Aberrant Right Coronary Artery Research Articles

253 EXCERCISE-INDUCED PULMONARY HYPERTENSION AND CORONARY ARTERY ANOMALY: AN UNUSUAL ASSOCIATION

Abstract A healthy 55-year-old competitive sportsman, with familial history of early sudden cardiac death, came to our attention following the finding of asymptomatic exercise-induced myocardial ischemia (ST depression in V3- V6). Computed tomography (CT) coronary angiogram excluded atherosclerotic disease but showed a dominant right coronary artery (RCA) originating from left Valsalva sinus and with an interarterial course between the ascending aorta and the pulmonary artery. Both the trunk of the pulmonary artery and the right ventricle were reported as mildly dilated Transthoracic echocardiography showed a normal left ventricle (LV), while confirmed right ventricle (RV) dilatation, moderate tricuspid regurgitation (TR) and interatrial septal aneurysm. Stress echocardiography excluded inducible ischemia, but highlighted exercise-induced pulmonary hypertension (PH) (PAPs 25 → 70 mmHg), while a transesophageal echo confirmed a left-to-right shunt due to a 8-mm Patent Foramen Ovale (PFO). Rheumatological, thromboembolic and parenchymal lung diseases were excluded as possible causes of exercise-induced PH; a rest right heart catheterization (RHC) showed a Qp/Qs ratio at the upper limits of normal range without PH. Nuclear stress testing identified trivial asymptomatic septal ischemia. The patients started medium dose of beta-blockers and early follow-up was planned. This clinical case raises some questions: why is RV dilated? What role does PFO play? What is the cause of the inducible ischemia? What is the pathogenesis of exercise-induced PH? Pulmonary Arterial Hypertension, in early stages, often manifests only under exertion, but it is usually characterized by exercise dyspnea and low oxygen saturation. Moreover, intracardiac shunts may be involved in developing PH. In this specific case, pulmonary trunk may be expanded by pressure overload, causing the compression of aberrant RCA and consequent ischemic abnormalities. RV dilatation might be explained by exercise-induced PH itself, but it was not severe and has to be demonstrated by exercise right heart catheterization. The main questions are: which is the primary etiology of right chamber enlargement and myocardial ischemia? Which is the most appropriate therapeutic approach (i.e. conservative vs interventional)?

Surgical management and long-term follow-up of aberrant right coronary arteries in adults.

Anomalous origins of the right coronary artery (RCA) can cause ischaemia and sudden cardiac death, particularly if the RCA runs between the aorta and pulmonary artery. Conventional coronary artery bypass grafting (CABG) can be affected by early graft failure due to collateral blood flow. We present our institutional experience in managing patients with RCA anomalies. A single-center retrospective review of all patients who underwent surgery for aberrant right coronary arteries between 2005 and 2021 was conducted and in-hospital and long-term outcomes were analysed at our institution. A total of 10 patients (5 females, median age: 51 years, 36-62) were identified. They presented with symptoms of chest pain (n = 8), dyspnoea (n = 1) or following cardiac arrest (n = 1). In the majority the RCA originated from the left coronary sinus (n = 9). In one of those patients and one in whom the RCA originated directly from the left anterior descending artery CABG was performed. The other 8 patients were treated using transfer of the RCA ostium. All patients were discharged home (median hospital stay 5 days, range: 4-10). Four patients experienced post-op atrial fibrillation. No other complications were observed. At a median follow-up of 10 years and 9 months, 9 patients were alive and free from cardiac symptoms. One patient died 3 years postsurgery due to liver failure, unrelated to cardiac disease. In patients with an aberrant RCA, transfer of the ostium into the RCS carries a low surgical risk. It overcomes early graft failure in these patients, who present with a dynamic impairment in RCA blood flow. However, if fixed proximal RCA flow-limiting pathology exists, conventional bypass surgery is feasible.

A case of stent thrombosis presenting as acute myocardial infarction related to right coronary artery originating from the left coronary system

Right coronary artery (RCA) originating from the left coronary system is a subtype of single coronary artery (SCA) anomaly, and the origin of RCA as a branch from the left anterior descending artery (LAD) is a very rare variant. A 55-year-old male who had a percutaneous coronary intervention (PCI) history was hospitalized due to acute coronary syndrome. Coronary angiography revealed an aberrant RCA originating from the mid-LAD as well as stent thrombosis. A successful PCI was performed and he was discharged from the hospital three days after the PCI. It is known that there is an increased incidence of atherosclerosis and stent thrombosis in coronary anomaly patients. Therefore, interventional cardiologists should consider the most suitable PCI strategy before stenting and avoid complex techniques.

Surgical treatment of aberrant aortic origin of coronary arteries.

Aberrant origin of the coronary arteries is rare but can be life threatening. It is an important cause of sudden death in athletes and other young adults, and may be treated surgically. Consensus exists that interarterial left coronary artery (LCA) should be surgically repaired. For interarterial right coronary artery (RCA), the discussion remains open. The purpose of this study was to analyse our surgical experience. From 2001 until 2014, 31 patients were operated for interarterial RCA, interarterial LCA or intraseptal course of the LCA. Twenty-six patients had interarterial RCA, 4 patients interarterial LCA and 1 patient an intraseptal course of the LCA. Median age at operation was 38 years (range 9-66 years). Twenty-eight patients had previous or current symptoms. The most important were a life-threatening event with resuscitation in 3 and myocardial infarction in 3 others. Surgical repair of interarterial RCA consisted of unroofing of the ostium with or without reimplantation in 25 patients and CABG on the RCA with a venous graft in 1 patient. Reconstruction of interarterial LCA consisted of ostium reconstruction of the LCA with a venous patch in 4 patients. The patient with an intraseptal course had a complete release of the LCA out of the septum and reimplantation in the correct coronary sinus. Follow-up was done by analysis of outpatient records, direct patient contact, echocardiography, electrocardiography, CT-angiography and an exercise test. Median follow-up was 6 years (range 0-11 years). One patient was lost to follow-up. No early or late mortality occurred. Three patients had ischaemia with ventricular fibrillation or ventricular tachycardia shortly after surgery. Two were immediately reoperated, 1 had a stent implantation 1.5 months after release of intraseptal LCA. Two of these patients show a slight dysfunction of the left ventricle at follow-up. All other patients are asymptomatic. Surgery for aberrant origin of coronary arteries is safe. There is a risk of cardiac ischaemia shortly after operation, especially in LCA reconstruction. We strongly believe that a slit-like coronary ostium and an intramural aortic course is an absolute indication for surgical repair, also in asymptomatic aberrant RCA.

One coronary artery, three abnormalities

A 57-year-old man with atypical chest pain was referred for computed tomography coronary angiography (CTCA) (256 slice, Philips Brilliance iCT). CTCA showed three distinct abnormalities in the right coronary artery (RCA). First, the RCA had an anomalous origin from the ascending aorta, 3 cm distal to the right coronary sinus, with a proximal inter-arterial course between aorta and pulmonary trunk (Fig. 1, Panel a). Second, the proximal RCA was occluded by calcified atherosclerotic plaque (Panel B, black arrow). Third, distal of the occlusion, a thrombosed aneurysm (29 × 27 mm) was found (Panel B, white arrow). Invasive coronary angiography confirmed proximal occlusion of the aberrant RCA (Panel C) with collateral retrograde filling from the circumflex coronary artery. Additional adenosine stress first pass magnetic resonance myocardial perfusion imaging showed a reversible myocardial perfusion defect in the inferoseptal and inferior wall (Panel D). The patient received optimal medical therapy. This case illustrates how CTCA can visualise different features of coronary artery disease. Fig. 1 Panel a and b: Computed tomography coronary angiography images (a: axial orientation at the level of bifurcation of pulmonary trunk; b: Curved multiplanar reconstruction of anomalous right coronary artery); Panel c: Invasive coronary angiography image ...

A young adult case of ventricular fibrillation (VF) due to aberrant right coronary artery from the left sinus of Valsalva illustratively the importance of syncope as past history

冠動脈起始異常は，生来健康な若年者に突然発症することが多いので，突然死の前に医療機関を受診することは少なく，たとえ受診したとしても無症状時の一般的な心電図や心臓超音波検査などで所見が得られにくい。これらの理由から本症が心停止前に診断されることは稀である。今回我々が経験した症例は，生来健康な22歳男性でバスケットボールのクラブ活動中に発症，心肺停止で搬送された。剖検で右冠動脈起始異常が確認され，死因として疑われた。本症例は既往に2回の失神があった。失神は救急外来では比較的頻度の高い症候であるが，受診時に本症のような致死的な原因を鑑別することは必ずしも容易ではない。若年者とくにスポーツ愛好者の反復する失神は，本症を積極的に疑い，マルチスライスCTを行うことで心停止前に本症が診断でき，若年者の突然死が予防できる可能性が示唆された。