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

Anomalous origin of the right coronary artery from the main pulmonary artery treated surgically in a 6-week-old infant. A case report and review of the literature

BACKGROUND

In the present paper, the authors describe a case of a rare congenital defect - anomalous origin of the right coronary artery from the main pulmonary artery diagnosed in a 5-week-old infant who was deemed eligible for surgical treatment based solely on echocardiography. Such anatomical abnormalities of the coronary arteries are subtle and thus extremely difficult to visualize, especially in patients in whom permanent extensive damage of the cardiac muscle has not yet occurred. For this reason, the diagnosis is usually established when the disease is highly advanced, oftentimes only postmortem. In this paper, the authors present early echocardiographic evaluation, successful surgical treatment and post-operative echocardiographic examination.

CASE PRESENTATION

Fetal echocardiographic examinations demonstrated single vascular anomalies. The suspicion was verified after birth. Other congenital defects, including genetic defects, were also investigated. In the 5th week of life, cardiac ECHO showed abnormal origin of the right coronary artery from the trunk of the pulmonary artery. The child was deemed eligible for surgical treatment of the defect. The surgical translocation of the ostium of the right coronary artery to the aorta was done with success, and the child was discharged on the 14th day of hospitalization.

CONCLUSION

The present case report demonstrates that careful examination of the child with precise echocardiographic examination makes it possible to establish an early diagnosis of this rare defect. This discrete defect can be treated early, before the symptoms, often connected with irreversible changes in the myocardium, appear.

Surgical treatment of an infant with myocardial ischemia due to an anomalous origin of the right coronary artery from the main pulmonary artery: report of a case

An anomalous origin of the right coronary artery from the main pulmonary artery (ARCAPA) is a rare cardiac malformation, and only three cases of isolated ARCAPA in patients younger than 2 years of age have been reported. This report describes the surgical treatment of a 12-month-old girl with myocardial ischemia due to ARCAPA. The diagnosis was made by echocardiography. A reimplantation of the aberrant coronary artery was performed, and the patient had a successful postoperative course.

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

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

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Isolated Anomalous Origin of Right Coronary Artery from the Main Pulmonary Artery

The anomalous origin of the right coronary artery (ARCA) from the main pulmonary artery (MPA) is a rare congenital cardiac malformation and usually associated with other cardiac anomalies. Most patients with isolated ARCA from MPA remain asymptomatic, but they may develop myocardial ischemia and even sudden death. We reported an asymptomatic 7-year-old boy referred for evaluation of a heart murmur. Isolation of ARCA from MPA was diagnosed by echocardiography and then confirmed by cardiac catheterization and angiography. The right coronary artery was re-implanted into the ascending aorta. A preoperative thallium-201 myocardial perfusion showed a myocardial ischemia pattern in the anterolateral septal area after a dipyridamole stress test; the ischemia was completely resolved after surgery.

Anomalous Origin of the Coronary Arteries from the Pulmonary Trunk in Two Separate Patients with a Review of the Clinical Implications and Current Treatment Recommendations

Anomalous origin of a coronary artery from the pulmonary artery (PA) is an unusual abnormality. These anomalies are often hemodynamically significant and can lead to myocardial ischemia, myocardial infarction, and sudden cardiac death. Anomalous origin of the left coronary artery (LCA) from the pulmonary trunk is known as Bland-White-Garland syndrome and causes death in 80% to 85% of affected children in the first year of life. Treatment of the LCA arising from the PA is typically surgical, with ligation and reimplantation of the LCA to the aorta. In contrast, origination of the right coronary artery from the PA is usually a benign anomaly, although clinically significant sequelae can develop. Controversy exists regarding the need to intervene in the cases of patients with this usually incidentally discovered anomaly. We review the clinical presentation and treatment of patients with each anomaly and the current recommendations regarding the clinical course and management of such patients.

Use of navigator-echo-gated MRI to diagnose a coronary shunt involving an anomalous origin of the right coronary artery from the pulmonary artery

Origin of the right coronary artery from the main pulmonary artery is an anomaly that can cause formation of a left-to-right coronary shunt, leading to myocardial ischemia and early onset of congestive heart failure. We describe a case in which magnetic resonance imaging was able to show the anomalous origin of the right coronary artery, and magnetic resonance phase velocity mapping was able to demonstrate the presence of a left-to-right shunt through the coronary artery by showing retrograde flow in the right coronary artery.

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

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

Anomalous origin of the right coronary artery from the pulmonary trunk: is surgical reimplantation into the aorta a method of choice?

The origin of the right coronary artery (RCA) from the pulmonary trunk (PT) is a rare congenital anomaly. Although most of the patients remain asymptomatic, prophylactic reimplantation of the RCA into the aorta has been recommended to prevent an adverse outcome. The report describes postoperative results in two patients following uneventful RCA reimplantation. A 47-year-old man, with coexisting diffuse atherosclerotic involvement of the left coronary artery, remained symptomatic despite the establishment of a two-coronary system. The second patient, a 36-year-old woman, with isolated anomalous origin of the RCA from the PT, continued to present with myocardial ischemia on exertion. The original observation of an angiographic "slow-flow" phenomenon in the reimplanted RCA in both patients implies the impairment of myocardial microvessels. These findings give rise to the question of whether the reimplantation of the anomalous artery is really superior to simple ligation of its origin in order to relieve the "coronary steal" effect.

Anomalous origin of right coronary artery from pulmonary artery

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