardiology (T.L.), and Department of Cardiac Surgery (B.Y.), University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Radiology, University of Ottawa, Ottawa, Ont, Canada (C.D., E.P.); and Department of Radiology, University of Toronto, Toronto, Ont, Canada (E.N.)
| | - Bo Yang
- From the Department of Radiology (P.P.A., S.P.), Department of Internal Medicine, Division of Cardiology (T.L.), and Department of Cardiac Surgery (B.Y.), University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Radiology, University of Ottawa, Ottawa, Ont, Canada (C.D., E.P.); and Department of Radiology, University of Toronto, Toronto, Ont, Canada (E.N.)
| | - Smita Patel
- From the Department of Radiology (P.P.A., S.P.), Department of Internal Medicine, Division of Cardiology (T.L.), and Department of Cardiac Surgery (B.Y.), University of Michigan Health System, 1500 E Medical Center Dr, Ann Arbor, MI 48109; Department of Radiology, University of Ottawa, Ottawa, Ont, Canada (C.D., E.P.); and Department of Radiology, University of Toronto, Toronto, Ont, Canada (E.N.)
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Mainwaring RD, Murphy DJ, Rogers IS, Chan FP, Petrossian E, Palmon M, Hanley FL. Surgical Repair of 115 Patients With Anomalous Aortic Origin of a Coronary Artery From a Single Institution. World J Pediatr Congenit Heart Surg 2017; 7:353-9. [PMID: 27142404 DOI: 10.1177/2150135116641892] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 03/06/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Anomalous aortic origin of a coronary artery (AAOCA) has been associated with myocardial ischemia and sudden death. The past decade has provided important insights into the natural history and typical patterns of presentation. However, there are also a number of unresolved controversies regarding the indications for surgery and the efficacy of that surgery. The purpose of this study was to review our surgical experience with AAOCA in 115 patients at a single institution. DESIGN One hundred and fifteen patients have undergone surgical repair of AAOCA at our institution. There were 82 males and 33 females, and the median age at surgery was 16 years. Fifty-nine patients had preoperative symptoms of myocardial ischemia, including 56 with exertional chest pain or syncope and 3 sudden death events. Twenty-four patients had associated congenital heart defects. Seven patients had an associated myocardial bridge. RESULTS Surgical repair was accomplished by unroofing of an intramural coronary in 86, reimplantation in 9, and pulmonary artery translocation in 20. There has been no early or late mortality. Fifty-seven (97%) of the 59 symptomatic patients have been free of any cardiac symptoms postoperatively. Two patients had recurrent symptoms and underwent reoperation (one had revision of the initial repair and one had repair of a myocardial bridge). CONCLUSIONS Surgical repair of AAOCA can be safely performed and is highly efficacious in relieving symptoms of myocardial ischemia. The two "surgical failures" in this series had an anatomic basis and underscore the need to reassess both the proximal and distal anatomy in these patients.
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Affiliation(s)
- Richard D Mainwaring
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, CA, USA
| | - Daniel J Murphy
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital/Stanford University, Stanford, CA, USA
| | - Ian S Rogers
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital/Stanford University, Stanford, CA, USA Division of Cardiovascular Medicine, Stanford University, Stanford, CA, USA
| | - Frandics P Chan
- Division of Pediatric Radiology, Lucile Packard Children's Hospital/Stanford University, Stanford, CA, USA
| | - Edwin Petrossian
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, CA, USA
| | - Michal Palmon
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, CA, USA
| | - Frank L Hanley
- Division of Pediatric Cardiac Surgery, Lucile Packard Children's Hospital/Stanford University, Stanford, CA, USA
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Cheezum MK, Ghoshhajra B, Bittencourt MS, Hulten EA, Bhatt A, Mousavi N, Shah NR, Valente AM, Rybicki FJ, Steigner M, Hainer J, MacGillivray T, Hoffmann U, Abbara S, Di Carli MF, DeFaria Yeh D, Landzberg M, Liberthson R, Blankstein R. Anomalous origin of the coronary artery arising from the opposite sinus: prevalence and outcomes in patients undergoing coronary CTA. Eur Heart J Cardiovasc Imaging 2017; 18:224-235. [PMID: 26848152 PMCID: PMC6279103 DOI: 10.1093/ehjci/jev323] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 11/15/2015] [Indexed: 12/16/2022] Open
Abstract
AIMS The impact of coronary computed tomographic angiography (CTA) on management of anomalous origin of the coronary artery arising from the opposite sinus (ACAOS) remains uncertain. We examined the prevalence, anatomical characterization, and outcomes of ACAOS patients undergoing CTA. METHODS AND RESULTS Among 5991 patients referred for CTA at two tertiary hospitals between January 2004 and June 2014, we identified 103 patients (1.7% prevalence) with 110 ACAOS vessels. Mean age was 52 years (range 5-83, 63% male), with 55% previously known ACAOS and 45% discovered on CTA. ACAOS subtypes included: 39% interarterial (n = 40 anomalous right coronary artery, n = 3 anomalous left coronary artery), 38% retroaortic, 15% subpulmonic, 5% prepulmonic, and 2% other. ACAOS patients were assessed for symptoms, ischaemic test results, revascularization, all-cause or cardiovascular (CV) death, and myocardial infarction. CTAs were reviewed for ACAOS course, take-off height and angle, length and severity of proximal narrowing, intramural course, and obstructive coronary artery disease (CAD). In follow-up (median 5.8 years), there were 20 surgical revascularizations and 3 CV deaths. After adjusting for obstructive CAD (n = 21/103, 20%), variables associated with ACAOS revascularization included the following: CV symptoms, proximal vessel narrowing ≥50%, length of narrowing >5.4 mm, and an interarterial course. CONCLUSION The prevalence of ACAOS on CTA was 1.7%, including 45% of cases discovered incidentally. CTA provided excellent characterization of ACAOS features associated with coronary revascularization, including the length and severity of proximal vessel narrowing.
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Affiliation(s)
- Michael K Cheezum
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcio S Bittencourt
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
- Center for Clinical and Epidemiological Research, Division of Internal Medicine, University of São Paulo, São Paulo, Brazil
| | - Edward A Hulten
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
- Cardiology Service, Division of Medicine, Walter Reed National Military Medical Center and Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Ami Bhatt
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Negareh Mousavi
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Nishant R Shah
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anne Marie Valente
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Frank J Rybicki
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Steigner
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas MacGillivray
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Suhny Abbara
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marcelo F Di Carli
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
| | - Doreen DeFaria Yeh
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Landzberg
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Richard Liberthson
- Department of Medicine, Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ron Blankstein
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine (Cardiovascular Division), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115, USA
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Herrmann JL, Goldberg LA, Khan AM, Partington SL, Brothers JA, Mascio CE, Spray TL, Kim YY, Fuller S. A Comparison of Perioperative Management of Anomalous Aortic Origin of a Coronary Artery Between an Adult and Pediatric Cardiac Center. World J Pediatr Congenit Heart Surg 2016; 7:721-726. [DOI: 10.1177/2150135116668333] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/25/2016] [Indexed: 11/17/2022]
Abstract
Background: Anomalous aortic origin of a coronary artery (AAOCA) presents in varying age-groups. Assuming management algorithms differ between pediatric and adult institutions, we compared the perioperative management of patients with AAOCA at two such centers. Methods: A retrospective review was conducted at a pediatric and an adult institution of patients 14 years or older who underwent surgical repair of AAOCA between January 2000 and May 2014. Results: Twenty patients from the pediatric center (median age: 16.5 years, range: 14-18 years) and nine patients from the adult center (median age: 40 years, range: 37-52 years) were included. An anomalous aortic origin of a right coronary artery was the most frequent pathology at each institution. Chest pain was the most common presenting symptom at both institutions. Preoperative echocardiography was performed in 95% patients at the pediatric center and in 100% of patients at the adult center. Cardiac catheterization was utilized more frequently at the adult center, and cardiac magnetic resonance imaging more commonly employed at the pediatric center. Isolated coronary unroofing was performed in 19 of 20 cases at the pediatric center and in only 2 (22%) cases at the adult institution, both by congenitally trained cardiac surgeons. More concomitant cardiac procedures were performed at the adult center with associated longer operative times and hospital stays. Conclusion: Management strategies for AAOCA vary depending on both patient-specific factors and expertise of the managing team. Further studies are needed to optimally standardize diagnostic and treatment pathways regardless of location venue.
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Affiliation(s)
- Jeremy L. Herrmann
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Division of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Leah A. Goldberg
- Division of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abigail M. Khan
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Sara L. Partington
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Julie A. Brothers
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher E. Mascio
- Division of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thomas L. Spray
- Division of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yuli Y. Kim
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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Abstract
PURPOSE OF REVIEW To better understand the risk of sudden death from coronary anomalies. RECENT FINDINGS Most coronary anomalies are benign, but there are certain coronary anomalies that increase the risk of sudden cardiac death (SCD) in the young, notably anomalous aortic origin of a coronary artery from the wrong sinus. Previously, the risk of SCD attributed to certain coronary anomalies was felt to be quite high, as the risk assessment was based on autopsy series. Recent studies have shown that the risk attributed to anomalous coronary arteries is much lower than once believed. Risk appears to be highest with anomalous left coronary artery from the right sinus of Valsalva with interarterial course, notably when the young patient is participating in vigorous physical exertion, such as with competitive sports. SUMMARY Treatment strategies may include exercise restriction or surgical repair. Management decisions should be based on a complete understanding of the risk for SCD because of anomalous coronary arteries. Future directions should focus on better methods to risk stratify these pediatric patients.
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Abstract
OBJECTIVES The objectives of this review are to discuss the spectrum of coronary artery anomalies and the evidence behind current treatment strategies. DATA SOURCE MEDLINE and PubMed. CONCLUSION Coronary artery anomalies exist in up to 1% of the population and most of these do not cause symptoms or ischemia and do not require any surgical intervention whereas others are potentially fatal. The type of surgical intervention is often dictated by the type of lesion, and upon the unique anatomic and physiologic variables associated with each lesion. Postoperative care can be challenging particularly after surgical repair of anomalous left coronary artery from the pulmonary artery.
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Brothers JA, Kim TS, Fogel MA, Whitehead KK, Morrison TM, Paridon SM, Harris MA. Cardiac magnetic resonance imaging characterizes stenosis, perfusion, and fibrosis preoperatively and postoperatively in children with anomalous coronary arteries. J Thorac Cardiovasc Surg 2016; 152:205-10. [DOI: 10.1016/j.jtcvs.2015.12.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/18/2015] [Accepted: 12/24/2015] [Indexed: 01/07/2023]
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Mery CM. Invited Commentary. Ann Thorac Surg 2016; 102:198-9. [PMID: 27343498 DOI: 10.1016/j.athoracsur.2016.02.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 02/26/2016] [Accepted: 02/29/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Carlos M Mery
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital/Baylor College of Medicine, 6621 Fannin St, MC 19345H, Houston, TX77030.
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Fabozzo A, DiOrio M, Newburger JW, Powell AJ, Liu H, Fynn-Thompson F, Sanders SP, Pigula FA, del Nido PJ, Nathan M. Anomalous Aortic Origin of Coronary Arteries: A Single-Center Experience. Semin Thorac Cardiovasc Surg 2016; 28:791-800. [DOI: 10.1053/j.semtcvs.2016.08.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2016] [Indexed: 02/08/2023]
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Abstract
The anomalous aortic origin of a coronary artery from the wrong sinus of Valsalva with an interarterial, intramural, and/or intraconal course is a relatively rare congenital defect of the heart that may be associated with an increased risk of ischaemia of the myocardium and sudden death, notably in children and young adults. Data are limited regarding stratification of risk and long-term outcomes of these patients. In 2009, the Anomalous Coronary Artery Working Group formed the Congenital Heart Surgeons' Society Registry of Anomalous Aortic Origin of a Coronary Artery to obtain information on large numbers of young patients with anomalous aortic origin of a coronary artery with the goal to better understand the natural and surgical history of this anomaly as well as to develop evidence-based treatment and management guidelines. In this report, we describe the data we have collected from the registry and the current state of the registry.
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Abstract
Anomalous aortic origins of the coronary arteries comprise approximately one-third of all coronary artery anomalies and are characterised by coronary arteries with anomalies of aortic origin involving abnormal courses, stenoses, and compression that can lead to myocardial ischaemia and sudden death. Operative techniques to treat these anomalies have not been standardised yet. Moreover, the management of potential complications has not been addressed. Common and rare forms of anomalous aortic origins of the coronary arteries are reviewed and understood standard techniques for an uncomplicated unroofing procedure are illustrated. Also noted are techniques that can be applied to unexpected anatomical findings and unwanted complications that could prove to be life-threatening. Several technical recommendations are offered.
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Mavroudis C, Williams WG. History of the Congenital Heart Surgeons’ Society. World J Pediatr Congenit Heart Surg 2015; 6:541-50. [DOI: 10.1177/2150135115604840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The Congenital Heart Surgeons’ Society is a group of over 100 pediatric heart surgeons representing 72 institutions that specialize in the treatment of patients with congenital heart defects. The Society began in 1972 and incorporated as a not-for-profit charitable organization in 2004. It has become the face and voice of congenital heart surgery in North America. In 1985, the Society established a data center for multicenter clinical research studies to encourage congenital heart professionals to participate in improving outcomes for our patients. The goals of the Congenital Heart Surgeons’ Society are to stimulate the study of congenital cardiac physiology, pathology, and management options which are instantiated in data collection, multi-institutional studies, and scientific meetings. Honest and open discussion of problems with possible solutions to the challenges facing congenital heart professionals have been the strength of the Congenital Heart Surgeons’ Society. It is imperative for the growth of an organization to know from where it came in order to know to where it is going. The purpose of this article is to review the history of the Congenital Heart Surgeons’ Society.
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Affiliation(s)
- Constantine Mavroudis
- Johns Hopkins University School of Medicine, Florida Hospital for Children, Orlando, FL, USA
| | - William G. Williams
- Congenital Heart Surgeons’ Society Data Center, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Fuglsang S, Heiberg J, Byg J, Hjortdal VE. Anomalous origin of the right coronary artery with an interarterial course and intramural part. Int J Surg Case Rep 2015; 14:92-4. [PMID: 26255002 PMCID: PMC5963140 DOI: 10.1016/j.ijscr.2015.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 07/16/2015] [Accepted: 07/18/2015] [Indexed: 11/29/2022] Open
Abstract
Exercise-induced angina and dyspnea caused by anomalous origin of the RCA from the left sinus. Possible mechanisms are discussed. The patient successfully underwent surgery with complete remission of all symptoms. Unique images of the RCAs entire course demonstrating its vulnerability. Different symptoms and surgical approaches from key case series
Introduction An anomalous origin and course of the right coronary artery (RCA)1 is a very rare congenital anomaly that can be fatal if it remains undiscovered. Presentation of case In this case report, we present a patient with a one-year history of exercise-induced angina and dyspnea caused by anomalous origin of the RCA from the left sinus, and anomalous course between the aorta and the pulmonary artery. Discussion Possible mechanisms of this disease’s symptomatology are compression of the RCA between the aorta and the pulmonary artery in its anomalous inter-arterial course, and squeezing of the RCA in the proximal intramural part. Conclusion In this report, we present some unique images of the RCAs course, which contribute to the understanding of this disease’s symptomatology. The patient successfully underwent surgery with Right Internal Mammary Artery to RCA (RIMA–RCA)2 bypass with complete remission of all symptoms.
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Affiliation(s)
- Simon Fuglsang
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital Skejby, Denmark.
| | - Johan Heiberg
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital Skejby, Denmark
| | - Jørgen Byg
- Department of Cardiology, Hospital of Southern Jutland, Denmark
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Surgery for anomalous aortic origin of a coronary artery: More is better? J Thorac Cardiovasc Surg 2015; 150:425-6. [DOI: 10.1016/j.jtcvs.2015.05.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 05/26/2015] [Indexed: 11/20/2022]
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