Angiography was used to diagnose a rare congenital coronary anomaly with myocardial ischaemia in a woman with typical angina. All three coronary arteries arose from a solitary coronary ostium in the right aortic sinus; the left anterior descending coronary artery followed a septal course, the circumflex coronary artery ran behind the ascending aorta, and the right coronary artery followed a normal course. No significant coronary lumen narrowing was found. Transoesophageal echocardiography confirmed the anomalous origin and course of the aberrant coronary arteries. An exercise test reproduced angina, and ECG changes and myocardial perfusion study showed an anterior reversible defect. In contrast to previous reports, myocardial ischaemia was associated with the septal (intramuscular) course of the left anterior descending coronary artery; there was no other significant coronary artery disease.
Keywords: congenital heart defects; myocardial ischaemia; angiography; echocardiography
The coronary arterial pattern was studied in two patients with superoinferior ventricular heart and haemodynamically complete transposition. In one of them the aorta was dextro-positioned and in the other laevo-positioned. In both the right coronary artery arose from the posterior aortic sinus and the left coronary artery from the left aortic sinus. This pattern is similar to the common coronary arterial pattern in complete transposition of the great arteries. The similarity supports the theory that in the superoinferior ventricular heart the connections between the ventricles and the great arteries (concordant or discordant) area those of the basic condition--complete transposition or corrected transposition. The angiocardiographic findings indicate that relations are not always as expected for a given connection.
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.
Anomalous left main coronary artery; Atherosclerosis; Coronary artery anomalies; Drug-eluting stent; Multi-detector computed tomography; Percutaneous coronary intervention; Retro-aortic course
Because of the variety of their anatomy and clinical implications, coronary anomalies tend to confuse many observers. Recently, our group and other investigators have proposed that only 1 specific type of anomaly, by means of a specific mechanism, is able to cause both symptoms of myocardial ischemia and sudden death. This anomaly is known as anomalous origin of a coronary artery from the opposite sinus of Valsalva, with intramural course (ACAOS). Its defining pathophysiologic feature is that the proximal section of the ectopic artery has an intramural course, which leads to variable degrees of functional obstruction. Herein, we describe an unusual, previously unreported coronary anomaly: a “normal origin” of the left main coronary artery from the left sinus of Valsalva that resulted in progressive, critical ischemia. The proximal few millimeters of this artery were intramural, embedded into the aortic-sinus wall, and laterally compressed. Therefore, this anomaly may be regarded also as “ACAOS of the left coronary artery without an ectopic origin.” Angiography and intravascular ultrasonography revealed a variable degree of obstruction without intimal thickening and, likely, without spasm. Surgical repair, including ostioplasty, completely relieved the patient's clinical symptoms.
Angina pectoris/etiology/pathology; coronary angiography/methods; coronary stenosis/surgery; coronary vessel anomalies/complications/diagnosis/epidemiology/physiopathology/surgery; coronary vessels/anatomy & histology; myocardial ischemia/epidemiology/pathology; sinus of Valsalva; ultrasonography, interventional
A 43-year-old patient was admitted to hospital because of an inferior-posterior myocardial infarction. The admission electrocardiogram was suggestive of a right coronary artery (RCA) culprit lesion. Coronary angiography following successful thrombolysis revealed a normal left system and mild intraluminal disease of the dominant RCA, which arose from the left aortic sinus and travelled an interarterial course; the latter was depicted in a subsequent computed tomographic angiogram. The lack of ST segment elevation in V4R and the absence of right ventricular wall motion abnormalities on echocardiography precluded the proximal ectopic vessel from being the culprit. The patient was managed medically; one year following discharge, he is asymptomatic. In cases of aberrant anomalous origin of a coronary artery from the opposite sinus with interarterial course, the proximal ectopic vessel is intussuscepted within the aortic wall, potentially leading to ischemia. The present article highlights that, although medical treatment in cases of such an aberrant RCA without apparent ischemia-driven sequelae may be valid, the need for interventional treatment could be substantiated following investigation of the anatomofunctional features of the intussuscepted proximal ectopic segment with intravascular ultrasound.
Anomalous coronary course; Anomalous right coronary artery; Coronary angiography; CT coronary angiography; Inferior myocardial infarction
Left coronary artery arising from the right sinus of Valsalva is an uncommon congenital coro-nary anomaly that seems to be associated with sudden death in young patients.
We report a case of cardiac arrest in a 59-year-old patient after sexual intercourse and Silde-nafil ingestion. A coronary arteriography and an angiographic computed tomography scan subsequently revealed a LCA origin from the right aortic sinus along with an intramural course of the left main stem. In addition a distal stenosis of the right coronary artery was detected. After successful resuscitation without neurological deficits coronary artery bypass surgery was performed.
To our knowledge, this is the first report demonstrating sudden cardiac arrest associated with Sildenafil ingestion in a patient with this type of coronary anomaly. The question arises, whether a cardiac screening is necessary before a Sildenafil therapy is initiated.
Localized aneurysms of the sinus of Valsalva are uncommon. Repair is tailored to the defective anatomy of the sinus, the aortic valve, and the coronary artery.
Herein, we report the successful surgical treatment of 2 patients who had unruptured pseudoaneurysms of the sinus of Valsalva. An evident fissure in the intima of the sinus of Valsalva was seen in both patients. Patient 1 was a 57-year-old man with annuloaortic ectasia who was diagnosed with pseudoaneurysm of the right sinus of Valsalva. A thrombus that had formed in the pseudoaneurysm subsequently migrated into the right coronary artery. Aortic root remodeling was performed. Patient 2 was a 23-year-old man with a history of blunt chest trauma. He developed a pseudoaneurysm in the right sinus of Valsalva and tears on the aortic cusps. He underwent aortic valve replacement and repair of the Valsalva wall.
Aorta/injuries; aortic aneurysm/complications/diagnosis/epidemiology/pathology/surgery; heart valve prosthesis implantation; sinus of Valsalva/abnormalities/pathology/radiography/surgery; thrombosis/complications/surgery; vascular fistula
Aneurysms of the sinus of Valsalva are extremely rare. Ruptured aneurysms of the sinus of Valsalva are frequently associated with other congenital defects, particularly with ventricular septal defect, aortic valve regurgitation, and bicuspid aortic valve. We describe the case of a 26-year-old man who had a ruptured aneurysm of the right coronary sinus, a ventricular septal defect, and an anomalous origin of the right coronary artery. Successful surgical correction of the aneurysm and ventricular septal defect was performed with patch repair and aortic valve replacement. A review of the English-language medical literature revealed only 1 other case of a sinus of Valsalva aneurysm associated with a ventricular septal defect and an anomalous coronary artery. Previously published reports of the coexistence of a single coronary artery with a sinus of Valsalva aneurysm or with a ventricular septal defect, and their management, are discussed herein.
Aortic aneurysm/congenital; aortic rupture/surgery; heart defects; congenital; heart septal defects; ventricular; coronary vessel anomalies/surgery; sinus of Valsalva/abnormalities/surgery
Anomalous aortic origin of the coronary artery from the opposite sinus with interarterial course (AAOCA) is a rare condition with a high risk of sudden cardiac death (SCD) during or after strenuous exertion. SCD after repair of this anomaly is extremely rare. Here we present a 15-year-old athlete who collapsed on the basketball court in whom an anomalous origin of the left coronary artery from the right sinus of Valsalva with interarterial course (ALCA) was diagnosed. In spite of extensive pre-sport participation testing, SCD occurred shortly after surgical correction. We reviewed the literature to establish an evidence-based recommendation to aid physicians in conducting the optimal pre-sport participation management for the prevention of SCD in patients with a surgically corrected AAOCA/ALCA, especially for those who participate in strenuous exercise. Review of the literature (60 articles with 325 patients) reveals that post-surgical, pre-sport participation testing varies greatly but that mortality after surgical repair is extremely low (1.5 %). In conclusion, SCD can still rarely occur after repair of AAOCA despite extensive pre-sport participation testing. This should raise awareness among physicians treating these patients and raises the question whether or not return-to-play guidelines need to be revised.
Anomalous coronary artery; Interarterial course; Sudden cardiac death; Surgery; Pre-sport participation testing
Before coronary evaluation by modern imaging techniques was feasible, premorbid diagnoses of coronary artery anomalies (CAAs) were usually made fortuitously by invasive coronary angiography (ICA). However, this technique is limited by its invasive and projectional nature. Coronary magnetic resonance angiography (CMRA) and multi-slice computed tomography (MSCT) broadened clinical information by enabling visualisation of the coronary arteries in their anatomical environment.
This case series visualises and reviews anomalous coronary artery from the opposite sinus (ACAOS) and coronary artery fistulae. All CAAs were detected by means of 64-slice dual source computed tomography after 1000 cardiac scans at the Erasmus MC, Rotterdam, the Netherlands.
Eight ACAOS cases, one anomalous left coronary artery from the pulmonary artery (ALCAPA) and one congenital aneurysm of an aortic sinus were found. Seven out often detected CAAs were considered malignant whereas three CAAs of the ACAOS type (retroaortic path) were considered benign. Significant coronary artery disease was found in three out of eight ACAOS cases. In one of the ACAOS cases complete evaluation of the anomalous coronary artery was limited by motion artifacts. All five cases of right ACAOS were referred for MSCT because the right coronary artery could not be located by invasive angiography.
All CAAs were easy to diagnose because of 3D imaging and high temporal and spatial resolution. High resolution made it possible to not only depict coronary artery abnormalities, but also to quantify luminal and vessel properties such as stenosis grade, aspects of plaque, anomalous vessel length, luminal area ratio and the asymmetry ratio. Because of its comprehensiveness, MSCT can be an effective imaging modality in patients suspected of coronary artery abnormalities caused by coronary artery disease, CAAs, or a combination of both. (Neth Heart J 2008;16:369-75.)
coronary anomalies; anomalous coronary artery from the opposite sinus; coronary artery fistulae; computed tomography; invasive coronary angiography
Aneurysm of the left sinus of Valsalva is extremely rare. Compression of the left coronary artery by such an aneurysm is an unusual complication of this condition and can cause coronary insufficiency.
We describe the case of a 75-year-old woman who had an isolated unruptured aneurysm of the left coronary sinus with intraluminal thrombus, which caused coronary artery compression. We performed successful surgical correction by closing the mouth of the aneurysm without aortic valve replacement or coronary artery bypass grafting. A review of the world medical literature revealed 19 cases of sinus of Valsalva aneurysms that hindered the coronary arterial flow. The previously published reports of this rare condition and its treatment are discussed herein. (Tex Heart Inst J 2002;29:40–4)
Angina pectoris/etiology; aortic aneurysm/complications/diagnosis/surgery; coronary arteries; heart defects, congenital; myocardial ischemia/etiology; sinus of Valsalva
Coronary bypass graft has been the conventional treatment of choice in anomalous left man coronary artery stenosis. We are reporting an interesting case with anomalous left main coronary artery originating from right aortic sinus having retroaortic course complicated by significant atherosclerotic narrowing of the vessel and its percutaneous management.
Acute aortic valvular insufficiency was induced in open chest dogs by employing a special intravascular cannula, or by rupturing an aortic valve leaflet. Phasic and mean coronary flow were assessed in some animals, while in others data were obtained on arterial and coronary sinus blood lactate, pyruvate, PO2, PCO2, and pH, and on myocardial tissue lactate, pyruvate, and water content in the outer and inner halves of the free wall of the left ventricle. Results showed that in acute aortic insufficiency diastolic coronary flow decreased as a function of aortic diastolic pressure, but systolic coronary flow increased in such proportion that mean coronary flow did not decrease. With moderate reductions in aortic diastolic pressure due to aortic insufficiency, myocardial blood flow was judged to be nutritionally adequate in both the outer and inner regions of the left ventricle. With more severe reductions in aortic diastolic pressure, the inner region exihibited biochemical signs of anaerobic metabolism. The presence of these metabolic changes could be correlated with either of two previously described pressure indexes. These findings suggest that the reduced coronary perfusion pressure and the intramyocardial tissue pressure gradient can be compensated for by autoregulation in some cases of aortic insufficiency, but in others such compensation may be incomplete, in which case oxygen delivery to the subendocardium will be inadequate to meet local tissue oxygen needs.
Aorta–right atrial tunnel is a vascular channel that originates from one of the sinuses of Valsalva and terminates in either the superior vena cava or the right atrium. The tunnel is classified as anterior or posterior, depending upon its course in relation to the ascending aorta. An origin above the sinotubular ridge differentiates the tunnel from an aneurysm of the sinus of Valsalva, and the absence of myocardial branches differentiates it from a coronary–cameral fistula. Clinical presentation ranges from an asymptomatic precordial murmur to congestive heart failure. The embryologic background and pathogenesis of this lesion are attributable either to an aneurysmal dilation of the sinus nodal artery or to a congenital weakness of the aortic media. In either circumstance, progressive enlargement of the tunnel and ultimate rupture into the low-pressure right atrium could occur under the influence of the systemic pressure.
The lesion is diagnosed by use of 2-dimensional echocardiography and cardiac catheterization. Computed tomographic angiography is an additional noninvasive diagnostic tool. The possibility of complications necessitates early therapy, even in asymptomatic patients or those with a hemodynamically insignificant shunt. Available treatments are catheter-based intervention, external ligation under controlled hypotension, or surgical closure with the patient under cardiopulmonary bypass.
Herein, we discuss the cases of 2 patients who had this unusual anomaly. We highlight the outcome on follow-up imaging (patient 1) and the identification and safe reimplantation of the coronary artery (patient 2).
Aorta/abnormalities/surgery; coronary vessel anomalies/classification/diagnosis; diagnosis, differential; heart atria/abnormalities/surgery; sinus of Valsalva; tomography, X-ray computed; treatment outcome; vena cava, superior/abnormalities
This report describes the case of a 45-year-old Korean female who had suffered from Behçet's syndrome for two years with a huge, unruptured aneurysm originating from the left coronary sinus. The aneurysm had caused myocardial and aortic insufficiency by compressing the proximal left anterior descending coronary artery. The orifice of the aneurysm was at the left coronary sinus, about 5mm from the left main coronary ostium, and it was filled with organized thrombi. Surgical repair was performed by closing the entrance of the aneurysm with a Dacron patch and by implementing aortic valve repair and coronary artery bypass grafting. The patient's coronary flow was restored postoperatively, and all anginal symptoms disappeared.
Aneurysm; coronary sinus; myocardial infarction
We report a case of acute myocardial infarction and syncope in an 18-year-old athlete during high-performance exercise. A coronary arteriography and an angiographic computed tomography scan subsequently revealed a left coronary arterial origin from the right aortic sinus along with an intramural course of the left main stem. The patient was successfully treated with surgical unroofing of the left main stem from inside the aorta. To our knowledge, this is the first report demonstrating this type of anomaly pre- and postoperatively by use of angiographic computed tomography scan in the context of acute coronary syndrome.
The coronary circulation originating from a single coronary ostium is rare. All possible anatomical variations were the basis of a recent classification. This case report describes a previously unreported IID1 pattern, comprising a solitary coronary ostium in the right coronary sinus with an anatomical course of the right coronary artery. The left circumflex coronary artery arises from the proximal right coronary artery coursing behind the aorta to the left. The left anterior descending coronary artery arises from the proximal right coronary artery coursing to the left side anterior to the right ventricle.
Keywords: single coronary ostium; coronary artery anatomy
Most medical literature regarding the anomalous origin of a coronary artery from the opposite sinus of Valsalva pertains to sudden death in the young. The surgical treatment of anomalous origin of the left main coronary artery from the right sinus of Valsalva is not particularly well codified, and when an anomalous left main coronary artery is associated with an extramural stenosis, treatment becomes more technically challenging. Herein, we describe a unique approach toward treating this combination of conditions.
A 15-year-old adolescent boy was diagnosed with anomalous origin of the left main coronary artery from the right sinus of Valsalva. The condition was accompanied by a slit ostium and an extramural stenosis of the left main coronary artery. Surgery was offered to the patient in view of his young age and the uncertain prospective course of the disease. Coronary unroofing was not indicated, due to the extramural location of the stenosis. With the patient under cardiopulmonary bypass, the stenotic segment of the left main coronary artery was transected outside the aorta, repaired by vein patch augmentation, and reimplanted directly into the left coronary sinus. The patient recovered uneventfully. A postoperative computed tomographic angiogram showed good patency of the reconstructed artery. We expect excellent longevity of the directly reimplanted coronary artery.
Adolescent; cardiac surgical procedures; chest pain/etiology; coronary angiography; coronary vessel anomalies/classification/diagnosis/surgery; death, sudden/prevention & control; prognosis; replantation; sinus of Valsalva/abnormalities
Right Coronary Artery (RCA) originating from left anterior descending artery is a very rare congenital coronary artery anomaly. A 66-year-old man presented with hypertension and complaints of exertional chest pain. The angiography was performed. Aortic root angiography showed no coronary ostium orginating from the right sinus of valsalva. Right coronary artery was vizualized as anomalously originating from the midportion of left anterior descending artery. Severe stenosis were seen in ostium of anomalous right coronary artery, in midportion of left anterior descending and in midportion of circumflex artery. The patient was referred for coronary artery bypass grafting. The patient underwent coronary artery bypass surgery for three vessels. He was discharged home on postoperative day 7 without any complication. His echocardiogram on follow-up visit revealed good biventricular function.
To examine how leading clinical journals report research findings, aiming to assess how they frame their implications for medical practice and to compare that literature's patterns with those of the management literature.
Clinically relevant research articles from three leading clinical journals (N Engl J Med, JAMA, and Ann Intern Med).
Review of wording of a sequential sample from 2010, with categorisation, comparison among journals, and comparison with management literature.
Clinical journals usually state that one approach did or did not differ from another approach (35 of 51 articles, 68.6%), but they recommended a specific course of action (‘therefore, x should be done’) in just 25.5%. One article gave instruction on how to implement the changes. Two-thirds of the reports called for further research. Half used tentative language. Management research articles nearly always specified who should use the information and drew from over 60 types of potential users, whereas the clinical literature named the audience in only 23.5% of clinicians.
Authors and editors of the clinical literature could test being more clear and direct in presenting implications of research findings for practice, including stating when the findings do not justify changes in practice.
Implications for practice; policy making; research quality; medical literature; quality improvement; continuous quality improvement; health policy; healthcare quality improvement; research
Anomalous origin of the coronary artery from the opposite sinus of Valsalva and a course of that artery between the ascending aorta and the pulmonary artery is a rare congenital anomaly. It can cause myocardial ischemia, syncope, and sudden cardiac death in young people. Herein, we report the case of a 24-year-old man who was brought to our hospital after cardiac arrest due to ventricular fibrillation. Emergent coronary angiography revealed that the left coronary artery was normal; however, the right coronary artery originated at the left sinus of Valsalva. After admission, the patient was treated with mild therapeutic hypothermia for 48 hours and had a favorable neurologic recovery. Subsequent 16-slice multidetector computed tomography revealed that the right coronary artery arose from the left main coronary artery, took an intramural course, and was severely compressed between the ascending aorta and the pulmonary artery. The patient underwent direct implantation of the anomalous artery into the correct aortic sinus. Histologic specimens from the proximal end of the right coronary artery showed an intramural segment with intimal fibrous thickening, fragmentation and random arrangement of the elastic fiber, degeneration of the medial smooth-muscle cells, and an increase in the medial stromal substance. Postoperatively, repeat coronary angiography with provocation testing for coronary spasm revealed no myocardial ischemic change. The patient recovered uneventfully. We found that cardiac multidetector computed tomography was useful in evaluating the cause of the sudden cardiac arrest, identifying the anomalous coronary artery, and helping to guide the surgical decisions.
WEB SITE FEATURE
Coronary angiography; coronary vessel anomalies/diagnosis/physiopathology/surgery; death, sudden, cardiac/prevention & control; replantation; risk assessment; sinus of Valsalva/abnormalities/surgery; treatment outcome
A 58 year old man with a history of cerebral infarction was admitted to hospital with chest discomfort and dyspnoea. He had no history of precordial chest discomfort. Angiography and left ventriculography showed that coronary fistulas connected the coronary sinus with the left circumflex and right coronary arteries. His coronary sinus did not communicate with the right atrium, draining instead into a persistent left superior vena cava. Angiography showed a mass, suspected to be a thrombus, in the coronary sinus. Transoesophageal echocardiography confirmed the presence of a mass in the atrioventricular groove. The mass was removed at surgery and proved to be a cavernous haemangioma.
Keywords: coronary fistulas; persistent left superior vena cava; cavernous haemangioma; coronary sinus
The conus coronary artery has been reported to arise independently from the aorta in approximately 45 per cent of hearts. In this study, 305 necropsy specimens were examined to determine the origin of the conus coronary artery and variations in patterns of origin with respect to age. Three patterns were recognised: 1, in which the conus artery arose from the aorta independently of the right coronary artery; 2, in which the conus artery and the right coronary arose from a common ostium; and 3, in which only the right coronary artery took origin from the right aortic sinus. The relative incidence of the three patterns varied with age. Pattern 1 was recognised in 14 to 24 per cent of specimens from patients under the age of 2 years, whereas in older patients, it occurred in 41 to 63 per cent. These data suggest that aortic origin of the conus arterial ostium may appear in some individuals between 2 and 4 years of age, and they support the concept that some coronary arterial patterns are not fully established at the time of birth.
A 26 year old man who presented with the first signs of right heart failure was found to have a large congenital aneurysm of the aortic sinus of Valsalva and of the left coronary sinus. These were combined with left heart anomalies in the form of a bicuspid aortic valve, a rare variant of a persistent left superior vena cava with blood flow from the left atrium through the brachiocephalic vein into the superior vena cava and a kink in the aortic arch. An aortic coarctation had been corrected with a patch 12 years earlier. Although the aneurysm was not perforated and there were no clinical signs of infarction, the aneurysm was resected prophylactically and the left coronary artery was reinserted through a bypass with a Gore-Tex conduit. The case is noteworthy because this diagnosis is very rare and its early treatment may prevent several complications. The clinical features, treatment, and outcome are discussed.
left sinus of Valsalva; aneurysm
In an article in an earlier edition of the Journal of Medical Ethics (1) Dr Iglesias bases her analysis upon the mediaeval interpretation of Platonic metaphysics and Aristotelian logic as given by Aquinas. Propositional forms are applied to the analysis of experience. This results in a very abstract analysis. The essential connection of events and their changing temporal relationships are ignored. The dichotomy between body and soul is a central concept. The unchanging elements in experience are assumed to be more real than the actual world of experienced process. Such a view makes the analysis of the temporal factors in experience impossible. Its abstractness is quite unsuitable for the analysis of the ontological structure and development of the neonate from fertilisation to birth. A N Whitehead made the notion of organism central to his philosophy. He refused to place human experience outside nature, or admit dualism. His philosophy of organism is an attempt to uncover the essential elements connecting human experience with the physical and biological sciences. Time, change and process are, in his view, more real than the static abstractions obtainable by the use of the fallacy of misplaced concreteness. Use of the latter negates the essential connectedness of events and the importance of temporarily and change (2). In this paper I argue that the embryo, being an organism, is not analysable in terms of thinghood. It is a process. To apply Aristotelian logical concepts to it is to distort the real nature of the datum.