Anomalous left coronary artery from pulmonary artery with an intramural and inter-arterial course.

Surgical Treatment of Anomalous Aortic Origin of Coronary Arteries: The Reimplantation Technique and Its Modifications

Multimodal Imaging of an Incidental Anomalous Coronary Artery

An aberrant origin of the left main coronary artery (LM) or left anterior descending coronary artery (LAD) from the right sinus of Valsalva is a rare anomaly that has been associated with myocardial ischemia and sudden cardiac death. Depending on the anatomic relationship of the anomalous vessel to the aorta and the pulmonary trunk, the anomaly can be classified into 4 common courses: posterior, interarterial, anterior, and septal course. Contrast-enhanced electron beam tomography (EBT) has been shown to permit classification of anomalous coronary arteries. We present 4 cases that illustrate the common variations of this anomaly. In all cases, EBT was performed using a C-150 XP EBT scanner (Imatron Inc). During inspiratory breathhold, 40 to 50 axial cross-sections of the heart were acquired triggered to the ECG at 40% of the R-R interval (100 ms acquisition time, slice thickness 3 mm, table feed 2 mm, intravenous injection of 160 mL contrast agent …

Expert consensus guidelines: Anomalous aortic origin of a coronary artery

Surgical Unroofing for Anomalous Aortic Origin of Coronary Arteries

Left coronary artery from the right coronary sinus: What can CT angiography tell us?

Current surgical management of anomalous aortic origin of a coronary artery

Sudden unexpected cardiac deaths in approximately 20% of young athletes are due to acquired or congenital coronary artery abnormalities. Kawasaki disease is the leading cause for acquired coronary artery abnormalities, which can cause late coronary artery sequelae including aneurysms, stenosis, and thrombosis, leading to myocardial ischaemia and ventricular fibrillation. Patients with anomalous left coronary artery from the pulmonary artery can develop adequate collateral circulation from the right coronary artery in the newborn period, which remains asymptomatic only to manifest in adulthood with myocardial ischaemia, ventricular arrhythmias, and sudden death. Anomalous origin of coronary artery from the opposite sinus occurs in 0.7% of the young general population aged between 11 and 15 years. If the anomalous coronary artery courses between the pulmonary artery and the aorta, sudden cardiac death may occur during or shortly after vigorous exercise, especially in patients where the anomalous left coronary artery originates from the right sinus of Valsalva. Symptomatic patients with evidence of ischaemia should have surgical correction. No treatment is needed for asymptomatic patients with an anomalous right coronary artery from the left sinus of Valsalva. At present, there is no consensus regarding how to manage asymptomatic patients with anomalous left coronary artery from the right sinus of Valsalva and interarterial course. Myocardial bridging is commonly observed in cardiac catheterisation and it rarely causes exercise-induced coronary syndrome or cardiac death. In symptomatic patients, refractory or β-blocker treatment and surgical un-bridging may be considered.

Anomalous left coronary artery from the pulmonary artery is a rare CHD. It is the most common type of anomalous coronary origin. It may cause myocardial ischaemia or infarction, mitral regurgitation, congestive heart failure, and early death in infancy if left untreated. Surgery is the only treatment for anomalous left coronary artery from the pulmonary artery. In recent years, with advancements in surgical techniques and the widespread utilisation of extracorporeal cardiac assist devices such as extracorporeal membrane oxygenation, the treatment outcomes for anomalous left coronary artery from the pulmonary artery have demonstrated significant improvements. However, the surgical indications and methods of anomalous left coronary artery from the pulmonary artery, especially the surgical methods of anomalous left coronary artery from the pulmonary artery with intramural coronary artery, and whether to treat mitral regurgitation at the same time are still controversial. The long-term complications and prognosis remain discouraging simultaneously, with significant variations in outcomes across different centres. The present review specifically addresses these aforementioned concerns. Based on the literature published at home and abroad, we found that no matter what type of anomalous left coronary artery from the pulmonary artery patients, even asymptomatic patients, regardless of the collateral circulation between the left and right coronary arteries, should immediately undergo surgical treatment to promote the recovery of left ventricular function. Based on different coronary artery anatomical morphology and preoperative cardiac function, the long-term follow-up results of individualised surgical treatment of anomalous left coronary artery from the pulmonary artery children show good prognosis, and most children have significant improvement in cardiac function. Patients with moderate to severe mitral regurgitation should undergo mitral valve operation at the same time as anomalous left coronary artery from the pulmonary artery repair. Mitral valvuloplasty can quickly improve mitral regurgitation and promote the early recovery of cardiac function after operation, and does not increase the risk of operation. Mechanical circulatory support is a safe and effective means of early postoperative transition for children with severe anomalous left coronary artery from the pulmonary artery. Anomalous left coronary artery from the pulmonary artery with intramural coronary artery is a rare anomaly. According to different anatomical types, different surgical methods can be used for anatomical correction, and satisfactory early and mid-term results can be obtained.

The left coronary artery from the right sinus of Valsalva represents an incidence of 0.017% of angiographic series and 1.3% of total coronary anomalies of angiographic series. The anomalous left coronary artery arising from the right sinus of Valsalva may take either a septal, anterior, interarterial or posterior course. Sudden death is thought to result from transient occlusion of anomalous left coronary artery, particulary when the anomalous artery passes between the aorta and the pulmonary trunk. The left coronary artery from the right sinus of Valsalva with posterior course are thought to be benign anomalies, although rarely myocardial ischemia may occur. A 69-year old woman died suddenly at rest. Coronary angiography revealed that anomalous left coronary artery origin from right sinus of Valsalva without any significant stenotic lesion, the anomalous left coronary artery passed posterior to the aorta. We report the patient with anomalous origined left coronary artery and its course posterior to aorta associated with the sudden death. (Korean Circulation J 2000;30(12):1578-1582)

Background and aims Anomalous origin of a coronary artery (AOCA) from the inappropriate sinus of Valsalva or from the pulmonary artery is increasingly diagnosed with current imaging techniques. Although most AOCA subtypes are benign, they can rarely cause sudden cardiac death (SCD). The aim of the study was to describe the clinical and pathological features of AOCA in SCD victims. Methods We reviewed a database of 5100 consecutive cases of SCDs referred to our specialist cardiac pathology centre between 1994 and March 2017 and identified a subgroup of 30 (0.6%) cases with AOCA. All cases underwent detailed post-mortem evaluation including histological analysis by an expert cardiac pathologist. Clinical information was obtained from referring coroners. Results The mean age was 28±16 years and 23 individuals were males (77%). In 8 (27%) cases SCD occurred before 18 years of age. Cardiac symptoms were present in 11 (37%) individuals and syncope was the most common (n=6, 20%). The mean heart weight was 367±115 g. The most common anomalies were anomalous left coronary artery arising from the right sinus of Valsalva (ALCA) with inter-arterial course (n=11) and anomalous right coronary artery arising from the left sinus of Valsalva (ARCA) with inter-arterial course (n=11). Anomalous left coronary artery arising from pulmonary artery (ALCAPA) was present in 7 cases, while in 1 case the LCA arose from the non-coronaric cusp. Death occurred during exercise in 14 (47%) cases. The AOCA variant where death occurred more frequently during physical activity was ALCA (7/11, 64%), followed by ALCAPA (4/7, 57%) and ARCA (2/11, 18%). Conclusions AOCA is a rare cause of SCD. Anomalous left or right coronary artery arising from the wrong sinus of Valsalva with inter-arterial course is the most common anatomical variant recognised at the post-mortem of SCD victims. While in ALCA death is commonly associated with exercise, in ARCA death occurs usually during rest or sleep.

Introduction Coronary artery anomalies (CAA) are congenital anomalies affecting the origin, course, structure, or number of coronary arteries; certain high-risk configurations, particularly those involving interarterial or intramural segments, can predispose individuals to ischemia, arrhythmias, or sudden cardiac death (SCD). Populations at particular risk include young athletes and individuals with anomalies exhibiting interarterial or intramural courses. This study aimed to characterize the prevalence, imaging features, management strategies, and outcomes of CAAs, including rare variants such as anomalous left coronary artery from the pulmonary artery (ALCAPA), and interarterial left main in a single tertiary care center cohort. Methods We retrospectively analyzed 8,000 patients who underwent coronary angiography between January 2012 and December 2021 and identified 133 patients with CAAs. Diagnostic modalities included invasive coronary angiography (CAG)for typical ischemic or acute presentations and coronary CT angiography (CTA) for atypical or lower-risk cases; MRI was unavailable. Demographic data, clinical features, anomaly subtypes, and management strategies [medical therapy, percutaneous coronary intervention (PCI), or surgery] were documented. Outcomes at a median 36-month follow-up included symptom resolution and adverse events clearly defined as myocardial infarction (Fourth Universal Definition), revascularization [PCI/coronary artery bypass grafting (CABG) for stenosis >60%], and cardiac death. Results A total of 133 patients (mean age: 52.3 ± 10.5 years; 62% male) were included. Chest pain (60%) was the most common symptom, with 10% asymptomatic. The most frequent anomalies were classified asbenign variants, including anomalous right coronary artery (RCA)from the left sinus (37.6%) and left circumflex artery (LCx) from the right sinus (30.1%).Malignant variantsincluded five cases of ALCAPA (3.8%), two interarterial left main origins (1.5%), and two single coronary artery cases (1.5%). One patient with an interarterial left main died of SCD during follow-up. Other less common forms (e.g., high takeoff, fistulas, significant myocardial bridging) were grouped under "Other" (7.5%). Significant concomitant coronary artery disease (CAD) (>50% stenosis) was present in 17.5%. Management strategies included medical therapy (60%), PCI (22.5%), and surgical correction (17.5%). Symptom resolution occurred in 70% of medically treated, 80% of PCI-treated, and 100% of surgically treated patients. Adverse events (overall 10%) - defined as myocardial infarction, revascularization, or cardiac death - occurred in 5% of the medical group, 8.9% of PCI, and 4.3% of surgical cases. Outcome data for rare variants were limited due to low sample size, but suggest higher risk with malignant anatomies. Conclusions Anomalous coronary arteries show wide clinical variability; high-risk types like interarterial left main and ALCAPA warrant careful follow-up. While most patients achieve good outcomes, SCD in one case in our cohort highlights the need for timely intervention. Current challenges include limited awareness, lack of standardized screening, inconsistent risk assessment, and absence of personalized treatment protocols. Advancements in imaging, genetics, and artificial intelligence (AI)-driven risk models may enhance early detection and tailored management of CAAs.

Despite its fame in the news, the city of Tehran has not often been discussed in the international literature of urban studies. Today, Tehran is one of the largest metropolitan areas of the world, ranking the second place in the Middle East after Cairo. Tehran city’s population, excluding its satellite towns, is estimated to be 8 million. With its current rate of population growth and urban development, in about 20 years it will become the fifth most populated city in the world. During the last three decades, Iranian architects and urban planners have published a significant level of researches in Iran and abroad about the urban history of Tehran, but unfortunately most of these publications and papers have been written in Farsi. Non-Farsi speaking urban planners who were interested in Tehran’s urban history were limited to a small number of Anglo-American, French and German publications. 
\n The concern of this thesis is look at the little-known outer-city of Tehran to understand the transformation of Tehran’s outskirt’s into different kind of suburbs. 
\n During the last century, many transformations and reforms have occurred in Tehran, one of the most important of which has been the change in suburbs of the city. During the last century, the population which lived in the outskirts has increased rapidly and there was also an increase in the number of new peripheral towns. 
\nThis paper presents the historical evaluation and development of Tehran’s suburbs during four historical eras. The periods are: 
\n•\tThe period of Qajars (until 1920), 
\n•\tthe period of Reza Shah (1920-1940) 
\n•\tMohammad Reza Shah (1946-1979) 
\n•\tPost-revolution era (the period after the 1979's revolution). 
\nTherefore we will have a look at some of the famous urban projects during these periods to understand the scale and structure of sub-urbanity.

An anomalous coronary artery from the opposite sinus of Valsalva may increase sudden death risk in children and young adults, and surgical intervention is often recommended. The impact of this lesion when recognized in the adult and its management are ill defined. We reviewed 210 700 cardiac catheterizations performed over a 35-year period at a single institution and identified 301 adults with an anomalous coronary artery from the opposite sinus of Valsalva, either anomalous right coronary artery from the left cusp or anomalous left main coronary artery from the right cusp. Patients were stratified by the pathway of the anomalous artery and the chosen treatment. Among the 301 patients with anomalous coronary artery from the opposite sinus of Valsalva (0.14% of the cohort), 79% had anomalous right coronary artery from the left cusp, and 18% had an interarterial course (IAC). Patients with IAC were younger (52±13 versus 59±13 years; P=0.001) and more likely to undergo surgical intervention (52% versus 27%; P<0.001), but mortality was not increased with IAC. Among the 54 patients with IAC, 28 underwent surgical repair with no perioperative deaths. Patients evaluated since 2000 were significantly more likely to be referred for surgery (P=0.004). Surgical patients were more likely to have abnormal stress tests (90% versus 43%; P=0.01) and had more extensive atherosclerosis but less diabetes mellitus (0% versus 23%; P=0.01). Long-term survival at 10 years appeared similar in both groups. In this single-center cohort study of patients with an anomalous coronary artery from the opposite sinus of Valsalva, surgical management appears to have been favored recently. Despite no perioperative mortality, a positive impact on long-term survival was not observed. The impact of surgery in older adults with anomalous coronary arteries arising from the opposite coronary sinus with IAC deserves further study.

Sudden Cardiac Arrest on the Treadmill