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.
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.
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Coronary angiography; coronary vessel anomalies/diagnosis/physiopathology/surgery; death, sudden, cardiac/prevention & control; replantation; risk assessment; sinus of Valsalva/abnormalities/surgery; treatment outcome
Coronary anomalies are rare angiographic findings. Moreover, there are few reports of cases of an anomalous origin of the right coronary artery from the left sinus of Valsalva and of the left coronary artery from the posterior sinus of Valsalva. Here, we report a case with an anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva and the left coronary artery from the posterior sinus of Valsalva. This was observed in a patient who was treated for a myocardial infarction of the inferior wall caused by a thrombus in the proximal right coronary artery. The patient was treated successfully with the implantation of a stent in the anomalous origin of the right coronary artery using a 6Fr Amplatz left 1 catheter.
Anomalous origin of coronary artery; 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.
One of the single anomalous origins of coronary artery that has rarely been reported is a congenital anomaly of coronary circulation that occurs in the left coronary artery originating from the right coronary sinus of valsalva. We report a 49-year-old male patient with non-ST segment elevated myocardial infarction that was identified to have an anomalous origin of the left coronary artery from the right coronary artery (RCA) with thrombotic total occlusion of RCA by coronary angiography and cardiac computed tomography. The patient underwent successful percutaneous coronary intervention in total occlusion of the RCA and was discharged after uneventful recovery.
Coronary vessel anomalies; Myocardial infarction; Percutaneous transluminal coronary angioplasty
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
Anomaly of the left anterior descending (LAD) coronary artery arising from the right sinus of valsalva is frequently seen with tetralogy of Fallot (TOF). The association of the LAD coronary artery with ventricular septal defect (VSD) is uncommon. We described an anomalous origin of the LAD coronary artery from the right sinus of valsalva with ventricular septal defect in a 38-year-old male patient suffering from atypical angina. The LAD coronary artery arose from the right sinus of valsalva, just next to the right coronary artery. There was a single opening in the membranous part of the interventricular septum. From this case, we suggest that angiography is useful for both documenting anomalies of the LAD coronary artery associated with VSD and for determining the safest surgical procedures.
Coronary vessels; ventricular septal defects; congenital abnormalities
Anomalous origin of the left main coronary artery from the right sinus of Valsalva is extremely rare when not associated with other congenital cardiac anomalies. In this report we present a patient with a single coronary ostium, with both the left and right coronary artery systems arising from it. The right coronary artery was found to contain a significant flow-limiting lesion that was successfully treated with percutaneous coronary intervention.
single coronary artery; percutaneous coronary intervention
Anomalous origination of a coronary artery can have serious, even fatal, consequences. Intravascular ultrasonography has recently provided new insights into anomalous coronary artery origination from the opposite sinus of Valsalva. On the basis of these insights, we describe 3 typical forms of this anomaly with left coronary artery involvement, including clinical presentations, diagnostic methods (particularly intravascular ultrasonography), and details of surgical treatment. In this case series, the left coronary artery originated from the noncoronary sinus in 1 patient and from the right sinus in another patient. In the 3rd patient, both the left and right coronary arteries originated from the ascending aorta above the sinotubular junction. Baseline areas of stenosis ranged from 48.6% to 70.1%. Intravascular ultrasonography was the only method that enabled us to clarify the mechanisms and the severity of the anomaly. Pharmacologic challenge was useful to predict worsening that might have occurred under physiologic conditions.
We found that, in cases of symptomatic left anomalous coronary artery origination from the opposite sinus of Valsalva, the proximal segment of the left coronary artery consistently has 1) an intramural course inside the aortic wall; 2) hypoplasia, as determined by its circumference; and 3) a cross-sectional ovaloid deformity (lateral compression) with phasic and exercise-induced worsening of the deformity. With regard to surgical treatment, ostioplasty is preferable to coronary bypass.
To establish sound guidelines for managing these anomalies, a larger series should be studied prospectively with quantitative parameters and long-term follow-up.
Anomalous left coronary artery; coronary angiography; coronary artery bypass; coronary vessel anomalies/classification/diagnosis/pathology/surgery/ultrasonography; death, sudden, cardiac/prevention & control; diagnostic imaging/methods; magnetic resonance imaging; myocardial ischemia/mechanism
Anomalous origin of a coronary artery is rare and does not generally lead to myocardial infarction and paroxysmal supraventricular tachycardia (PSVT). We report an uncommon case of anomalous origin of the right coronary artery (RCA) originating from the left sinus of Valsalva with PSVT and myocardial ischemia. A 58-year-old man presented with PSVT. After arrhythmia subsided, electrocardiogram showed ST and T wave abnormalities, and transient cardiac enzymes were found to be elevated. Coronary CT angiography confirmed that there was anomalous origin of the RCA originating from the left sinus of Valsalva and no intracoronary stenotic lesion. He was managed with conservative treatment, having no symptoms on clinical follow-up for 4 years.
Coronary vessel anomalies; Tachycardia, paroxysmal; Myocardial ischemia; Multidetector computed tomography
Coronary artery anomalies (CAAs) are present at birth, but are usually asymptomatic and are found during coronary angiography or multi-slice computed tomography (MSCT) detection. The most common coronary anomaly is the separating origin of left anterior descending coronary artery (LAD) and left circumflex artery (LCX) from the left sinus of Valsalva, and this variant is benign. Herein, we present three extremely rare cases of anomalous right coronary artery (RCA) detected incidentally during routine coronary angiography and confirmed by multi-slice computed tomography (MSCT) technique. All the anomalous right coronary artery coursed between the pulmonary artery and aorta. We discuss how to make an accurate diagnosis for appropriate management.
coronary anomaly; anomalous right coronary artery; coronary angiography; elderly
The anomalous origin of the left circumflex coronary artery from the right sinus of Valsalva is a relatively common anatomical variation. Difficulties may occur in the diagnostic procedure, but recognition and adequate visualization of the anomaly is essential for proper patient management, especially in patients undergoing evaluation for percutaneous coronary intervention, coronary artery surgery or prosthetic valve replacement. In the present report, a patient who had undergone percutaneous coronary intervention for a right coronary artery lesion after inferior myocardial infarction is described. The anomalous origin of the left circumflex coronary artery arising independently from the right sinus of Valsalva was previously undetected.
Anomaly; Coronary arteriography; Left circumflex coronary artery; Right sinus of Valsalva
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
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
Background and Objective. Dual-source CT (DSCT) has been used to detect coronary artery anomalies. The purpose of this study was to assess the incidence of anomalous origin of the coronary artery in Chinese adults.
Methods. We summarised all patients who underwent DSCT coronary angiography (CTCA) from December 2006 to February 2008, and data of anomalous origin of the coronary artery in Chinese adults were recorded.
Results. 1879 patients underwent CTCA during that period; 24 patients with an anomalous origin of the coronary artery were detected, giving an incidence of 1.3%. Fifteen patients had an anomalous origin of the right coronary artery (12 from left coronary sinus, 3 high takeoff), eight patients had an anomalous origin of the left coronary artery (LCA from posterior sinus of Valsalva in three cases, LCX from the right coronary sinus, LCX from RCA, high takeoff, LCA from right coronary sinus, and single coronary artery in one case, respectively), and one patient had an anomalous origin of both coronary arteries (high takeoff).
Conclusion. The incidence of anomalous origin of the coronary artery in Chinese adults in this study is 1.3%. DSCT can clearly visualise the anomalous origin and course of the coronary artery and is a useful screening modality. (Neth Heart J 2010;18:466–70.)
Coronary Artery Disease; Coronary Artery Anomaly; Tomography; X-ray Computed; Angiography
The diseases responsible for sudden deaths in athletes differ considerably with regard to age. In young athletes, congenital malformations of the heart and/or vascular system cause the majority of deaths and can only be detected noninvasively by complex diagnostics. In contrast, in older athletes who die suddenly, atherosclerotic disease of the coronary arteries is mostly found. Reports of congenital coronary anomalies as a cause of sudden death in older athletes are rare.
A 48-year-old man who was a well-trained, long-distance runner collapsed at the finish of a half marathon because of a myocardial infarction with ventricular fibrillation. Coronary angiography showed an anomalous origin of the right coronary artery from the left sinus of Valsalva with minimal wall alterations. Multislice computed tomography of the coronary arteries confirmed these findings. Cardiomagnetic resonance imaging demonstrated a mild hypokinesia of the basal right- and left-ventricular posterior wall. An electrophysiological study showed an inducible temporary polymorphic ventricular tachycardia and an inducible ventricular fibrillation. The athlete was subsequently treated by acetylsalicylic acid 100 mg (0-1-0), bisoprolol 2.5 mg (1-0-0) and atorvastatin 10 mg (0-0-1) and was instructed to keep his training intensity under the 'individual anaerobic threshold'. Intense and long-lasting exercise under extreme environmental conditions, particularly heat, should also be avoided.
This case report presents a coronary anomaly as the most likely reason for an exercise-induced myocardial infarction with ventricular fibrillation in a well-trained 48-year-old endurance athlete. Therefore, coronary anomalies have also to be considered as a possible cause of cardiac problems in older athletes.
A 37 year old man presenting with acute heart failure, hypotension, and acute renal failure was diagnosed by cardiac catheterisation and angiography to have the rare combination of congenital aneurysm of the non-coronary sinus of Valsalva rupturing into the right ventricle, and an anomalous origin of the right coronary artery from the main pulmonary artery. The diagnosis could not be confirmed by transthoracic echocardiography in this patient. This combination of defects, confirmed at cardiac surgery, has not been reported before, and this case report highlights the importance of preoperative definition of congenital defects associated with an aneurysm of the sinus of Valsalva.
The cause of chest pain in patients with anomalous origin of the right coronary artery from the left sinus of Valsalva has not yet been elucidated. In the following case, this anomaly was demonstrated, upon angiography, in a patient with recurrent chest pain and a negative stress test; in addition, spasm of the left anterior descending coronary artery was documented during ergonovine provocation. To our knowledge, this is the first time coronary artery spasm has been documented in a patient with this anomaly. On the basis of this case, we recommend ergonovine testing for all angina patients with aberrant coronary arteries in whom no other cause of chest pain is found at cardiac catheterization. (Texas Heart Institute Journal 1988; 15:124-127)
Coronary vasospasm; coronary vessel anomalies; coronary circulation; angina pectoris, variant; sinus of Valsalva
A double left anterior descending (LAD) coronary artery emerging from the left and right coronary arteries is classified among rare coronary anomalies. We herein report a 73-year-old man presenting with acute coronary syndrome (posterolateral myocardial infarction). He was admitted with typical chest pain, and due to his progressive ischemic changes on electrocardiography (ECG) and elevated cardiac enzyme, he was candidated for cardiac catheterization. The coronary angiography revealed an anomalous LAD from the right sinus of Valsalva. The unusual coronary anatomy was perfectly matched with the distribution of ischemia and its clinical evidence on echocardiography and ECG. The culprit lesion was stented, and the patient was discharged in good physical condition from the hospital.
Coronary vessel anomalies; Myocardial infarction; Acute coronary syndrome
Split right coronary artery is a rare congenital anomaly. Most cases originate from the same orifice in the right sinus of Valsalva. The correct diagnosis of split right coronary artery with separate ostia is believed to be extremely rare. The true incidence of this anomaly is unknown. The main problem in diagnosis is that another ostium might be missed on selective coronary angiography. The use of multidetector computed tomography has been emphasized in the diagnosis of the anomaly. Two cases of patients with a split coronary artery arising from two separate ostia are reported; the cases were both detected by conventional coronary angiography. To avoid missing the diagnosis of this rare anomaly by conventional coronary angiography, the possibility should be kept in mind and a Judkins catheter technique may be helpful.
Conventional coronary angiography; Separate ostia; Simultaneous; Split coronary artery
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.
Coronary artery anomalies; Cardiac CT; Coronary Angiography (AC)
Coronary anomalies affect a small percentage of the general population. A solitary coronary ostium in the absence of other major congenital anomalies is very rare. We describe a case of a patient, admitted to our cardiology department with an acute myocardial infarction. A coronary angiogram shows a solitary ostium originating from the right sinus of Valsalva with the left
anterior descending coronary artery (LAD) ventral to the pulmonary artery and the circumflex artery (Cx) following its course
retroaortically. The theoretical variant of this type of malformation has been described but has not been reported in a
clinical case before. Coronary anomalies are usually detected during coronary angiography, but exact course determination and
relationships are difficult to visualize. The use of cardiac computed tomography (CCT) allows visualization of the coronary
anatomy in a 3-dimensional image and demonstrated an added value to coronary angiography.
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
Coronary artery anomalies are present at birth, but relatively few are symptomatic. The majority are discovered incidentally. In the present study, coronary angiograms performed in the authors’ centre (Ondokuz Mayis University Hospital, Samsun, Turkey) were analyzed to determine the prevalence and types of coronary artery origin and course anomalies.
Coronary angiographic data of 16,573 patients were analyzed. Anomalous origins and courses of coronary arteries were assessed.
Anomalous coronary arteries were detected in 48 (0.29%) of 16,573 patients. The origin of the circumflex (Cx) artery from the right coronary artery (RCA) or right sinus of Valsalva was the most common anomaly (28 patients [58.3%]). An anomalous RCA originating from the left anterior descending artery (LAD) or Cx artery was observed in six patients (12.5%). The left coronary artery originated from the right sinus of Valsalva in five patients, and the LAD originated from the RCA or the right sinus of Valsalva in five patients. The RCA originated from the left sinus of Valsalva in three patients and from an ectopic ostium in the ascending aorta in one patient.
The most frequent anomaly observed in the present study was related to the Cx artery, which is consistent with previous reports. Although coronary artery anomalies are rare, they may cause difficulties during coronary interventions or cardiac surgery and may occasionally result in sudden cardiac death. Therefore, the recognition and diagnosis of these anomalies is important and requires specialization in coronary angiographic techniques and other imaging modalities.
Coronary angiography; Coronary artery anomaly; Sinus of Valsalva
Coronary artery anomalies are a rare type of congenital anomalies with an incidence of 1.3% during routine cardiac catheterization. Anomalous origin of the coronary arteries is considered an incidental finding without clinical significance. This case describes a patient in whom evaluation of chest pain revealed an obstructive left anterior descending artery as well as an anomalous right coronary artery arising from the left coronary sinus. The patient underwent successful percutaneous coronary intervention of the left anterior descending artery and was discharged home free of angina 3 days later.
Anomalous Right Coronary Artery; Obstructive Left Anterior Descending Artery; Percutaneous Coronary Intervention