Invited Commentary

Abstract

Anomalous origin of a coronary artery from the contralateral sinus of Valsalva is associated with sudden death in young athletes. Mechanisms of exercise induced ischemia include; an abnormal slitlike coronary ostial origin and compression of the intramural portion of the coronary artery. Surgical unroofing of the intramural portion of the anomalous coronary removes the likely anatomic causes of ischemia. Although low risk in comparison to other commonly performed congenital, heart surgery is still a major surgical procedure with a definable morbidity and mortality. Surgery is indicated for patients with an anomalous coronary and evidence of ischemia, but the management of the asymptomatic patient remains controversial. Compounding this problem, in recent years an increasing number of asymptomatic patients are being identified. Risk stratification and management of the asymptomatic individual is challenging. Many patients are submitted for surgery despite the fact that the risks of surgical intervention outweigh the benefits. Others are given arbitrary activity restrictions that can affect their social development and quality of life while not substantially lowering their risk of sudden death. In this study, Harris and colleagues [1Harris M.A. Whitehead K.K. Shin D.C. Keller M.S. Weinberg P.M. Fogel M.A. Identifying abnormal ostial morphology in anomalous aortic origin of a coronary artery.Ann Thorac Surg. 2015; 100: 174-180Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar] from the Children’s Hospital of Philadelphia used virtual angioscopy, reconstructed images from three-dimensional cardiac magnetic resonance imaging studies, to characterize the origins of these abnormal coronary arteries. They identified elliptical as opposed to circular coronary origins in all patients with anomalous origin of the coronary artery. Although it is not surprising that a coronary artery with acute angulation at the origin would have an elliptical shape, studies such as this are important in attempting to quantify the abnormal origin. Ultimately, improved noninvasive imaging of this kind will result in better characterization of the anatomy of anomalous coronary artery origin, with the goal of identifying the asymptomatic patient who is at increased risk of sudden death and therefore a candidate for prophylactic surgical intervention. Identifying Abnormal Ostial Morphology in Anomalous Aortic Origin of a Coronary ArteryThe Annals of Thoracic SurgeryVol. 100Issue 1PreviewAnomalous origin of a coronary artery from the contralateral sinus of Valsalva is associated with exercise-induced ischemia and sudden death. That is thought to be due to aortic enlargement in patients with an elliptical ostium. We hypothesize that virtual angioscopy can identify abnormal coronary ostial morphology in these patients. Full-Text PDF