A report of fifty cases with incidental diagnosis of anomalous origin of the right coronary artery from the left sinus of Valsalva

INTRODUCTION

Anomalous origin of the right coronary artery from the left sinus of Valsalva (R-ACAOS) is a relatively rare condition that can potentially lead to devastating outcomes. The current study aims to investigate the cardiac-related disorders among patients with incidental R-ACAOS diagnosis through computed tomography angiography (CTA).

METHODS

The current cross-sectional study has been conducted on 50 patients diagnosed with R-ACAOS who underwent CTA. Based on CTA, the patients' were categorized as R-ACAOS with interarterial course and non-interarterial course. The demographic and medical characteristics, any history of cardiac intervention and New York Heart Association (NYHA) Functional Classification at the time of diagnosis were recruited. Patients were revisited to assess cardiac-associated variables, including symptoms, the presence of heart failure and current NYHA function class.

RESULTS

The variables including the history of cardiac intervention (P-value<0.001), the presence of heart failure (P-value = 0.010) and NYHA function class at the time of diagnosis (P-value = 0.006) were remarkably higher among those with interarterial course of R-ACAOS; while, the other variables including chest pain at rest (P-value = 0.55) or on exertion (P-value = 0.12), current NYHA function class, current cardiac-associated symptoms except for dyspnea at rest (P-value = 0.012), mortality and coronary calium score did not differ (P-value>0.05). coronary interventions led to significantly improved NYHA function class (P-value<0.05).

CONCLUSION

Based on the findings of the current study, R-ACAOS with interarterial course leads to significantly higher rates of atherosclerotic-related symptoms and events compared with the other types of RCA anomalies. Moreover, coronary interventions led to significantly improved NYHA functional class regardless of R-ACAOS category.

Coronary Artery Aneurysms Following Repair of Transposition of the Great Arteries

•Periodic surveillance after ASO for TGA with multimodality imaging is recommended. •New aneurysms may be detected in patients with antecedent KD. •KD should be suspected in patients with CAA even without previously known illness.

Anomalous Coronary Arteries: A State-of-the-Art Approach

Congenital coronary anomalies are not an infrequent occurrence and their clinical presentation typically occurs during early years, though may be manifested only in adulthood. In the setting of anomalous aortic origin of a coronary artery, this is particularly concerning as it inflicts sudden loss of healthy young lives. Risk stratification remains a challenge and so does the best management decision-making in these patients, particularly if asymptomatic. Standardized approach to evaluation and management, with careful data collection and collaboration among centers, will likely impact future outcomes in this patient population, thus allowing for exercise participation and healthier lives.

Coronary artery anomalies and the role of echocardiography in pre-participation screening of athletes: a practical guide

Transthoracic echocardiography is an essential and widely available diagnostic tool for assessing individuals reporting cardiovascular symptoms, monitoring those with established cardiac conditions and for preparticipation screening of athletes. While its use is well-defined in hospital and clinic settings, echocardiography is increasingly being utilised in the community, including in the rapidly expanding sub-speciality of sports cardiology. There is, however, a knowledge and practical gap in the challenging area of the assessment of coronary artery anomalies, which is an important cause of sudden cardiac death, often in asymptomatic athletic individuals. To address this, we present a step-by-step guide to facilitate the recognition and assessment of anomalous coronary arteries using transthoracic echocardiography at the bedside; whilst recognising the importance of performing dedicated cross-sectional imaging, specifically coronary computed tomography (CTCA) where clinically indicated on a case-by-case basis. This guide is intended to be useful for echocardiographers and physicians in their routine clinical practice whilst recognising that echocardiography remains a highly skill-dependent technique that relies on expertise at the bedside.

Anomalous Coronary Arteries: A State-of-the-Art Approach

Congenital coronary anomalies are not an infrequent occurrence and their clinical presentation typically occurs during early years, though may be manifested only in adulthood. In the setting of anomalous aortic origin of a coronary artery, this is particularly concerning as it inflicts sudden loss of healthy young lives. Risk stratification remains a challenge and so does the best management decision-making in these patients, particularly if asymptomatic. Standardized approach to evaluation and management, with careful data collection and collaboration among centers, will likely impact future outcomes in this patient population, thus allowing for exercise participation and healthier lives.

Prevalence and characteristics of coronary artery anomalies (CAAS) in 3016 symptomatic adult participants undergoing coronary computed tomography angiography (CCTA): A single-center retrospective study in Iran

Introduction

Coronary artery anomalies (CAAs) are associated with an increased risk of cardiovascular events, including sudden cardiac death, especially in young people. A different prevalence has been reported based on the USED diagnostic modality. This study aimed to determine the prevalence and type of these anomalies using coronary computed tomography angiography (CCTA).

Methods

This single-center retrospective study was performed on 3016 consecutive cases who underwent CCTA for cardiac symptoms from March 2015 to August 2020 and the prevalence and types of CAAs were evaluated.

Results

38 cases (overall prevalence of 1.26%) including 21 men (55.3%) and 17 women (44.7%) were retrospectively diagnosed with CAAs. The most common anomalies were the Anomalous origin of LCX from the right coronary sinus (11 cases, 28.9%), Anomalous origin of RCA from the left coronary sinus (11 cases, 28.9%), and Anomalous origin of LM from the right coronary sinus (6 cases, 15.8%). There was no difference in the prevalence of CAAs in terms of patient's gender (P value=0.16) and age (P value=0.61).

Conclusion

The prevalence of CAAs among patients who underwent CCTA was 1.26%. The most common anomalies observed were the anomalous origin of the LCX arising from the right coronary sinus, the anomalous origin of the RCA arising from the left coronary sinus, and the anomalous origin of the LM arising from the right coronary sinus. These findings emphasize the importance of CCTA in detecting and characterizing coronary artery anomalies, which may have clinical implications for patient management and treatment decisions.

A Survey on the Management of Anomalous Aortic Origins of the Coronary Arteries

The management of patients with an anomalous aortic origin of a coronary artery (AAOCA) remains controversial despite the publication of the 2017 American Association for Thoracic Surgery (AATS) expert guidelines. We surveyed the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery and the Pediheart.net online community regarding their care of patients with anomalous origins of the right or left coronary from the opposite cusp with inter-arterial courses and compared them to the AATS guidelines. We received 111 complete responses. Four notable variations from the AATS recommendations were identified. Respondents were more likely to use ECG exercise testing than the stress imaging recommended in the AATS guidelines. For a 16-year-old with AAOCA, recommendations for surgery generally followed the AATS guidelines. However, for asymptomatic left AAOCA without signs of ischemia on stress imaging, only 69.4% felt surgery was appropriate or somewhat appropriate. In the setting of a 16-year-old with right AAOCA free from signs or symptoms of ischemia, respondents were more likely to recommend surgery if the patient was a competitive athlete, a topic not directly addressed in the AATS guidelines. After surgical treatment of AAOCA, only 24% of respondents recommended lifelong antiplatelet therapy despite recommendations for this in the AATS guidelines. Respondents recommendations were generally consistent with the 2017 AATS guidelines but with important variations in the use of stress imaging, indications for surgery in asymptomatic left AAOCA, the impact of identification as a competitive athlete and duration of postoperative antiplatelet therapy.

Juvenile sudden cardiac death due to congenital coronary ostial valve-like ridges: A case report and literature review

Coronary artery anomalies are a heterogeneous group of congenital disorders affecting the coronary pattern with a characteristic (origin, number, number of hosts, course, etc.). They are rarely found in the population. We report the case of a 21-year-old male who died from sudden cardiac death caused by an isolated coronary ostial obstruction, secondary to a rare anomaly, the presence of a valve-like ridge consisting of a small fold in the Valsalva aortic sinus. The study provides a brief literature review on the pathophysiology, diagnosis, and clinical and medico-legal issues in coronary artery anomaly cases that may be helpful in forensic practice when dealing with sudden cardiac death in young people and highlights key points for further research and public health measures.

Narrative Review of Anomalous Origin of Coronary Arteries: Pathophysiology, Management, and Treatment

Coronary artery anomalies (CAA) are a diverse group of congenital anomalies and are the second most common cause of sudden cardiac death in the young population after Hypertrophic Cardiomyopathy (HCM). Symptoms range from chest pain, syncope, or sudden cardiac arrest to completely asymptomatic. The prevalence of congenital coronary artery anomalies in the general population is estimated to be between 1% and 2%. CAA often gets underdiagnosed due to the lack of knowledge of the disease process. Approximately 5% of patients with acute myocardial infarction do not have atherosclerotic coronary artery disease or luminal narrowing due to other causes. Congenital coronary artery anomalies account for 50-60% of this 5% of patients. Most patients are asymptomatic for most of their lives, and chest pain is the most common symptom in symptomatic patients when referred for coronary angiography, typically when the diagnosis is typically made. The malignant coronary artery is a rare presentation of a coronary anomaly when associated with atherosclerotic coronary artery disease or valvular heart disease. Patients with symptoms of an abnormal coronary artery origin will receive medical treatment/observation, exercise restriction, coronary angioplasty with stent deployment, or surgical repair.

Aortopulmonary window and coronary anatomy - still a pre-operative diagnostic trouble!

We present a case of aortopulmonary window in which the diagnosis of anomalous left coronary artery originating from pulmonary artery was made intra-operatively even if the coronary arteries anatomy was correctly studied pre-operatively with echocardiography. No evidence of coronary anomalies or indirect sings of coronary anomalies has been noted. Should we improve our pre-operative diagnostic accuracy and how?

Double right coronary artery with fistula to the right atrium and mitral insufficiency: A case report

INTRODUCTION AND IMPORTANCE

Coronary artery abnormalities are uncommon and mostly asymptomatic. The combination of double right coronary artery (RCA) with a fistula and valvar deformity is very rarely reported in the literature. However, it is important to identify these deformities as they have relatively high complication rates.

PRESENTATIONS OF CASE

A 47-year-old male came with chest pain that radiated to the lower jaw. ECG showed equivalent changes. Blood tests including troponin were within normal range. However, echocardiogram showed a severe mitral valve regurgitation with anterior leaflet prolapse and hypokinesia of the ventricular wall. Coronary angiogram showed a double RCA with a complete block in the main RCA and a fistula to the right atrium (RA). The left coronary system showed atherosclerosis in left anterior descending artery (LAD) and circumflex artery (CX). Surgical treatment, including the repair of the RCA-RA fistula, replacement of mitral valve and coronary artery bypass grafting (CABG) were performed. The patient had no complications in the follow-ups.

DISCUSSION

Coronary fistulas may be congenital or acquired malformations. Their treatment depends on the symptoms, origin, size and the receiving chamber. Furthermore, double RCA is debatable whether the rate of atherosclerosis and other cardiac abnormalities are increased with this anomaly. The surgeon must keep in mind these rare anomalies before cardiac operations.

CONCLUSION

Double RCA might accompany other deformities which are important to detect before intervention. More studies are required to decrease complications and have better outcomes.

Imaging Findings of Coronary Artery Fistula in Children: A Pictorial Review

Coronary artery fistula, defined as an abnormal communication between the coronary arteries and a cardiac chamber (most commonly) or a thoracic great vessel, may result in hemodynamically significant problems due to vascular shunting in children. Echocardiography, cardiac catheterization, cardiac MRI, and cardiac CT may be used to evaluate coronary artery fistula in children. Recently, CT has played a pivotal role for the accurate diagnosis of coronary artery fistula in children. Surgical or interventional treatment is performed for hemodynamically significant coronary artery fistulas. In this pictorial review, the detailed imaging findings of coronary artery fistula in children are described.

Coronary artery anomalies evaluation with cardiac computed tomography: A review

Coronary artery anomalies involve either their origin, course, or termination of the vessel. Coronary artery anomalies are congenital and relatively few develop symptoms, which can include potentially serious effects like arrhythmia, chest pain, syncope, myocardial infarction, or sudden death. Conventional coronary angiography has been used extensively in the past few decades for evaluation of coronary anomalies. With recent advancements in the software and hardware, noninvasive nature, and excellent temporal and spatial resolution; coronary computed tomographic angiography (CTA) is now the mainstay in the diagnosis of coronary arterial anomalies. Many studies have shown better performance of cardiac CTA compared to invasive angiography in detection of anomalous coronary arteries.

Congenital atresia of the left main coronary artery: management of a 5-year-old child in extremis

Atresia of the left main coronary artery is a rare coronary anomaly. We describe the case of a 5-year-old child presenting in emergency in extremis. Clinical findings of haemodynamic collapse, malignant ventricular tachyarrhythmias and severe mitral regurgitation were indicative of a possible ischaemic aetiology. Surgical revascularization of the atretic left main coronary artery segment using an interposition autologous saphenous vein graft was successfully performed.

Computed Tomography-based Patient-specific Biomechanical and Fluid Dynamic Study of Anomalous Coronary Arteries with Origin from the Opposite Sinus and Intramural Course

BACKGROUND

The anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) constitutes one of the most clinically relevant coronary artery anomalies in adults. Exact pathophysiology and the impact of intramural (IM) course segment stenting in ACAOS with IM course (ACAOS-IM) has not been clarified. We aimed to elucidate the pathophysiology and impact of stenting applying biomechanical and computational fluid dynamics to computed tomography (CT) in patient-specific coronary vessel reconstruction.

METHODS

We separated coronary artery (left or L-, right or R-) ACAOS-IM into segments (proximal, mid and distal), based on coronary angiography and coronary CT angiography features, in a series of patients at Rovigo General Hospital, Italy, between 1 January 2003 and 1 January 2018. Blood pressure gradient across the coronary circulation, calculated blood flow, vorticity magnitude, wall shear stress (WSS) and IM segment deformation were analysed by simulating exercise, before and after virtual stent implantation.

RESULTS

In 21 symptomatic patients (13 males, mean age 46.1 ± 8.1 years, L-ACAOS-IM in 9 and R-ACAOS-IM in 12 patients), computational fluid dynamic analysis in both L- and R-ACAOS demonstrated higher basal WSS values in the IM course (9.5 ± 0.2 and 8.6 ± 0.2 Pa for R- and L-ACAOS, respectively), than in the rest of the vessels. These values decreased after stenting. Vorticity magnitude significantly decreased after stenting as well, compared with baseline. Biomechanical deformation analysis revealed not only compression, but also a twisting of the IM segment with a mean distal pressure drop of 32% and 35% in R- and L-ACAOS, respectively, which was corrected by stent implantation.

CONCLUSIONS

In both L- and R-ACAOS subtypes, the IM segment appeared to be phasically compressed and deformed with a degree of twisting that causes resting and exercise cross-sectional deformation and a drop in distal pressure. Stenting of the IM segment results in normalisation of the flow profile, correction of the IM segment deformation and reverses the drop in pressure, for both variants of ACAOS.

Surgical management of an anomalous right coronary artery

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.

Off pump surgical epicardial closure of left anterior descending to pulmonary artery fistula

BACKGROUND

Coronary artery fistulae (CAF) are rare anomalies. Left anterior descending(LAD) to Pulmonary artery (PA) CAF, represent a minority of cases. Large fistulas, create a significant shunt and a "steal phenomenon", and can lead to myocardial ischemia and heart failure (HF) if left untreated.

CASE PRESENTATION

We present a 57 years old female with a large LAD to PA fistulae. Given the rare occurrence and the predominance of low shunt of LAD to PA CAF, this case is functionally exceptional in this fistulae variant, causing a significant shunt which resulted in daily cardiac ischemic chest pain. Diagnosis work up included a nuclear stress test, Coronary Angiography and 3-D Coronary Computed Tomography Angiogram (CCTA). Traditionally, surgery has been the main therapy for symptomatic CAF, but transcatheter closure has emerged as a less invasive strategy and is a valuable alternative or even preferable if no associated cardiac conditions are present, provided the anatomical characteristics of the fistulae are appropriate. The surgical approach includes off pump epicardial interruption of the fistula or closure through a cardiac chamber (trans-cameral) or transpulmonary, or epicardial closure using Cardiopulmonary bypass. Caution must be taken in cases of CAF with Coronary Artery (CA) aneurysm in dominant CA, or drainage into the Coronary Sinus, as the possibility of ischemic complications are higher. Due to anatomical considerations and tortuosity of the fistulae, our patient was considered not amenable for percutaneous closure and surgery was opted. Epicardial closure of the fistula was performed on a beating heart, off pump. Outcome was favorable with complete resolution of ischemic symptoms.

CONCLUSION

Symptomatic, high shunt CAF must be interrupted. The presence of daily ischemic symptoms in our case report patient, is worth to be remarked. Alternatives for fistulae closure are transcatheter or surgery, depending on anatomic variables and the presence of associated cardiac conditions. Surgical epicardial closure of LAD to PA fistulae variant can be done with very low mortality and morbidity, but other variants with coronary aneurysm, drainage in the coronary sinus or other concomitant cardiac defects, may result in ischemic complications and higher perioperative mortality and worse long- term outcome.

Congenital coronary collateral

Intercoronary communications are a very rare congenital coronary artery anomalies. We report a case of a man who underwent elective coronary angiography that showed a bidirectional direct intercoronary communication between right coronary and left circumflex arteries.

Dual-source computed tomography coronary artery imaging in children

Computed tomography (CT) has a well-established diagnostic role in the assessment of coronary arteries in adults. However, its application in a pediatric setting is still limited and often impaired by several technical issues, such as high heart rates, poor patient cooperation, and radiation dose exposure. Nonetheless, CT is becoming crucial in the noninvasive approach of children affected by coronary abnormalities and congenital heart disease. In some circumstances, CT might be preferred to other noninvasive techniques such as echocardiography and MRI for its lack of acoustic window influence, shorter acquisition time, and high spatial resolution. The introduction of dual-source CT has expanded the role of CT in the evaluation of pediatric cardiovascular anatomy and pathology. Furthermore, technical advances in the optimization of low-dose protocols represent an attractive innovation. Dual-source CT can play a key role in several clinical settings in children, namely in the evaluation of children with suspected congenital coronary artery anomalies, both isolated and in association with congenital heart disease. Moreover, it can be used to assess acquired coronary artery abnormalities, as in children with Kawasaki disease and after surgical manipulation, especially in case of transposition of the great arteries treated with arterial switch operation and in case of coronary re-implantation.

Incidence, Characteristics and Atherosclerotic Involvement of Coronary Artery Anomalies in Adult Population Undergoing Catheter Coronary Angiography

Background

Coronary artery anomalies (CAAs) are rare disorders of coronary anatomy with varied clinical presentations. There are widespread geographic variations in incidence and patterns of these anomalies, with limited data from North Indian population. We performed a retrospective study to evaluate the incidence, characteristics and atherosclerotic involvement of CAAs in adult population undergoing catheter coronary angiography.

Methods

Serial coronary angiographies performed at our institution over a period of 2.5 years (from January 2017 to June 2019) were retrospectively analyzed. We identified patients with anomalous coronaries and studied their clinical characteristics and angiographic profiles.

Results

Among 3,233 coronary angiograms analyzed, CAAs were found in 99 patients with an incidence of 3.06%. Mean age of the patients was 56.2 ± 12.9 years (range: 20 - 86 years), with 74.75% being males and 25.25% females. Split right coronary artery (RCA) was the most common coronary anomaly, being seen in 27 patients; with an angiographic incidence of 0.84%. Dual left anterior descending artery (LAD) was the second most common anomaly and was seen in 22 cases with an angiographic incidence of 0.68%. Absent left main trunk was noted in 14 patients (0.43%). Ectopic origin of RCA from left sinus was seen in 12 patients (0.37%), while ectopic origin of RCA from ascending aorta was seen in four patients (0.12%). Ectopic origin of left circumflex artery (LCX) from right sinus or RCA was noted in 13 patients (0.40%). One patient (0.03%) had a superdominant LAD supplying the posterior descending artery (PDA). Coronary artery fistulae were seen in six patients (0.18%). Significant coronary artery disease (CAD) was seen in 89 of 268 (33.21%) normal vessels, whereas it was seen in 56 of 114 (49.12%) of anomalous vessels. This difference was statistically significant (P = 0.003).

Conclusions

The incidence of CAAs in our study was slightly higher than many of the previous angiographic series. The patterns of coronary anomalies in our study were different from most of the previous studies. Our study had higher incidence of atherosclerotic involvement of anomalous vessels as compared to normal vessels.

Percutaneous coronary intervention to left anterior descending artery/right coronary artery bifurcation: this is not a typo! A case report

Background

Anomalous origin of the right coronary artery (RCA) is a rare congenital anomaly. A single coronary artery arising from the left sinus of Valsalva, with the RCA originating from the left anterior descending artery (LAD), is extremely rare. We report the case of an anomalous origin of the RCA from the mid LAD with a significant bifurcation lesion, in the setting of an acute coronary syndrome, endangering both the RCA and LAD territories.

Case summary

An 85-year-old female presented with a non-ST elevation acute coronary syndrome. Transradial coronary angiography revealed an anomalous origin of the RCA arising from the mid LAD beyond a large first septal perforator. There was significant stenosis involving anomalous RCA/LAD bifurcation classified as Medina 1, 1, 1. Following discussion at heart team meeting, she underwent successful percutaneous coronary intervention. The LAD/RCA bifurcation was treated using a two-stent culotte technique without any complications. Computed tomography coronary angiogram was performed which confirmed a benign course of the anomalous RCA anterior to aorta and pulmonary artery.

Discussion

This anomaly poses a significant challenge in revascularization due to the large area of myocardium subtended by the LAD and RCA and usually an acute angle of bifurcation. Moreover, CTCA can be useful to ascertain the course of anomalous RCA.

Anomalous Right Coronary Artery Origin from Left Main Stem: Role of Cardio-Computed Tomography in the Diagnosis and Therapeutic Approach

Anomalous coronary arteries (ACAs) are rare but potentially life-threatening abnormalities of coronary circulation. Most of the variants are benign; however, some may lead to myocardial ischemia and/or sudden cardiac arrest. We report the case of a 75-year-old male complaining of exertion chest discomfort. Admission electrocardiogram on presentation showed sinus bradycardia with a slight elevation of ST-T in inferior leads. Troponin levels, however, were normal. Coronary angiography showed an anomalous right coronary artery (RCA) originating from the left main stem without significant stenosis. Cardio-CT confirmed the anomalous origin of the RCA from the left main stem and showed its anomalous course between the aorta and the pulmonary artery. The patient was deemed a candidate for surgery and transferred to a cardiac surgery center. Only the exact definition of the anatomic and clinical features of ACAs may allow the identification of the most appropriate and effective treatment. Multislice computed tomography may play a fundamental role in the diagnosis and treatment of ACAs.

Anomalies of coronary artery origin: Evaluation on multidetector CT angiography

Anomalies of origin of coronary arteries are an uncommon occurrence and found in approximately 1-2% of the general population. While a large proportion of these anomalies are clinically silent, a few might be hemodynamically significant and may even result in sudden cardiac death. Comprehensive knowledge of the normal as well as variant anatomies of the coronary artery origin and familiarity with imaging appearances and clinical significance of these anomalies is imperative for precise diagnosis and subsequent planning of treatment, whenever required. Multidetector computed tomography angiography, on account of its non-invasiveness, faster scan times and multiplanar reconstruction capabilities, is increasingly being utilized for characterization of coronary artery origin anomalies and their three-dimensional spatial relations. It shows a superior rate of detection of these anomalies compared to conventional angiography, providing more accurate delineation of the ostium as well as course. With the advent of newer generation CT scanners and use of advanced dose reduction techniques, images can be obtained rapidly having excellent spatial resolution and with minimal radiation dose. In this review article, we present the multidetector CT angiography imaging findings of the spectrum of anomalous coronary artery origin, using a third-generation dual-source CT scanner.

Right single coronary artery as an incidental finding in Takotsubo syndrome and acute heart failure: Case report and review of the literature

INTRODUCTION

Single coronary artery (SCA) with no associated congenital heart disease is a rare congenital anomaly. Most cases are asymptomatic and incidental findings, but SCA can cause ischemia, congestive heart failure, and sudden cardiac death (SCD).

CASE REPORT

A 44-year-old woman presented with Takotsubo cardiomyopathy and cardiogenic shock. Selective cannulation of the left coronary artery (LCA) was not possible on coronary angiography (CA); an SCA was revealed arising from the right sinus, continuing distally as the circumflex artery and thereafter as the left anterior descending artery. Coronary computed tomography angiography (CCTA) confirmed left main atresia and no coronary stenosis. Cardiac magnetic resonance imaging (MRI) showed diffuse myocardial edema and no perfusion defects. The patient's clinical course was favorable under conservative management.

DISCUSSION

Our paper describes an incidental finding of right SCA. We report a Lipton type R-I, in which a dominant right SCA supplies the entire myocardium. It is the rarest SCA presentation, with an incidence of 0.0008%; only 15 cases have been reported in the literature, all of which were studied by CA. Of these 15, one had SCD, five angina, one ventricular arrhythmia and one complicated acute coronary syndrome. CCTA confirmed the diagnosis in seven patients, MRI in one and transesophageal echocardiography in another. Nine patients had coronary lesions. Two underwent coronary artery bypass grafting, one percutaneous intervention and 11 conservative treatment.

CONCLUSION

Right SCA with congenital absence of the LCA is one of the rarest coronary artery anomalies. In a significant percentage of patients it is associated with ischemia and can be life-threatening. CCTA and MRI are the modalities of choice for diagnosis and risk stratification.

A case of co-existence of muscle bridge and anomalous origin of coronary artery

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Myocardial bridge is muscle overlying intramyocardial segment of an epicardial coronary artery.

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Arrhythmic complications were reported in patients with myocardial bridge.

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ARCA surgery is recommended in symptomatic patients.

Introduction

Coronary artery anomalies result from disturbances which may occur to the fetus in the third week of development. These disturbances may lead to anatomical variations which may affect the origin, trajectory, and termination of these arteries, or alterations in their intrinsic anatomy.

Presentation of case

We report an unusual case in which both anomalous origin of the right coronary artery and myocardial bridge on left anterior descending artery were detected concurrently.

Discussion

An investigation for myocardial bridge should be performed in all congenital coronary artery anomalies.

Conclusion

Invasive testing could be considered in patients with myocardial and equivocal non-invasive functional testing, in order to obtain better risk stratification and treatment.

Diagnostic detection with cardiac tomography and resonance of extremely rare coronary anomaly: A case report and review of literature

BACKGROUND

The association of two congenital coronary artery anomalies (CAAs) is extremely rare but represents one of the main cause of sudden cardiac death in young athletes. Although coronary angiography (CX-A) is still widely used in childhood, cardiac magnetic resonance (C-MRI) and cardiac computed tomography (C-CT) have recently taken on an increasing diagnostic role in early detection of CAAs and concomitant congenital cardiac malformations.

CASE SUMMARY

A healthy 10-year-old male patient was referred to the Radiological Department of our Institution due to no evidence of left coronary artery in echocardiographic examination. With C-MRI was detected marked myocardial trabeculation and was suspected anomalous origin and course of left circumflex (LCx) artery and of left anterior descending (LAD) artery. With third generation Dual Source C-CT 192x2-sections (SOMATOM Force, Siemens, Germany) was confirmed anomalous origin of LCx artery from right pulmonary artery associated with anomalous origin of LAD artery from right coronary artery with course in front of right ventricular outflow tract. The patient underwent surgical treatment with reimplantation of the anomalous LCX and LAD arteries into the wall of ascending aorta, with no postoperative complications. The patient remained asymptomatic and follow-up C-MRI scan four months after operation showed complete success of surgery treatment.

CONCLUSION

This case highlights the diagnostic potential of C-CT and C-MRI in evaluation of CAAs and of cardiac morphology and functionality, with very low radiation dose and without the risks related to invasive procedure.

Mechanisms of Myocardial Ischemia Inducing Sudden Cardiac Death in Athletes with Anomalous Coronary Origin from the Opposite Sinus: Insights from a computational fluid dynamic study

AIMS

The left coronary anomalous origin from the opposite sinus (L- ACAOS) constitutes the most clinically relevant arterial abnormality among the wide spectrum of coronary artery anomalies. We investigated the physiology of L-ACAOS with and without intramural course (IM) in athletes, using the computational fluid dynamic (CFD) analysis.

METHODS AND RESULTS

The coronary artery circulation with L-ACAOS with and without IM has been segmented and then reconstructed, after reviewing both the angiographic and computed tomography findings of 13 consecutive athletes (10 males, mean age 45.1 ± 8.2 years) with L-ACAOS collected in our institution between 1st January 2003 and 1st January 2018. Vorticity magnitude, static pressure and wall shear stress (WSS) have been analysed in a model of L-ACAOS with no IM course and in L-ACAOS-IM at rest and during exercise. The mean vorticity magnitude and WSS significantly increased from rest to exercise in both models, in right coronary artery, left anterior descending and left circumflex coronary arteries. The mean static pressure significantly increased with exercise in IM (1.118e + 004 vs 1.164e + 004 Pa, p < 0.001) as well as the mean vorticity magnitude and the mean WSS (7012.78 1/s vs 9019.56 1/s, p < 0.001, Δ = 2006.78 1/s and 3.02 Pa vs 2.11 Pa, p < 0.001, Δ = 0.91 Pa). This net increment was transmitted to the entire left coronary system in L-ACAOS-IM but not in L-ACAOS with no IM.

CONCLUSIONS

In L-ACAOS, different hemodynamic parameters observed in the intramural segment seem to confirm that IM is compressed during exercise. These rheological properties might propagated along the left coronary system, potentially predisposing, if confirmed in vivo, distal coronary segments to a higher risk of spasm and thrombosis in athletes.

Overview of coronary artery variants, aberrations and anomalies

Coronary artery anomalies and variants are relatively uncommon congenital disorders of the coronary artery anatomy and constitute the second most common cause of sudden cardiac death in young competitive athletes. The rapid advancement of imaging techniques, including computed tomography, magnetic resonance imaging, intravascular ultrasound and optical coherence tomography, have provided us with a wealth of new information on the subject. Anomalous origin of a coronary artery from the contralateral sinus is the anomaly most frequently associated with sudden cardiac death, in particular if the anomalous coronary artery has a course between the aorta and the pulmonary artery. However, other coronary anomalies, like anomalous origin of the left coronary artery from the pulmonary artery, atresia of the left main stem and coronary fistulae, have also been implicated in cases of sudden cardiac death. Patients are usually asymptomatic, and in most of the cases, coronary anomalies are discovered incidentally during coronary angiography or on autopsy following sudden cardiac death. However, in some cases, symptoms like angina, syncope, heart failure and myocardial infarction may occur. The aims of this article are to present a brief overview of the diverse coronary variants and anomalies, focusing especially on anatomical features, clinical manifestations, risk of sudden cardiac death and pathophysiologic mechanism of symptoms, as well as to provide valuable information regarding diagnostic workup, follow-up, therapeutic choices and timing of surgical treatment.

Left Main Coronary Artery Diverticulum: Case Report and Review of the Literature

Coronary artery disease is a major cause of morbidity and mortality, and while most commonly is atherosclerotic, it can present with variable manifestations, both congenital and acquired. One such manifestation is coronary aneurysm, which is a localized dilatation of a coronary artery wall segment to greater than 1.5 times the adjacent normal segments. While a dilated outpouching of a coronary artery has been commonly classified as a coronary aneurysm, a non-dilated outpouching is rare and is referred to as a diverticulum, with only one previous case report in the literature. It is conceivable that other cases of coronary artery diverticulum may have been previously reported as an aneurysm, given the overlapping angiographic appearance. We present a case of a 72-year-old female patient with an incidental finding of left main coronary artery diverticulum on diagnostic coronary angiogram done for preoperative liver transplantation evaluation.

Prevalence and Characteristics of Coronary Artery Anomalies Using Invasive Coronary Angiography in 6237 Consecutive Patients in a Single Center in Turkey

BACKGROUND

Coronary artery anomalies (CAAs) include clinically and anatomically diverse types of congenital heart defects occurring in a complicated spectrum. The aim of the present study is to describe congenital anomalies of coronary arteries (CAs) and their variations, and also identify the prevalence of these anomalies in our center.

METHODS

The study included a total of 6237 consecutive patients. Cine-angiographies and digital data of all patients undergoing coronary angiography (CAG) were reviewed by at least 2 independent and experienced observers. The Basic Anatomic Classification method was used to classify patients with CAAs.

RESULTS

Of a total of 6237 patients, 2,313 were females (37.1%) and 3924 (62.9 %) were males. CAAs were detected in 247 out of 6237 patients (3.9%, 95% CI: 3.4-4.4). Of these patients, 48 (19.4%, 95% CI: 14.4-24.2) had absent left main coronary artery (LMCA), 21 (8.5%, 95% CI: 5-11.9) had anomalous origin from the appropriate sinus, 23 (9.3%, 95% CI: 5.7-12.9) had anomalous origin from structures other than appropriate sinus, 31 (12.6%, 95% CI: 8.5-16.6 ) had anomalous origin from the opposite sinus, 101 (40.9%, 95% CI: 34.8-46.9) had myocardial bridge, and 23 (9.3%, 95% CI: 5.7-12.9) had a coronary artery fistula.

CONCLUSION

Our study results suggested that the total rate of coronary anomaly was found much higher than those reported in various invasive angiographic studies.

Prevalence and spectrum of coronary artery anomalies in 8021 patients: A single center study in South India

Objective

To identify the prevalence of coronary artery anomalies (CAAs) and their subtypes based on Angelini et al. classification in symptomatic yet stable population of South India using 64- slice dual source multi detector CT coronary angiography (MDCT-CA).

Methods

We retrospectively reviewed reports of 8021 symptomatic patients predominantly South Indians who were referred for CT coronary angiography (CT-CA) to our tertiary cardiac care center in Hyderabad, India from January 2011 to March 2017.

Results

We identified a total of 838 coronary artery anomalies in 812 patients with a prevalence of 10.09%. 96.9% of patients were older than 30 years of age with a M:F ratio of 1.39:1. Coronary artery disease (CAD) was seen in 61.5% of these patients. Among these anomalies, myocardial bridging (MB) was the most common anomaly followed by anomalous location of coronary ostium at improper sinus (ACOIS).

Conclusion

There is no significant difference in prevalence of CAAs (including and excluding MB) in Indian and World population. CAAs were more common in males than females and most of these patients remain asymptomatic during first three decades of their life. Myocardial bridging is the most common anomaly detected by MDCT-CA followed by ACOIS. Right coronary artery (RCA) arising from left coronary sinus (LCS) is the most commonly encountered ACOIS.

Primary Percutaneous Coronary Intervention Angioplasty of Occluded Twin Circumflex Coronary Artery in a Patient of Acute Inferior Wall Myocardial Infarction: A Rare Anomaly

Anomalies of the coronary arteries are reported in 1-2% of patients among diagnostic angiogram. Dual origin of a circumflex from both sinuses is extremely rare among them. We report a case of a patient who underwent primary percutaneous coronary intervention for acute inferior wall myocardial infarction where left coronary injection demonstrated normal obtuse marginal and right coronary injection demonstrated normal right coronary artery (RCA). On further probing, an anomalous left circumflex (LCx) artery was seen arising from RCA ostium which was subsequently cannulated and revascularized by deployment of 2.75 × 26 mm Xience Prime drug-eluting stent (Abott Vascular, USA). Herein, we report for the first time primary percutaneous coronary intervention of twin circumflex and also illustrate that anomalous circumflex can be missed if it arises from RCA ostium and if not probed carefully.

The prevalence of coronary artery anomalies in Qassim Province detected by cardiac computed tomography angiography

BACKGROUND

Coronary artery anomalies (CAAs) affect about 1% of the general population based on invasive coronary angiography (ICA) data, computed tomography angiography (CTA) enables better visualization of the origin, course, relation to the adjacent structures, and termination of CAAs compared to ICA.

OBJECTIVE

The aim of our work is to estimate the frequency of CAAs in Qassim province among patients underwent cardiac CTA at Prince Sultan Cardiac Center.

METHODS

Retrospective analysis of the CTA data of 2235 patients between 2009 and 2015.

RESULTS

The prevalence of CAAs in our study was 1.029%. Among the 2235 patients, 241 (10.78%) had CAAs or coronary variants, 198 (8.85%) had myocardial bridging, 34 (1.52%) had a variable location of the Coronary Ostia, Twenty two (0.98%) had a separate origin of left anterior descending (LAD) and left circumflex coronary (LCX) arteries, ten (0.447%) had a separate origin of the RCA and the Conus artery. Seventeen (0.76%) had an anomalous origin of the coronaries. Six (0.268%) had a coronary artery fistula, which is connected mainly to the right heart chambers, one of these fistulas was complicated by acute myocardial infarction.

CONCLUSIONS

The incidence of CAAs in our patient population was similar to the former studies, CTA is an excellent tool for diagnosis and guiding the management of the CAAs.

A new variation of dual left anterior descending coronary artery

A 63-year-old male with past medical history of type II diabetes mellitus, hypertension, hyperlipidemia, stroke, and permanent pacemaker implant for poor chronotropic response to exercise underwent coronary computed tomography angiography (CCTA) for worsening atypical chest pain. The patient had normal myocardial perfusion by nuclear stress testing 3 months prior to this test. A rare variation of dual left anterior descending coronary artery (LAD) was identified by CCTA and subsequent coronary angiography confirmed a dual LAD and revealed no significant stenosis of the coronary arteries. Six types of dual LADs have been previously reported. However, this case showed a short LAD directly originating from the left coronary sinus and long LAD originating from the left main coronary artery. This configuration has not been reported previously in the literature to our knowledge. The short LAD main stem showed an intramyocardial course and provided septal perforators to the basal-mid interventricular septum (IVS) and right ventricular branches. The long LAD provided both diagonal branches and septal perforators to the distal IVS. CCTA in conjunction with coronary angiography played an essential role to characterize this anomaly and awareness of this anomaly merits reducing misinterpretation of coronary angiography for cardiology care providers. .

A study of coronary artery variants and anomalies observed at a tertiary care armed forces hospital using 64-slice MDCT

BACKGROUND

Isolated coronary artery anomalies are usually clinically silent and mostly detected incidentally during angiography or autopsy. However, few of them may be implicated in cases of sudden cardiac death even in the absence of additional heart abnormalities. Prior knowledge of such variants and anomalies is necessary for planning various interventional procedures. Multiple detector computed tomography coronary angiography has proved a very useful non-invasive modality in this field given its superiority over conventional coronary angiography in providing detailed coronary artery anatomy.

METHODS

A retrospective review of the coronary CT angiography studies was carried out at our center between August 2014 and December 2015 with the purpose of describing the coronary artery variants and anomalies that we came across in our cohort.

RESULTS

In our cohort, about 77% (n=391) of the patients had a right dominant system while left dominant and co-dominant systems were seen in 12% (n=61) and 11% (n=56) respectively. Coronary CT angiography was successful in visualizing smaller branches, such as the conus artery (96.25%, n=489), the sinus node artery (83.07%, n=422), and the septal branches (95.27%, n=484). Coronary anomalies were observed in the 10.04% of our population (n=51). Eleven anomalies of origin and course were found.

CONCLUSION

Coronary CT angiography gives us a good understanding of the variations and anomalies of the anatomy of the coronary arteries. This can be of immense help to the clinician planning interventional procedures.

Percutaneous coronary intervention in a rare variety of single coronary artery

We present a case of 50-year-old male having unstable angina. A rare type of single coronary artery was identified during the Coronary angiogram. The left anterior descending (LAD) and left circumflex artery (LCX) had originated from the proximal segment of right coronary artery along with significant lesion in LCX. Computed tomographic (CT) coronary angiogram confirmed the origin and course following which successful percutaneous coronary intervention (PCI) was done to LCX. The incidence of this type of coronary anomaly is 0.004%. We emphasize the importance of having a CT coronary angiogram to identify the course before the intervention. The procedural risk during PCI in patients with single coronary ostium is high. Moreover, the angulation and course of the culprit artery also pose a challenge. Good coaxial guide support by using an appropriate guiding catheter is the key to success.

A Very Rare Coronary Artery Anomaly: Two Circumflex Arteries Originating From Both Right and Left Coronary Sinuses of Valsalva

Coronary anomalies are found in less than 1% of diagnostic coronary angiograms. The clinical importance of coronary anomalies varies from insignificant to life-threatening. We report a very rare case of a patient with two circumflex arteries originating from both right and left coronary sinuses of Valsalva.

Congenital anomalies of coronary arteries in complex congenital heart disease: diagnosis and analysis with dual-source CT

BACKGROUND

Congenital heart diseases (CHDs) are sometimes associated with coronary artery anomalies (CAAs). Accurate preoperative evaluation of coronary artery anatomy is essential for successful surgical repair of complex CHD.

OBJECTIVE

The aim of this study was to evaluate the incidence of congenital CAAs in patients with complex CHD at dual-source CT.

METHODS

Four hundred seventeen consecutive patients with complex CHD underwent contrast-enhanced cardiac CT angiography. The results were retrospectively analyzed, including the types and incidences of CAAs in various forms of complex CHD. Each patient was analyzed independently by 2 experienced cardiovascular radiologists. Image quality of coronary arteries was assessed on a 5-point scale with 2 or less being nondiagnostic.

RESULTS

Thirty-five of 417 studies were nondiagnostic (8.39%). Sixty-three cases of CAA (15.11%) were detected by anomalous ostia and coronary arteries. CAA was involved in 6 of 108 patients with tetralogy of Fallot (5.56%), 18 of 84 patients with double outlet right ventricle (21.43%), 11 of 97 patients with pulmonary artery atresia (11.34%), 7 of 36 patients with transposition of the great arteries (22.22%), 15 of 41 patients with single ventricle (36.59%), 4 of 12 patients with truncus arteriosus/aortopulmonary window (33.33%), and 2 of 39 patients with interruption of the aortic arch/coarctation of the aorta (5.13%). Twenty of these were accompanied with an anomalous coronary course (31.74%).

CONCLUSION

Patients with complex CHD have a higher prevalence of CAAs, which should be considered before surgery. Dual-source CT is an effective technique to visualize and evaluate complex CHD.

Atypical type of dual left anterior descending coronary artery

Dual left anterior descending coronary artery (LAD) is a rare coronary anomaly and is divided into six subgroups in the literature according to the origin and course of the short and long branches of the anomalous artery. We present two distinct cases of dual LAD which are distinguished by two branches of equal length from their counterparts in the literature. <Learning objective: In our cases a novel dual LAD variant is presented with two main branches of equal length and reaches the cardiac apex. Cardiologists and cardiovascular surgeons should be aware of these variants to avoid misinterpretation of coronary angiography and intraoperative complications.>.

Twin circumflex arteries with left sinus of valsalva origin: a case report

Coronary artery anomalies are not uncommon. The importance of coronary anomalies varies from unimportant to life threatening. Herein, we report for the first time twin circumflex coronary arteries originating separately from the left sinus of Valsalva.

Percutaneous revascularization in a patient with anomalous origin of left main coronary artery

Anomalous origin of the coronary artery from opposite coronary sinus is infrequently observed during coronary angiography. Percutaneous coronary intervention (PCI) of anomalous coronary artery is technically difficult and challenging. It requires appropriate selection of guide catheters for adequate stability, coaxial alignment and backup support during the intervention. We hereby report a rare case of anomalous origin of left main coronary artery (LM) from the right coronary sinus, having a retro-aortic course to the left side before its bifurcation into left anterior descending (LAD) and circumflex artery. The 59-year-old man had successful PCI of atherosclerotic LAD lesions. A 64-slice Multi-Detector Computed Tomography (MDCT) performed at 4 years of follow-up demonstrated patency of coronary stents and also delineated the origin and course of the anomalous LM. The case illustrates the rarity of anomalous LM, and describes technical issues during PCI and the role of MDCT in coronary anomaly imaging.

Percutaneous Coronary Intervention on Right Coronary Artery With All Coronary Arteries From Three Separate Ostiums in the Right Sinus of Valsalva

Some of coronary artery anomalies, such as origin of all coronary arteries from three separate ostiums in the right sinus of valsalva, represent a small amount of coronary anomalies. We describe a 63-year-old female patient which coronary angiogram revealed an origin of all coronary arteries from three separate ostiums in the right sinus of valsalva, with significant atherosclerotic plaque at the midportion of the right coronary artery. The stenosis was treated through percutaneous coronary intervention.

Coronary artery anomalies: A diagnostic challenge

Coronary artery anomalies (CAAs) are found in approximately 1% of all patients undergoing coronary angiography and in 0.3% of patients undergoing autopsy (Roberts, 1986). CAAs may be classified into those of origin and course, intrinsic coronary arterial anatomy, and coronary termination (Angelini et al. 2002). The most common malformation is abnormal origin and course, origin of a coronary artery from a wrong aortic sinus of Valsalva; either the right from the left coronary sinus or the left from the right coronary sinus; these anomalies must be excluded in young adults with typically ischemic- sounding chest pain or syncope. Anomalies coronary artery termination typically presented as coronary artery fistula, commonly the right coronary artery is affected, although, left sided coronary artery fistulae are well documented (Gandy et al. 2004). The anomalies of intrinsic coronary arterial anatomy, such as ostial stenosis, Artesia, and single, absent, or hypoplastic coronary arteries are rare but may have clinical importance.

Diagnosis of variants of single right coronary trunk using 64 multidetector computed tomography

Single coronary anomalies are one of the rarest variants of coronary anatomy. Widespread use of coronary CT angiography has made it possible to diagnose these variants with increasing incidence. We report two cases of single right coronary trunk with different anatomic course of the left coronary artery; one anterior to the main pulmonary artery and the second between the main pulmonary artery and ascending aorta and then coursing within the interventricular septum.