HIDDEN DANGER: A RARE ANOMALOUS CORONARY ARTERY

Abstract

SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Anomalous aortic origin of a coronary artery (AAOCA) in the general population is quite rare. Generally, they are typically seen in 1-2% of the population that undergo coronary angiography. Although overall rare, these anomalies have a risk of sudden cardiac death (SCD), which is largely unknown, so it is important to properly evaluate them if seen in practice. CASE PRESENTATION: The patient is a 75-year-old woman with a past medical history of severe aortic stenosis who presented for a left heart cardiac catheterization prior to planned aortic valve replacement. Subsequent catheterization revealed evidence of an anomalous right coronary artery as seen in Figure 1. Consequently, coronary computed tomography (CT) was advised to further delineate the anatomy prior to aortic valve replacement in order to mitigate risks of surgery. The CT determined that this anomalous right coronary artery coursed in between the pulmonary artery and the aorta. A heart team discussion was started about performing a transcatheter aortic valve replacement (TAVR) versus a surgical aortic valve replacement. The patient was deemed a high risk due to the anomalous course of the right coronary artery and was subsequently sent for a single vessel bypass with a saphenous vein graft (SVG) to the distal RCA and a surgical aortic valve replacement. DISCUSSION: Overall, there is no typical way that patients present with AAOCA. Most are found incidentally on an echocardiogram or computed tomography (CT) angiogram that is performed for another reason, such as a heart murmur. The best method to identify AAOCA is a transthoracic echocardiogram with doppler color flow mapping due to availability, cost-effectiveness, and lack of radiation exposure as compared to coronary angiography. If needed, coronary CT angiography or cardiac MRI can be used to obtain better visualization of the coronary artery anatomy to confirm the diagnosis. For our patient, due to the high risk location, the heart team recommended a coronary artery bypass graft (CABG) along with a surgical aortic valve replacement. TAVR is typically chosen over surgical aortic valve replacement due to comparable outcomes with the benefit of TAVR not requiring open heart surgery. However, CABG requires an open heart surgery, so it was agreed that surgical aortic valve replacement would result in better outcomes since the patient requires an invasive surgery either way. CONCLUSIONS: This case highlights the importance of delineating the anatomy prior to going to percutaneous valve replacement in the setting of anomalous coronary arteries. Surgical intervention is recommended for those with signs of myocardial ischemia, but intervention in asymptomatic patients depends on interarterial course. AAOCA with an intramural course is associated with SCD due to ischemia and arrhythmias, so it is important to choose the correct surgical approach. Reference #1: Angelini, P. (2007). Coronary Artery Anomalies. Circulation, 115(10), 1296-1305. doi:10.1161/circulationaha.106.618082 Reference #2: Brothers, J. A., Frommelt, M. A., Jaquiss, R. D., Myerburg, R. J., Fraser, C. D., & Tweddell, J. S. (2017). Expert consensus guidelines: Anomalous aortic origin of a coronary artery. The Journal of Thoracic and Cardiovascular Surgery, 153(6), 1440-1457. doi:10.1016/j.jtcvs.2016.06.066 DISCLOSURES: No relevant relationships by Akash Patel, source=Web Response No relevant relationships by Sagar Patel, source=Web Response