Aberrant Coronary Artery Research Articles

Transesophageal echocardiography to diagnose anomalous right coronary artery type R2A in dogs

ObjectivesTo assess the feasibility of transesophageal echocardiography (TEE) as an alternative to angiography for the diagnosis of R2A coronary artery (CA) abnormalities. AnimalsTwenty-two dogs with a diagnosis of type R2A CA anomaly were reviewed/analyzed. MethodsA retrospective study of case records. Transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), angiography, and follow-up investigations of pulmonic stenosis (PS) with R2A CA were carried out to compare different diagnostic methods. ResultsBased on the TTE morphology, PS with an aberrant CA was suspected in all dogs (n = 22) and later confirmed by angiography in 18 cases (18/22), and necropsy in two cases (2/22). In 12 cases (12/22), TEE and angiography were both performed and confirmed the diagnosis of an R2A anomaly. Two cases (2/22) were diagnosed only with TEE. ConclusionsTransesophageal echocardiography may be considered an effective tool to diagnose CA abnormalities, in particular when TTE is inconclusive. Transesophageal echocardiography offers detailed and easily reproducible views of coronary ostia, and the spatial relationship between the right common CA and the great arteries. Although it is not possible to define the course of the more distal coronary branches, TEE has proven reliable in recognizing those elements that can constitute a risk for the execution of a balloon valvuloplasty (BV). Therefore, TEE can be used to confirm this type of CA anomaly and prevent a BV, which is contraindicated in these cases. In addition, TEE avoids any further vascular access, radiation exposure, and contrast medium injection.

Aberrant serum polyunsaturated fatty acids profile is relevant with acute coronary syndrome.

Although a robust relationship between aberrant serum polyunsaturated fatty acids (PUFAs) profile and coronary artery disease (CAD) has been reported, the details concerning the association between aberrant PUFAs profile and clinical feature of CAD are not fully discovered. Therefore, we investigated the relationship between serum PUFAs and clinical profiles in CAD patients. We classified 595 consecutive CAD patients, who underwent coronary angiography into 3 groups according to the clinical profiles of CAD (group A: early phase ACS, n=96; group B: stable CAD with previous history of ACS, n=259; group C: stable CAD without previous history of ACS, n=240) and measured serum n-3 [eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA)] and n-6 [arachidonic acid (AA)] PUFAs. Serum EPA, DHA, and EPA/AA ratio were significantly low in the order of group A<B<C [EPA; 48.1 (34.1-60.3) μg/ml, 61.7 (41.2-94.5) μg/ml, and 74.4 (52.7-104.9) μg/ml, DHA; 113.1 (92.8-135.1) μg/ml, 125.8 (100.4-167.2) μg/ml, and 140.1 (114.7-177.0) μg/ml, EPA/AA ratio; 0.31 (0.22-0.45), 0.39 (0.26-0.62), and 0.44 (0.31-0.69), medians with interquartile range, p<0.01]. Multiple regression analysis revealed that EPA (p=0.009) and EPA/AA ratio (p=0.023), but not DHA and DHA/AA ratio, were negatively associated with clinical profiles of ACS in CAD patients. Significant correlation was not observed between PUFAs profile and severity of coronary stenosis. Low serum EPA and EPA/AA ratio correlates with clinical profiles of ACS in patients with CAD, regardless of the extent and severity of coronary artery stenosis.

Clinical Case Session I: Sunday 3 May 2015, 10:00-11:00 * Room: Venecia

Clinical Case Session I: Sunday 3 May 2015, 10:00-11:00 * Room: Venecia

Successful Percutaneous Coronary Intervention of a Stenotic Aberrant Circumflex Artery: A Rare Cause of Acute Coronary Syndrome

Successful Percutaneous Coronary Intervention of a Stenotic Aberrant Circumflex Artery: A Rare Cause of Acute Coronary Syndrome Most coronary artery origin abnormalities are incidentally determined during coronary angiography. However, some cases of coronary artery abnormalities are related to severe life-threatening events such as myocardial ischemia, arrhythmia and acute myocardial infarction. A 55-years-old male was hospitalized due to acute coronary syndrome. Coronary angiography reveal that aberrant circumflex coronary artery (Cx) originated from right aortic sinus and with proximal and distal Cx severe stenosis. Coronary intervention was successfully carried out on a severe stenosis at the proximal and distal Cx artery. Determination of the anomalous origin of the coronary artery and the cardiovascular system is of great clinical importance due to its severe life-threatening complications. Cardiologists should be aware of the possibility aberrant coronaries may be cause of acute coronary syndrome.

Coronary artery imaging in children.

Coronary artery problems in children usually have a significant impact on both short-term and long-term outcomes. Early and accurate diagnosis, therefore, is crucial but technically challenging due to the small size of the coronary artery, high heart rates, and limited cooperation of children. Coronary artery visibility on CT and MRI in children is considerably improved with recent technical advancements. Consequently, CT and MRI are increasingly used for evaluating various congenital and acquired coronary artery abnormalities in children, such as coronary artery anomalies, aberrant coronary artery anatomy specific to congenital heart disease, Kawasaki disease, Williams syndrome, and cardiac allograft vasculopathy.

Computed tomography coronary angiography should be performed in all patients with Marfan Syndrome prior to aortic root replacement

Dear Editor,Aortic dissection is the most common cause of death in the naturalhistory of patients with Marfan Syndrome [1]. To prevent death due toacute aortic dissection, indications for aortic root replacement are muchless restrictive in patients with Marfan Syndrome, compared to the gen-eral population [2,3]. The number of young Marfan patients undergoingaortic root surgery is steadily increasing [4]. With increasing numbers ofpatients in the operating theater comes an increasing prevalence ofperi-operative complications.In our clinic, three patients with Marfan Syndrome who had toundergo aortic root replacement were diagnosed with an aberrantcoronary artery, of whom only one pre-operatively. All three patientsunderwent aortic root replacement for progressive aortic root dilata-tion;withamaximumdiameterof50mm.Noneofthepatientsexperi-encedanycardiaccomplaints.Atthetimeofsurgery,twopatientswereon β-blockade, oneincombination withanangiotensin II (AT II)recep-tor blocker, and one patient was not on any medication, as β-blockadewas poorly tolerated, and the beneficial effects of ACE inhibitors andAT II receptor blockers had not yet been proven at the time. In allthree patients the ramus circumflexus (RCX) was found to arise fromthe right coronary artery (RCA).In patient A (male, 28 years old, surgery in 2008), the aberrantcoronary artery was diagnosed on transesophageal echocardiographyintheoperatingtheaterunderanesthesia(Fig.1A).Surgerywasabortedto perform computed tomography (CT) coronary angiography, afterwhichasuccessfulDavidprocedurewasperformed.Thebuttonholdingboth the RCA and the RCX was re-implanted in the commissurebetween the right- and the non-coronary cusps without complication.In patient B (female, 43 years old, surgery in 2009), the aberrant coro-nary artery had not been diagnosed pre-operatively, and was uninten-tionally sliced during surgical dissection of the right coronary button.Fortunately, the RCX could successfully be re-implanted at the locationof the non-coronary cusp. In retrospect, pre-operative transesophagealechocardiographydidrevealtheaberrantRCX,buthadbeenoverlooked(Fig. 1B). To prevent such major complications during future surgery,we introduced CT coronary angiography in all Marfan patients prior toaortic surgery. Therefore, in patient C (male, 31 years old, surgery in2013),anaberrant RCX arisingfromthe RCAwasfound on CT coronaryangiographypriortosurgery(Fig.2).Inthispatient,aorticrootreplace-mentwassuccessfullyperformed,withre-implantationofthecoronaryarteries.In the general population, about 1.1% of individuals have an aberrantcoronary artery [5]. These numbers could somewhat underestimate thereal prevalence, as malign coronary anatomy may result in suddencardiac death prior to diagnosis. Our population consisted of 54 patientswho underwent surgery between 2003 and 2013, in which threepatients (5.6%, CI 95% −0.6% to 11.8%) were diagnosed with an aberrantcoronary artery. This higher percentage could well be incidental, asabsolute patient numbers are small. Currently, no data have been pub-lishedindicatingthatpatientswithMarfanSyndromehaveahigherprev-alence of aberrant coronary anatomy. On the other hand, the chance of aMarfan patient undergoing aortic surgery during his/her lifetime is muchgreater than in the general population, increasing the relative risk to en-counter coronary anomalies in these patients.Current European guidelines recommend cardiovascularmagnetic resonance (CMR) in all Marfanpatients to evaluate the entireaorta.Moreover,ifevaluationofcoronaryarterydiseasepriortosurgeryis warranted, CT coronary angiography is recommended, as catheter

The prevalence of coronary anomalies in a single center of Korea: origination, course, and termination anomalies of aberrant coronary arteries detected by ECG-gated cardiac MDCT.

BackgroundCoronary anomalies are rare congenital abnormalities often found incidentally on conventional coronary angiography (CCA) or coronary CT angiography (CTA). They may result in various clinical outcomes. CCA is invasive and not able to demonstrate all coronary anomalies in detail, especially those with complex courses. Multidetector computed tomography (MDCT) enables visualization of the origin and course of coronary arteries. The objective of this study was to investigate the prevalence of origin and termination coronary artery anomalies and the course of these anomalies in patients in a single center in Korea.MethodsTo diagnose coronary anomalies, the angiographic data of 8,864 consecutive patients undergoing 64- or 320-MDCT from September 2005 to November 2011 were analyzed retrospectively.ResultsAmong the 8,864 patients, 103 (1.16%) had coronary anomalies. Ninety (87.4%) patients had origin and distribution anomalies, and 13 (12.6%) patients had a coronary artery fistula. The most common anomaly (41, 39.8%) was an anomalous origin of the right coronary artery (RCA). Of these, three patients received a coronary artery bypass graft.ConclusionsThe prevalence of coronary anomalies in a single center of Korea was 1.16%. The incidence and patterns of coronary artery anomalies in our patient population were similar to those of previous studies.

Bilaterally originating double left circumflex artery: what is the course of the right-sided branch?

Dear Editor, I read with interest the case by Ulucay et al. [1] regarding a patient with chest discomfort in whom angiography revealed two separate left circumflex (LCx) arteries, one arising from the left main coronary artery and the other from the ostium of the right coronary artery. The patient refused to undergo computed tomography angiography (CTA) to define the course of the right-sided LCx artery and the authors speculated that the patient’s symptoms might be due to the aberrant vessel following an interarterial course between the aortic root and pulmonary trunk. This letter draws attention to the angiographic image of the aberrant LCx artery illustrating this article, which does not favour an interarterial course, and aims to prevent confusion of the readers. As seen in a left anterior oblique caudal angiographic view, the aberrant LCx artery passes just beneath the aortic root forming a caudal-posterior loop to reach its normal position in the left atrioventricular groove. Such an angiographic picture is indeed compatible with a retroaortic course that is posterior to the aorta [2]. The characteristic caudal and posterior loop formed by the retroaortic LCx artery could also have been identified in a right anterior oblique projection while during a 30° right anterior oblique ventriculography or aortography that vessel could have been seen in profile as a radiopaque ‘dot’ posteriorly and caudally to the non-coronary aortic sinus that is the aortic root sign [2,3]. To the best of my knowledge, the only case of aberrant interarterial LCx artery ever reported in the English literature is the case by Hur et al. [4] in which a 55-year-old man underwent CTA for chest pain and was found to have an interarterial right aortic sinus-connected LCx artery that crossed beneath the proximal segment of the left anterior descending artery before reaching the left atrioventricular groove; adenosine 201-thallium myocardial scintigraphy showed no perfusion defect in the territory of the ectopic vessel. Tomographic imaging techniques such as CTA are superior to conventional coronary angiography with regard to detection of aberrant coronary artery origin and proximal course, and certainly help in reaching the right diagnosis, particularly in ambiguous cases [5]. Although intussusception of the proximal ectopic segment within the aortic wall media has been shown to be a consistent feature of the interarterial course, it has also been described in a case of right aortic sinus-connected retroaortic LCx artery [6]. Hence, in such cases, particularly when the distribution of the LCx artery to the posterolateral wall is large and/or ischaemia has been documented across the LCx artery territory by a functional test or the patient presents with typical angina in the absence of significant atherosclerotic disease, CTA can be employed to investigate the possibility of an intramural retroaortic LCx artery course. The intramural segment will be narrowed relative to the distal reference extramural segment while its cross-section will be ovoid due to lateral compression [5]. However, evaluation of the pathophysiological mechanisms leading to ischaemia and quantification of their significance can only be made with the use of intravascular ultrasound scanning [6].

Percutaneous Closure of Atrial Septal Defects in Patients with an Aberrant Retroaortic Coronary Artery: Is It Safe?

Coexistence of an ostium secundum type atrial septal defect and a coronary artery anomaly with an aberrant retroaortic course is a rare congenital anomaly that may potentially complicate percutaneous atrial septal defects (ASD) closure. If the anterosuperior rim of the defect is deficient, the abnormally located coronary artery may be compressed or distorted by the implanted device causing myocardial ischemia, arrhythmias, and eventually sudden cardiac death. Due to the potential occurrence of these fatal cardiac events, diagnosis of an aberrant coronary artery with a retroaortic course must be established before percutaneous ASD closure. In this report, two patients with this rare association are described in whom percutaneous closure of the defect was feasible and uneventful. The importance of a careful periprocedural, noninvasive echocardiographic coronary artery imaging is emphasized, and the rational for percutaneous atrial septal defect closure in this unusual anatomic arrangement is proposed.

Prognosis of anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS): 15 year experience from two large CMR centres

Background Aberrant coronary arteries represent a diverse group of congenital disorders, many of which may have no clinical significance. Post mortem studies show a high risk of exercise related sudden cardiac death in those with an anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) that takes an interarterial (anterior) course. However, there is little documentation in life of the long term natural history of anomalous coronary arteries.

A Case of Acute Thrombotic Occlusion of an Anomalous Origin of the Right Coronary Artery From the Left Coronary Sinus: Focus on the Importance of Dual-Source Computed Tomography for Failed Emergency Coronary Angiography

Coronary artery anomalies in patients undergoing coronary angiography are often technically challenging for invasive cardiologists and may delay revascularization time. We report a patient who underwent successful bailout revascularization using dual-source computed tomography after failed emergency angiography. This case emphasizes the utility of dual-source computed tomography, especially in an urgent clinical setting, for allowing interventional cardiologists to rapidly identify and effectively treat the aberrant coronary artery.

Apport du scanner multibarrettes dans la détection des anomalies de naissance des artères coronaires avec trajet inter-aortopulmonaire : à propos de deux cas et revue de la littérature

Coronary anomalies are a rare entity. The gold standard remains the coronary angiogram. However, the identification of the origin and the course of aberrant coronary arteries using angiography may be difficult. We report two cases regarding two patients who underwent coronary angiography in order to evaluate coronary heart disease. In the first case, angiography has shown a left anterior descending artery (LAD) originating from the right anterior sinus. A multidetector CT scan (MDCT) showed an inter-aortopulmonary course of the LAD. In the second case, selective catheterization of the right coronary artery could not be done. A MDCT scan was performed. An abnormal origin of the right coronary artery was detected. It originates from the left sinus with a separate ostium of the left main coronary artery. This artery had an inter-aortopulmonary course. The 64 MDCT scan can be useful as a complementary tool for the diagnosis of coronary artery anomalies. Detection of the inter-aortopulmonary course is essential, since this situation will require surgical treatment to avoid sudden cardiac death.

Ventricular Tachycardia due to Anomalous Origin of Right Coronary Artery

Coronary anomalies are observed in 0.8 to 1% of patients on angiography and about 8% of these occur in Right coronary artery (RCA). Anomalous origin of RCA from left coronary sinus (AORCALS) can cause myocardial ischemia, arrhythmia, syncope and sudden cardiac death (SCD). We report a case of AORCALS presenting as exercise induced ventricular tachycardia (VT). A 48 year old Afro-American female with no known cardiac history presented with exertional palpitations and associated atypical exertional chest pain for couple of months. Dobutamine stress echocardiogram showed normal left ventricular structure and systolic function with mild reversible inferior wall ischemia. An event monitor revealed non sustained monomorphic ventricular tachycardia (VT). Coronary angiogram revealed RCA originating from the left coronary cusp without any significant luminal stenosis. . Further evaluation of RCA course with cardiac CT angiography or MRI was recommended. She declined any further invasive testing or treatment. Age less than 30 is more frequently associated with SCD. Sudden cardiac death is more common when aberrant coronary artery is dominant. We report the first case where ANRCA presents as exercises induced ventricular tachycardia. In our patient, compression of RCA between the great vessels was suspected. Any young patient presenting with ventricular arrhythmias or angina without cardiac risk factors should be considered for coronary anomalies. Young symptomatic patients should be considered for definitive treatment to prevent SCD.

Balloon Valvuloplasty for Treatment of Pulmonic Stenosis in English Bulldogs with an Aberrant Coronary Artery—2 Years Later

Dear Editor Between 2008 and 2009 we performed conservative balloon valvuloplasty (BV) of severe pulmonic stenosis (PS) in 4 English Bulldogs (EB) with aberrant coronary artery.1 All dogs survived the procedure, but only minor reductions of pulmonary velocities were achieved, the pressure gradient (PG) reduced from a median of 168 mmHg to 131 mmHg after BV. Measuring pulmonary artery (PA) and aortic (Ao) velocity time integrals (VTI) and calculating the ratio of PA VTI to Ao VTI (PA/Ao VTI) demonstrated an improvement. Furthermore, the owners reported a subjective improvement in exercise tolerance and demeanor of their dogs. One dog (dog 2) was in congestive heart failure (CHF) at BV and did not show any improvement. This dog was euthanized 3 months after the procedure. Dog 4, which showed best pressure reduction of all dogs (>50%, from 182 before to 72 mmHg after the procedure), was re-investigated after 1, 2, and 6 months. No restenosis was detected, the PG was unchanged at 72 mmHg. However, at the revisit 6 months after BV, this dog presented in right sided CHF. The PG had reduced to 52 mmHg and the PA and Ao VTIs were both significantly reduced (P<.001). The PA/Ao VTI had increased slightly but significantly (P=.02), which might suggest restenosis of the PS, although this was masked by myocardial failure, so not apparent from serial PA velocity measurements. The dog failed to respond adequately to management of his CHF and was euthanized 1 month later due to progressive right sided CHF. Dog 1 and 3 were re-investigated after 1 month (both), 4 months (dog 1), and 6 months (dog 3), 11–12 months (both) and 24–26 months (both). At the time of writing, dog 1 has a follow up time of 35 months and dog 3 of 29 months after BV. Both dogs are doing well with no evidence of CHF and the owners feel that they have a good quality of life, exercising normally. Pulmonic velocities are consistent with severe PS in both dogs (median of 158 mmHg and 140 mmHg for dog 1 and 3, respectively). Dog 1, with longest follow-up, showed evidence of increased PA/Ao VTI 11 months after procedure. An echocardiography after 26 months showed no further progression with similar PA/Ao VTI (P=.19). Dog 3 showed a further decrease of PA/Ao VTI 6 months after BV (P=.013), which increased again at the last visit after 24 months (P=.013). Both dogs have marked right ventricular hypertrophy and are continued on atenolol. It is unclear why dog 4, which showed best reduction of PG after BV, developed CHF. This dog had moderate tricuspid regurgitation (TR), which might have contributed to development of right sided CHF as reported previously.2 However, dog 3 presented also with moderate TR and is stable at present. Unfortunately, no further EB which were eligible for BV were presented to Liverpool that the number of EB undergoing BV has not increased. The slight but significant increase of PA/Ao VTI with time in dogs 1 and 3 is of concern and might indicate re-stenosis. This and the death of dog 4 might suggest that no significant improvement with BV can be obtained in these dogs. Conversely, the follow-up times of 29 and 35 months in these dogs indicate an improvement in quality and quantity of life for a significant period of time in these dogs. However, the quality of life was a subjective assessment of the owners and these dogs might have been also stable without BV. We are still not completely discouraged; these results show that larger numbers are needed for conclusive results and that the decision for BV in dogs with severe PS and an aberrant coronary artery needs to be taken individually for each single case.

Coronary anomaly diagnosed by computed tomography coronary angiography in a patient with atypical chest pain

A 64-year-old man was evaluated for atypical chest pain that was present during transurethral prostatectomy. He had no risk factors for coronary artery disease (CAD), no prior history of ischaemic heart disease and had not experienced any symptoms of chest pain during exercise before. Computed tomography coronary angiography (CTCA) was performed to exclude CAD. CTCA (Fig. 1) showed a normal right coronary artery (RCA). An aberrant circumflex coronary artery (CX) originated from the right coronary sinus and followed a benign retro-aortic course. A small coronary artery originated from the left coronary sinus and followed an anterolateral course. An anomalous left coronary artery originated from the right coronary sinus and followed an interarterial course between the aortic root and pulmonary trunk to the left ventricular anterior myocardial wall. Nonobstructive calcified atherosclerotic plaque was observed in the proximal RCA and mid CX. These findings were confirmed by invasive coronary angiography. Fig. 1 Computed tomography coronary angiography images (Siemens Sensation 64, collimation 64 × 0.6 at 900 mAs and 120 kV). Three-dimensional reconstruction (a) and transverse images (b, c, d) showing a normal right coronary ... Exercise and rest single-photon emission computed tomography (SPECT) imaging showed normal myocardial perfusion and no significant electrocardiographic changes were observed (Fig. 2). As the patient had never experienced any chest pain before and exercise-induced ischaemia was absent, he was treated conservatively with β-blockers. During a 6-month follow-up, he did not experience any chest pain. Fig. 2 Exercise stress (a) and rest (b) single-photon emission computed tomography images showing normal myocardial perfusion in all myocardial segments Coronary anomalies have a reported overall prevalence of 5.6%. Coronary anomalies originating from the opposite sinus have a reported prevalence of 1.0% [1]. They have a worse prognosis due to torsion or slit-like compression of the proximal parts, vasospasm, exercise-induced compression and ischaemic-induced ventricular arrhythmia. In contrast to more conventional noninvasive tests for the evaluation of patients with suspected CAD, such as exercise ECG and SPECT, CTCA visualises the coronary anatomy and atherosclerosis accurately [2]. With the increased use of CTCA in clinical practice, coronary anomalies may be detected more frequently. However, still little is known with respect to the appropriate treatment, and evidence is largely based on case reports. Recent expert opinions suggested stress nuclear testing as additional functional test to evaluate the presence of effort-induced ischaemia [1] and stated that older patients (>35 years) without inducible ischaemia may not need surgical therapy [3]. Recently, an ACC/AHA guideline [4] recommended surgical revascularisation of coronary anomalies with an interarterial course and documented ischaemia (class 1). In contrast, surgical revascularisation of the left anterior descending coronary artery with an interarterial course but without documented ischaemia was classified as a 2b indication and might be considered. Thus, CTCA can visualise coronary anomalies accurately; however, functional tests are still warranted to evaluate its haemodynamic relevance [5] and to direct further treatment.

Aberrant Left Coronary Artery, Modified Unroofing Technique, and Patch Angioplasty

We present a case of surgical correction of an aberrant left coronary artery arising from the right sinus of Valsalva. In order to prevent stenosis and kinking of the neo-ostium, modified unroofing technique was combined with patch angioplasty. The clinical outcome was excellent with complete preservation of ventricular function, resolution of angina, and absence of aortic regurgitation. Addition of patch angioplasty to the unroofing technique improves outcome.

Balloon Valvuloplasty for Treatment of Pulmonic Stenosis in English Bulldogs with an Aberrant Coronary Artery

English Bulldogs (EB) with pulmonic stenosis (PS) sometimes have an aberrant coronary artery (CA) type R2A encircling the pulmonary artery (PA). Balloon valvuloplasty (BV) is treatment of choice for severe PS, but is considered to be contraindicated in dogs with aberrant CA. Conservative BV in EB with aberrant CA is safe and improves clinical signs and quality of life. Four client-owned EB with severe PS were retrospectively reviewed/analysed. Retrospective study: Case records, echocardiography, BV, and follow-up investigations of EB diagnosed with severe PS and treated with BV were reviewed. The ratios of PA to aortic (Ao) velocity time integral (VTI) were calculated to assess progression/improvement of PS. An aberrant CA was confirmed on angiography in all EB. Conservative BV was performed, using a balloon of the size of the PA annulus or smaller (0.6-1 x PA annulus size). All dogs survived the procedure, but only a mild reduction in pressure gradient was achieved. There was an improvement in PA to Ao VTI in 3 of 4 dogs (P < or = .017), which were free of evidence of congestive heart failure (CHF) 5, 10, and 15 months after BV. One dog that had right-sided CHF when BV was performed died due to progressive right-sided CHF within 3 months. Conservative BV in EB might be safe and might improve quality and quantity of life.

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。

Anomalous Origin and Retropulmonary Course of an Atherosclerotic Stenosed Left Circumflex Coronary Artery

We here present the case of a rarely seen anomalous origin and retropulmonary course of the left circumflex artery from the proximal right coronary artery. The patient suffered from coronary ischemia due to stenotic lesions both in the aberrant circumflex coronary artery and in the first and second diagonal branches. Coronary bypass operation was performed.

Surgical treatment of an infant with myocardial ischemia due to an anomalous origin of the right coronary artery from the main pulmonary artery: Report of a case

An anomalous origin of the right coronary artery from the main pulmonary artery (ARCAPA) is a rare cardiac malformation, and only three cases of isolated ARCAPA in patients younger than 2 years of age have been reported. This report describes the surgical treatment of a 12-month-old girl with myocardial ischemia due to ARCAPA. The diagnosis was made by echocardiography. A reimplantation of the aberrant coronary artery was performed, and the patient had a successful postoperative course.