Anomalous Coronary Artery Research Articles

Interposition of right internal iliac artery free-graft for left coronary artery reimplantation in adults with anomalous left coronary artery originating from the pulmonary artery: case series and long-term results.

Anomalous left coronary artery originating from the pulmonary artery (ALCAPA) is an infrequent congenital anomaly. Presentation of this syndrome is rare in adults. Nevertheless, adult patients are at risk of ischaemia, arrhythmias or sudden cardiac death and always require surgical intervention. At our institution, a specific technique of interposition of the right internal iliac artery as a free-graft for left coronary artery reimplantation was used in adult ALCAPA patients. The aim of this report is to determine long-term results and experiences with this surgical technique.

Case report: A case of an anomalous right coronary artery arising from the left coronary cusp.

Abstract
 An anomalous origin of the right coronary artery is usually asymptomatic. It is mostly found incidentally on an invasive diagnostic angiogram. It does lead to an increased risk of sudden cardiac death, especially in younger patients. We present a case of a 41-year-old who had presented to the hospital with complaints of chest pain. The patient was evaluated by cardiology who performed an angiography that identified an anomalous origin of the right coronary artery arising from the left coronary cusp but no evidence of coronary artery disease. Once identified, these anomalous vessels should be corrected surgically, as these conditions increase the risk of sudden cardiac death arrhythmia and ischemic events.
 
 INTRODUCTION
 Anomalous aortic origin of the right coronary artery (AAORCA) is an uncommon congenital malformation with varying clinical presentations ranging from asymptomatic to sudden cardiac death (SCD). Those with symptoms or high-risk lesions are usually managed by unroofing or reimplantation, coronary artery bypass graft (CABG), AAORCA treated with right internal memory artery graft with proximal RCA ligation.
 
 CASE DESCRIPTION
 A 41-year-old female patient with obesity and hypertension presented with a 1-year history of intermittent exertional substernal pressure radiating to left shoulder and back. The pain, which lasted about 10 minutes per episode, had been more frequent and intense over the past week.Upon initial evaluation, she was hypertensive at 150/90 mmHg and heart rate 60 bpm. Blood work was unremarkable, including negative serial troponin levels. Electrocardiography showed sinus bradycardia without ischaemic changes. Anomalous origin of RCA was incidentally discovered from computed tomography (CT) of the chest. Coronary angiography and ascending aortography were then performed, which revealed a patent RCA originating from the left coronary cusp (Fig. 1A). CT heart angiography with reconstruction revealed the RCA ostium in the left coronary cusp with a malignant course between the aorta and pulmonary artery and without an obvious intramural segment
 Discussion:
 
 An anomalous origin of the right coronary artery (RCA) is a rare congenital anomaly that was first described in 1948 by White and Edwards. After carrying out angiography in 126,595 patients, Yamanaka and Hobbs reported the incidence of anomalous origin of the right and left coronary arteries as 136 (0.107%) and 22 (0.017%), respectively. The prevalence of an anomalous origin of RCA (ARCA) arising from the left coronary cusp with an inter-arterial course varies between 0.026% and 0.25%. An ARCA is more common than the anomalous origin of the left coronary artery (ALCA), but the latter is shown to be responsible for up to 85% of sudden cardiac deaths (SCD) related to the anomalous origins of arteries. Most coronary anomalies are detected incidentally on diagnostic angiography and are clinically insignificant; some, however, have been associated with an increased risk of SCD. It is second only to hypertrophic cardiomyopathy as a leading cause of SCD in young athletes. Mechanical compression of the RCA by the great vessels, which dilate and compress the RCA during periods of increased stroke volume, is the usual explanation for coronary ischemia. Patients usually have no ischemic changes on an electrocardiogram (ECG) at rest; however, multi-detector computed tomography (MDCT) is being used to evaluate the course of anomalous vessels outlying their relative positions to the aorta and the pulmonary artery. It also gives additional information regarding any stenotic lesion in these anomalous vessels. Echocardiography (Echo), magnetic resonance angiography (MRA), MCDT, and cardiac catheterization are all complementary diagnostic tools for evaluating anomalous coronary arteries [10]. While it is agreed that surgical correction is the standard of care for ALCA, when found, the management for right ARCA is more complicated. Treatment options for these patients include observation with medical therapy, percutaneous intervention (stenting), or surgery. Early diagnosis of coronary artery anomalies based on the patients’ symptoms can help decrease the incidence of sudden cardiac deaths, fatal arrhythmias, and ischemic events in the high-risk population.
 
 Conclusions 
 
 Coronary anomalies should be suspected in symptomatic young patients with a normal cardiac workup. Non-invasive imaging modalities such as a CTCA can help establish the diagnosis

Technical Details of a Novel Surgical Procedure of Anomalous Left Coronary Artery from the Pulmonary Trunk in a Child Using Autogenous Aortic and Pulmonary Arterial Flaps (UKC’s Modification): A Video Presentation

A 18-months-old male child diagnosed with anomalous origin of left coronary artery from the left posterior pulmonary sinus underwent the modification of the “trapdoor” technique, wherein the anomalous left coronary artery was detached from the pulmonary arterial sinus, and combined aortic and pulmonary arterial flaps were used to augment its length. The postoperative recovery was uneventful.

Abnormal aortic origin of coronary arteries

The anomalous aortic origin of the coronary arteries has an estimated prevalence of 0.02-5.7%. It can be associated with sudden death when it has an interarterial or intramural pathway or be damaged during interventions on the mitral, pulmonary and/or aortic annulus or percutaneous closure of an interatrial septal defect. To identify these patients by imaging techniques such as transthoracic color Doppler echocardiography (TTE), computed tomography (CT) multislice angiography or coronary angiography. The imaging techniques used for the detection of coronary anomalies were TTE, multislice coronary angiography or coronary angiography according to what is generally accepted. Fifteen patients were identified; in 12 of them the suspicion was due to TTE and in the remaining 3, CT multislice angiography was diagnostic. The circumflex artery was the coronary artery most involved, associated or not with another coronary anomaly (12/15 patients) and in the other three cases, the anomalous coronary artery had an interarterial course, with the right coronary arteries and the anterior descending coronary arteries being involved. The under diagnosis by TTE of coronary artery abnormalities may be due to the difficulty of visualization that is accentuated with age. Their detection is crucial because they can both, lead to sudden death associated with an intramural and/or interarterial pathway and complicate an interventional procedure on the interatrial septum or within the mitral, pulmonary and/or aortic rings.

Successful repair of the anomalous left coronary artery from the right pulmonary artery associated with aortic coarctation in the newborn

Anomalous left coronary artery from the pulmonary artery is a rare congenital pathology of the coronary arteries, which is associated with 90 % mortality during the first year of life, therefore it requires a detailed diagnosis and surgical intervention from the first days of the patient's life. The presence of additional congenital anomalies is a factor increasing the risk of surgery. We present a clinical case and successful hybrid approach for correction of anomalous course of the left coronary artery from the right pulmonary artery in combination with coarctation of the aorta in the newborn.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) in adult patients - a multimodality imaging approach.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital ano-maly of the origin of the coronary arteries. The prevalence of this anomaly in the adult patient population is low, and therefore there is virtually no original research on this topic. Reports are limited to case reports. We evaluated 16,264 computed tomography (CT) exams (cardiac and chest) performed in our heart imaging department between 2015 and 2022 on a dual-source 128-slice CT scanner (SOMATOM Definition Flash, Siemens Healthineers, Forchheim, Germany) and established a retrospective registry of adult patients (> 18 years old) with ALCAPA. The study included 7 cases. Next, we collected clinical and echocardiographic data, which could be assessed retrospectively. We found 7 cases of ALCAPA in adult patients (0.043%). Three of them were female, and 4 were male. The age varied between 20 and 60 years. Echocardiographic findings, as well as the clinical course, varied widely. ALCAPA is an extremely rare anomaly, which nonetheless must be taken into clinical consideration. This lesion may be fatal during infancy. Data regarding adult patients is scarce. Multicentre registries are needed to establish a more detailed clinical profile of adults with this anomaly.

Anomalous Great Cardiac Vein Mistaken for Left Main Coronary Artery Aneurysm in a Case of Anomalous Left Coronary Artery Arising from the Main Pulmonary Artery

Abstract Anomalous coronary venous drainage is rare and likely to be under-reported, with many cases found incidentally in cardiac imaging and autopsy studies. It may also occasionally have an important clinical implication. We report a rare case of anomalous great cardiac vein bypassing the coronary sinus to drain directly into the left brachiocephalic vein in a patient with anomalous left coronary artery arising from the main pulmonary artery. This anomalous course resulted in a misdiagnosis of coronary aneurysm on echocardiography.

CASE-TA-02 - VF Arrest Associated with Late Presentation Anomalous Left Coronary Artery from Pulmonary Artery (ALCAPA) Leading to ICD Insertion

CASE-TA-02 - VF Arrest Associated with Late Presentation Anomalous Left Coronary Artery from Pulmonary Artery (ALCAPA) Leading to ICD Insertion

An Unusual Anatomical Variance: Malignant Course of Anomalous Left Main Coronary Artery

An Unusual Anatomical Variance: Malignant Course of Anomalous Left Main Coronary Artery

Anomalous left coronary artery from the pulmonary artery - what we know about the disease 90 years after its discovery by Bland, White, and Garland

Anomalous left coronary artery from the pulmonary artery - what we know about the disease 90 years after its discovery by Bland, White, and Garland

A Rare Case of Symmetrical Peripheral Gangrene in Central Venoarterial Extracorporeal Membrane Oxygenator in a Pediatric Patient, an Unusual Complication of Extracorporeal Membrane Oxygenation

Symmetrical peripheral gangrene is an unusual complication of extracorporeal membrane oxygenation (ECMO) which can arise due to low cardiac output state, high inotropic support, inadequate anticoagulation, disseminated intravascular coagulation, and sepsis. In symmetrical peripheral gangrene, there is no evidence of large vessel occlusion or vasculitis. It can be due to the absence of pulsatile flow in the peripheral arteries that result in stasis and microthrombi formation which causes occlusion of small arterioles. A 10-month-old male child who underwent anomalous left coronary artery from pulmonary artery repair and required central venoarterial ECMO support post-surgery due to severe myocardial dysfunction developed symmetrical peripheral ischemia with gangrenous changes in the right-hand fingers while on extracorporeal membrane oxygenation (ECMO). The limb ischemic changes improved to normal after the child convalesced from heart failure. We describe these changes and the management here.

Rare Presentation of Myocardial Ischemia in a Patient with an Anomalous Right Coronary Artery

BACKGROUND: Coronary anomalies are coronary patterns that occur rarely in the general population. The most common type of these anomalies is the emergence of the right coronary artery (RCA) from the left coronary sinus, which in most patients is either asymptomatic or leads to sudden cardiac death (SCD). THE CASE: This case report presents the case of a 35-year-old male patient who had an inferior ST elevation myocardial infarction (STEMI) for which percutaneous coronary intervention was attempted and failed due to the patient going into cardiac arrest. The patient was subsequently managed medically in the cardiac intensive care unit and followed up outpatient with a cardiologist. The patient experienced symptoms of exertional angina and had a CT angiography of the heart and coronary vessels that identified an anomalous RCA emerging from the left coronary sinus. He was diagnosed with an anomalous RCA with malignant take-off from the left coronary sinus, and subsequent management was surgical with a coronary artery bypass graft (CABG) x1 using the right internal mammary artery (RIMA to RCA). Intraoperatively, the patient was found to have sclerosis of the RCA proximally for about 5cm. The patient did well post-operatively and had no symptoms of exertional angina upon outpatient follow up with both his cardiologist and cardiothoracic surgeon. CONCLUSION: Most cases of coronary anomalies have been found to be either completely asymptomatic or lead to SCD, especially in young patients, however very few cases in literature identified patients with this anomaly presenting with STEMI such as in this case. Another significant finding in this patient is sclerosis of the RCA, where although some articles propose that anomalous coronary arteries may be more susceptible to atherosclerosis, others conclude that there may be no association; concluding that factors such as intramural course, slit-like origin, and acute angle take-off might be more significantly associated. Moreover, patients with coronary anomalies rarely experience cardiac events solely due to their anomaly, such as with this patient. Finally, this patient’s significantly young age at 35 years old is significant given the mean age of patients undergoing CABG being 60.8 years in one cross-sectional study. Current management of symptomatic patients with these anomalies is under debate, with many patients undergoing CABG such as in this case, although one study shows no significant difference in mortality or 10-year survival with surgical intervention despite having higher surgical intervention rates. Percutaneous coronary intervention (PCI) of patients with coronary anomalies has been shown to be difficult or unsuccessful in most studies, although a few cases in literature were successful with tools such as multidetector CT (MDCT). Awareness of these anomalies and their possible presentation, risk factors, and radiologic findings is important especially given their potential for SCD. More research is needed to further elucidate the best treatment options and perhaps even improve the potential for non-invasive interventional techniques such as PCI.

Late angina due to anomalous Right Coronary Artery

Late angina due to anomalous Right Coronary Artery

Analysis of Perioperative and Long-Term Outcomes Among Presentations of Anomalous Left Coronary Artery from the Pulmonary Artery Diagnosed Beyond Infancy Versus During Infancy

Analysis of Perioperative and Long-Term Outcomes Among Presentations of Anomalous Left Coronary Artery from the Pulmonary Artery Diagnosed Beyond Infancy Versus During Infancy

Anomalous origin of left main coronary artery from the right sinus of Valsalva

BackgroundAnomalous coronary arteries are rare congenital variations with cases ranging from asymptomatic to life-threatening. Given the wide variability of coronary anomalies, it is challenging to predict their clinical consequences. Here, we present the ‘malignant’ variant – interarterial course of the left coronary artery between the aorta and pulmonary trunk – given the highest risk of sudden cardiac death among the various coronary anomalies.Case presentationOur case presents a 22-year-old male presenting to the emergency department after a syncopal episode that occurred while the patient was driving a motor vehicle. Initial Computed Tomography (CT) of the chest performed as part of the trauma work-up revealed a rare case of an anomalous origin of the left main coronary artery (LMCA) originating from a common ostium with the right coronary artery (RCA). The LMCA was found to have a malignant course, as it was positioned between the aorta and pulmonary artery. Given the high risk of sudden cardiac arrest with this congenital variant, the patient underwent coronary artery bypass grafting.ConclusionAnomalous coronary arteries remain the second leading cause of sudden cardiac death in young adult patients. The risk of sudden cardiac death depends on the congenital variant of the anomalous coronary artery as well as the course these vessels take. This case highlights a rare congenital variant featuring both the LMCA and RCA originating from a common ostium, with the LMCA having a malignant course, a variant with the highest risk of sudden cardiac death.

Pathophysiology and Treatment of Intraseptal-Course Left Coronary Anomaly: Surgery for All?

Intraseptal-course, ectopic coronary anomalies are not well characterized as to anatomy, function, prognosis, and treatment. Recently, a revolutionary but unsupported new theory is claiming that most patients with a Left Anomalous Coronary Artery originating from the Opposite Sinus with anomalous Intra-Septal course (L-ACAOS-IS)-even small children-have significant stenoses and require open-heart surgery to prevent acute myocardial infarction and death. This surprising view has spurred ongoing discussions among adult and pediatric cardiologists and cardiac surgeons, compelling us (the conservative party in the discussion) to offer an in-depth and comprehensive review of this anomaly, based on objective but opposite data. We and other adult cardiologists have followed numerous L-ACAOS-IS patients for many years and have observed none of the claimed catastrophes. Rather, we have consistently found that L-ACAOS-IS generally has a benign clinical prognosis. We present the general principle of coronary artery dysfunction in anatomical congenital anomalies (that only significant luminal coronary stenosis can have clinical repercussions). We then review anatomical and functional details of L-ACAOS-IS related to prognosis and treatment indications, which could explain many of the clinical presentations recently mentioned. Finally, we encourage our more liberal colleagues to recognize that, compared with normal coronary arteries, those with anomalies of origin and course are associated with frequent coronary spasm. In particular, we underscore that some of the ischemic manifestations and other results might actually be caused by pressure wire-induced artifacts (rigid wires tend to cause coronary spasm when advanced into tortuous coronary arteries).

An Unusual Presentation of Syncope in an Elderly Male Leading to a Diagnosis of an Anomalous Right Coronary Artery

An Unusual Presentation of Syncope in an Elderly Male Leading to a Diagnosis of an Anomalous Right Coronary Artery

Aorta Without Coronary Arteries: Anatomic Variants of a Rare Malformation.

Absence of connection of both coronary arteries to the aorta is an extremely rare congenital malformation. Most cases reported are anatomic variants of anomalous left coronary artery to pulmonary artery, found in isolation or in association with other congenital heart defects. We describe here four cases of patients born without any coronary artery connected to the aorta, including two with an almost complete absence of epicardial coronary arteries, one with single coronary artery to the right pulmonary artery, and one with left ventricular connection of a single coronary artery. Those exceptional coronary malformations have a poor prognosis and are often diagnosed at autopsy. Total absence of epicardial coronary arteries, present in two of our patients and described only once in the literature, leads us to reconsider current knowledge of human coronary artery development.

Hyper-dominant Left Anterior Descending Artery in the coronary circulation as a rare coronary anomaly

Hyper-dominant left anterior descending artery is rarely seen in the coronary distribution. Its involvement in ACS can often be detrimental as it supplies most of the anterior and inferior part of the right and left ventricles in compared to other variants of LAD artery. It is required to be recognized earlier and management strategies should be ascertained. Our report here describes such a case of anomalous coronary artery which is less commonly encountered during Coronary Angiography. This was case of a 60 year old hypertensive male who presented with atypical chest pain had normal ECG, echocardiography and cardiac biomarkers but TMT was positive, subsequent Coronary angiographic evaluation came up with LAD artery which was going beyond apex in the posterior interventricular groove up to crux forming PDA with 20 to 30% stenosis in proximal to distal part. Such a large LAD running into the interventricular groove forming PDA is known as “Hyper-dominant” LAD artery. The Right Coronary artery was non-dominant. Fortunately, there was no signifcant coronary artery disease to explain the cause of his chest pain, but the artery had unusual distribution provided that it has sole territorial supply to larger part of the myocardium which can worsen the clinical status if coronary artery disease progresses. He was kept under medical management and was doing good. The “Take away” lesson is that there are very few subjects with Hyper-dominant LAD artery till date and most other cases with this anatomy had presented with myocardial infarction and thus such anatomical variant of LAD artery ought to be matter of concern and further research in the feld of cardiology.

Coronary Artery Bypass Surgery to Treat Anomalous Origin of Coronary Arteries in Adults: A Systematic Review

To review the available literature on the use of coronary artery bypass grafting (CABG) as a treatment option for anomalous origin of coronary artery in adults. A systematic literature search was performed in March 2023 (including Ovid MEDLINE, Ovid Embase, and the Cochrane Library databases) to identify studies reporting the use of CABG in adult patients with anomalous origin of coronary artery. A total of 31 studies and 62 patients were included, 32 patients (52%) were women, and the mean age was 45.1±16.1 years. The most common coronary anomaly was the right coronary artery arising from the left coronary sinus in 26 patients (42%), followed by an anomalous left coronary artery from the pulmonary artery in 23 patients (37%). A total of 65 conduits were used in 61 patients, and 1 case report did not report conduit type. Reported grafts included saphenous vein (23 of 65 [35.4%]), left internal thoracic artery (15 of 65 [23.1%]), right internal thoracic artery (23 of 65 [35.4%]), and radial artery (2 of 65 [3.1%]); right gastroepiploic artery and basilic vein were used once (1.5%) each. Ligation of the native coronary artery was performed in 42 (67.7%) patients. Patient follow-up was available in 19 studies with a mean of 31.2 months. Only 1 operative mortality was reported. Based on the limited available data, CABG can be performed with good early results. Use of arterial conduits and ligation of the native coronary artery may improve long-term graft patency.