Anomalous Left Main Coronary Artery Research Articles

Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery: An Uncommon Coronary Anomaly With Serious Implications in Adulthood.

A 36-year-old woman was seen with complaints of exertional chest pain and shortness of breath. Her medical history included atrial fibrillation and diabetes. Physical examination was unremarkable except for an irregular cardiac rhythm. Myocardial perfusion imaging revealed the presence of a large area of infarction involving the entire anterior and apical walls and part of the anteroseptal wall with minimal periinfarct ischemia. Computed tomography coronary angiogram revealed an anomalous left main coronary artery arising from the main pulmonary artery. Right and left heart catheterizations demonstrated moderate pulmonary hypertension with a slight step-up in oxygen saturation between the right ventricle and main pulmonary artery. Coronary angiography showed a large tortuous right coronary artery with collaterals to the left anterior descending artery that drained into the main pulmonary artery. She was referred for surgery. This case demonstrates a rare coronary artery anomaly in an adult where survival is dependent on collateral circulation.

Coinciding anomalous coronary artery and papillary fibroelastoma.

Introduction: The primary cardiac tumors are extremely rare tumors that arise from the normal tissues that make up the heart. Those tumor can be divided into Benign, mostly myxoma or malignant tumors. Fibroelastoma are rare benign tumors of the endocardium. They are usually left sided, with few cases reported of pulmonary valve papillary fibroelastoma. No case of fibroelastoma and anamolous coronary artery. Case Presentation: 61 year old female with past medical history of diabetes mellitus was complaining of chronic stable angina. Admitted after an outpatient positive treadmill EKG test (ST segment depression inferiolaterally). Final/Working Diagnosis: Left heart cath demonstrated angiographically normal coronaries with an anomalous left main coronary artery originating from the right coronary cusp with no significant disease. Management: CT angiogram similarly demonstrated an anomalous origin of the left main coronary artery from a common ostium with the right coronary artery originating from the right sinus of Valsalva. The left main coronary courses between the aorta and right pulmonary outflow tract consistent with an intra-arterial course.Echo showed an incidental finding of a mobile structures attached to the pulmonic valve, 0.7x0.7 cm in size, whose appearance was consistent with papillary fibroelastoma . CardioThoracic surgery was consulted for patient continuous angina symptoms not responsive to medical therapy and the above coronary artery findings, it was believed that she would not benefit from relocation of the left main coronary artery due to the common ostia with the right and its intra-arterial course. Patient had 2 vessel coronary artery revascularization (LIMA to LAD, reverse saphenous vein graft to ramus with endoscopic vein harvest and excision of pulmonary valve mass). The pathology report confirmed the diagnosis of papillary fibroelastoma. Disclosure Saif Ibrahim, MD – No Relevant Financial Relationships to Disclose Steven Lavine, MD – No Relevant Financial Relationships to Disclose Jean Touchan, MD – No Relevant Financial Relationships to Disclose

Coronary Intervention of An Anomalous Left Main Coronary Artery Arising from the Right Sinus of Valsalva Presented as Acute Coronary Syndrome

Anomalous origin of the left coronary artery (LCA) from the right sinus of Valsalva is a rare congenital Anomaly. We report a 38 year old male presented with acute coronary syndrome (ACS). Referred to the Catheterization laboratory for Percutaneous Coronary Intervention (PCI). The coronary angiogram showed the LCA originating from the right coronary sinus. A critical stenotic lesion was observed in the shaft of the Left main coronary artery. CT coronary angiography displayed a benign retro aortic course. The lesion was treated successfully with stenting.

Anomalous left main coronary artery detected by CT angiography

The growing improvements of computed tomography have made this technique more and more available for cardiac evaluation. Coronary artery anomalies (CAAs) are often incidental findings in subjects with suspected coronary artery disease (CAD) undergoing coronary angiography or computed tomography coronary angiography (CTCA). In some cases, CAAs can be clinically relevant so their identification could change radically patient management and treatment. We report the case of a 68-year-old male patient with known CAD and associated anomalous origination of the left coronary artery from the opposite sinus.

Surgical Unroofing for Anomalous Aortic Origin of Coronary Arteries

Anomalous aortic origin of a coronary artery (AAOCA) from an opposite sinus of Valsalva is an uncommon congenital defect that is typically only discovered on cardiac catheterization or on autopsy following sudden cardiac death. Conjectured mechanisms for the ischemia are generally believed to relate to the unique and easily obstructed geometry of the coronary ostium and the stenotic intramural coronary segment. Given the potentially devastating consequences of not repairing an AAOCA—that is, sudden cardiac death—these patients should undergo repair of the anomaly when it is discovered. Multiple options for surgically correcting the AAOCA have been developed, and the most used approaches include coronary artery bypass grafting, coronary reimplantation, and unroofing of the intramural segment. Here we present the technique for surgical unroofing of the intramural segment of an anomalous coronary artery of aortic origin.

Anomalous Left Main Coronary Artery: Not Always a Simple Surgical Reimplantation.

We present the case of 56-year-old woman who required complex coronary artery bypass grafting for high-risk anomalous left main coronary artery (LMCA) originating from right coronary cusp including conventional reimplantation of the LMCA plus left internal mammary artery (LIMA) graft to the left anterior descending (LAD) and saphenous vein graft (SVG) to the left circumflex (LCx). On subsequent cardiac computed tomography screening and cardiac catheterization, the LIMA graft was occluded after just a few centimeters, but the SVG graft was patent with good run-off into the native LCx and also filled the LAD retrogradely. The reimplanted left main stem demonstrated at least moderate ostial stenosis although pressure wire assessment of this was not significant (fractional flow reserve 0.89), probably due to good retrograde filling of the LAD from the SVG to LCx, therefore, we did not proceed with ostial LMCA stenting. She remains on yearly review with a low threshold for further revascularization should the SVG to LCx develop progressive stenosis. This case illustrates how patients with anomalous LMCA may sometimes benefit from grafting in addition to conventional reimplantation.Electronic supplementary materialThe online version of this article (doi:10.1007/s40119-015-0039-x) contains supplementary material, which is available to authorized users.

Anomalous Left Main Coronary Artery Originating from the Right Sinus of Valsalva

caSE PrESEnTaTion A 66 year-old male with a history of hypertension, hyperlipidemia, and type II diabetes presented with progressive exertional mid-epigastric and mid-chest discomfort. The patient stated that he had been feeling this “heaviness” with various activities and occasionally at rest for the past nine months. When it occurred with activity, the pain was generally relieved by rest within several minutes. His medications on presentation included insulin glargine, glyburide, metformin, simvastatin, pioglitazone, and lisinopril. Vital signs at the time of presentation included a temperature of 98.2°F, heart rate of 82 beats per minute, and blood pressure of 130/70 mmHg in both arms.

Surgery for anomalous left main coronary artery from right coronary sinus in the asymptomatic adult

Surgery for anomalous left main coronary artery from right coronary sinus in the asymptomatic adult

Anomalous Origin of Left Coronary Artery from Main Pulmonary Artery (ALCAPA) Who Underwent Two Coronary System Repair with a Novel Technique

We report clinical, CT, invasive coronary angiography and intra-operative findings of a symptomatic elderly man with anomalous origin of left coronary artery from pulmonary artery (ALCAPA). ALCAPA is a rare syndrome with anomalous origin of left main coronary artery (LMCA) from main pulmonary artery (MPA). Survival into adulthood is rare and our case is probably the oldest survivor who has undergone two coronary system repairs for this anomaly. The unique features of our case include: 1) Absence of “q” wave myocardial infarction on ECG; 2) Absence of significant mitral regurgitation; 3) Demonstration of stress induced perfusion defects in nuclear imaging which as per our knowledge has been done for the first time in the literature; 4) A unique technique of closing anomalous LMCA origin by a pericardial patch, sutured on the internal aspect of MPA is the hallmark of this case.

Anomalous left main coronary artery originating from the pulmonary artery

An 81 year-old Caucasian female presented to the hospital with dyspnea on exertion and was found to be in new onset atrial fibrillation. She has a past medical history of hypertension and has led an active life till her symptoms of dyspnea started. An echocardiogram was performed as a part of the work up showing an ejection fraction of 35 % with moderate mitral valve regurgitation (Fig. 2). Given her new onset cardiomyopathy and reluctance to undergo invasive work up, a pharmacologic nuclear myocardial perfusion stress test was performed showing a moderate sized area of anterolateral wall mixed ischemia and scar with an ejection fraction of 36 % (Fig. 3). A coronary angiography was recommended but patient was still reluctant and preferred a non-invasive work-up. Thus, a cardiac CT angiography was recommended. This showed an anomalous left main coronary artery originating from the proximal main pulmonary artery just beyond the pulmonic valve. The contrast density in the left main coronary artery is slightly higher than in the pulmonary artery and matches the contrast density in the arterial circulation indicating collateral filling of the left coronary system from either the aorta or right coronary artery (Fig. 4). She was started on beta-blockers and lisinopril. She underwent a successful electrical cardioversion preceded by a transesophageal echocardiogram to rule out left atrial appendage clot. She was started and warfarin and discharged. On follow-up 3 months later, she remained in sinus rhythm with significant improvement in her symptoms. A repeated echocardiogram showed significant improvement in the left ventricular ejection fraction to 55 % with only mild mitral regurgitation. On six-month follow-up she remained asymptomatic with improved functional capacity.

Percutaneous revascularization of anomalous left main coronary artery stenosis with a retro-aortic course

We described the rare case of a 54-year-old male patient with an anomalous left main coronary artery, originating from the right sinus with a retro-aortic course. A signifi cant distal left main coronary artery (LM) atherosclerotic lesion was identifi ed and a successful PCI with direct stenting was performed.Coronary artery abnormalities represent the most technically challenging cases for interventional cardiologists. However, in selected cases, a percutaneous intervention can off er an eff ective and safe therapeutic option.

Young athlete with sudden cardiac arrest treated with therapeutic hypothermia

Reported herein is a coronary anomaly that occurred in a young adolescent athlete who presented with cardiopulmonary arrest. The patient was resuscitated and treated with therapeutic hypothermia. The patient had no associated neurological complications at follow up. Enhanced computed tomography of the heart indicated an anomalous left main coronary artery originating from the right coronary sinus and coursing between the aorta and the pulmonary artery. The patient underwent surgical intervention with coronary artery bypass grafting to prevent symptom recurrence.

Valve-Sparing Aortic Root Replacement With Translocation of Anomalous Left Coronary Artery

An anomalous left main coronary artery arising from the right coronary with a single coronary ostium is an exceptionally rare anatomic variant. Here, we report a patient with a left main coronary artery arising from the right coronary and also an aortic root aneurysm associated withmild aortic insufficiency. Valve-sparing aortic root replacement and coronary translocation were performed with an excellent outcome in this case.

ASSA13-05-3 Anomalous Left Main Coronary Artery Arising From The Right Sinus Of Valsalva

<h3></h3> Congenital anomalies of the coronary arteries are an uncommon but important cause of chest pain and sudden cardiac death. The incidence of coronary artery anomalies has been reported between 0.6 to 1.3% in angiography and 0.3% in autopsy. The anomalous origin of left and right coronary arteries from a single coronary ostium in the right sinus of Valsalva is extremely rare and accounts for a small fraction of these anomalies with reported prevalence of 0.017% to 0.03% according to angiographic studies. We report a case of 52-year-old woman, suffering from chest pain, with an anomalous common origin of all coronary arteries from the right sinus of Valsalva.

Successfull challenging percutaneous coronary interventions in two patients with anomalous left coronary artery origin from the right sinus of Valsalva

Congenital anomalies of the coronary arteries affect about 1.3% of individuals. One of the most commonly encountered anomalies involves the anomalous origination of a coronary artery from the opposite sinus of Valsalva. The incidence of ectopic left coronary artery arising from the right sinus of Valsalva was found between 0.017-0.15% in coronary angiography and autopsy series. Catheter-based revascularization of anomalous artery is a therapeutic challenge and needs experience. In this case report, we demonstrated successful percutaneous coronary interventions to anomalous left main coronary artery osteal lesion and proximal lesion in anomalous left anterior descending artery in two patients with anomalous left coronary artery origin from right sinus of Valsalva. J. Exp. Clin. Med., 2013; 30:93-95

An unusual co-anomaly: multiple coronary-cameral fistulas and left main coronary artery arising from the right sinus of Valsalva

A 70-year-old female patient was referred to the Cardiology Department for preoperative evaluation before undergoing total hysterectomy. She had no chest pain, but had experienced exertional dyspnea over the past several months. Besides age, she had no additional risk factors for coronary artery disease. Electrocardiogram showed normal sinus rhythm and nonspecific T wave changes, with a heart rate of 81 beats per minute. The physical examination was unremarkable, and exercise stress test was non-diagnostic. Coronary angiography revealed anomalous left main coronary artery (LMCA) arising from the right sinus of Valsalva (Fig. A, Video 1*) and the presence of multiple coronary-cameral fistulas (CCF) between the left ventricle and septal perforating branches of the left anterior descending (LAD) and right coronary arteries (Fig. B, Video 2; Fig. C, Video 3). According to the eye-dot method (Fig. B) and given the septal perforator branch before the LMCA bifurcation (Fig. A), its course was considered as septal, which was confirmed by computed tomography coronary angiography (CTCA) (Fig. D). Because of the benign nature of the abnormal septal course of the LMCA and clinically insignificant CCF, the patient was treated conservatively with β-blockers. She did not experience any chest pain during the hysterectomy and had an uneventful postoperative course. CCF is an uncommon clinical entity, which is defined as an anomalous communication between any epicardial coronary artery and the cardiac chambers. The functional significance and treatment of these fistulas remain unclear. As in our case, CCF originating from both coronary arteries and terminating in cardiac chambers is one of the least common forms. The anomalous origin of LMCA arising from the right sinus of Valsalva is quite rare, with an incidence of 0.1%. It has four possible courses: inter-arterial, retro-aortic, septal, and anterior. The clinical significance and management strategies in these arteries depend on the initial course of the anomalous vessel. In 1990, Serota et al. defined the ‘Dot and Eye’ method for identification of the initial course of anomalous coronary arteries in coronary angiography. In a septal course, the circumflex artery (Cx) will form an ellipse to the left of the aorta, similar to an ‘eye’, with the LMCA forming the inferior portion and the Cx forming the superior portion during 30 RAO injection. In conclusion, CTCA can visualize coronary anomalies accurately; however, a correct diagnosis can be made safely in selected cases by conventional angiography in the presence of clues. 782

Anomalous Left Main Coronary Artery: Case Series of Different Courses and Literature Review

Background. Congenital anomalies of the coronary arteries are a cause of sudden cardiac death. Of the known anatomic variants, anomalous origination of a coronary artery from an opposite sinus of Valsalva (ACAOS) remains the main focus of debate. Case Series. We present three cases, all presenting to our facility within one week's time, of patients with newly discovered anomalous origination of the left coronary artery from the right sinus of Valsalva (L-ACAOS). All patients underwent cardiac computed tomography for evaluation of coronary anatomy along with other forms of functional testing. Despite the high risk nature of two of the anomalies, the patients are being treated medically without recurrence of symptoms. Summary. After review of the literature, we have found that the risk of sudden cardiac death in patients with congenital coronary anomalies, even among variants considered the highest risk, may be overestimated. In addition, the exact prevalence of coronary anomalies in the general population is currently underestimated. A national coronary artery anomaly registry based on cardiac computed tomography and invasive coronary angiography data would be helpful in advancing our understanding of these cardiac peculiarities. The true prevalence of congenital coronary anomalies and overall risk of sudden cardiac death in this population are not well known. Surgical intervention remains the mainstay of therapy in certain patients though recent investigations into the pathophysiology of these abnormalities have shown that the risk of surgery may outweigh the minimal reduction in risk of sudden cardiac death.

Dual source multidetector computed tomography coronary angiography in the surgical planning regarding the major coronary artery anomalies in children

Background: This study aims to demonstrate major coronary artery anomalies such as anomalous origin and coronary artery fistulas on dual-source multi detector computed tomography (MDCT) coronary angiography in children before surgical treatment. Methods: Six children (3 boys, 3 girls; mean age 6 years; range 2 days to 15 years) referred for a MDCT coronary angiography for evaluation of coronary anomaly between January 2010 and June 2011 were included in this study. Electrocardiography (ECG)-gated dual-source MDCT coronary angiography was performed on all patients. No beta-blockers were given prior to the procedure. The mean heart rate was 98±20 bpm (range 128 to 75 bpm). In all patients, ostium, course, and end-distal portion of coronary artery were inspected for anomalies. Exact opening point was carefully assessed in patients with fistulas. Dual-source MDCT examination was performed with low kilovolt dose reduction algorithm (80 kV, range 150-350 mA) compatible with ALARA principles. Results: Three anomalous origin (one ALCAPA, two anomalous left main coronary artery originated from right sinus of Valsalva) and three fistulas (two coronary-cameral fistula, one left main coronary artery -coronary sinus fistula) were clearly identified with dual-source MDCT angiography. Conclusion: Dual source MDCT angiography is a noninvasive and effective method as an alternative to conventional coronary angiography for the preoperative assessment of major anomalous origin of coronary artery or coronary artery fistulas.

Anomalous Left Main Coronary Artery Origin From the Right Sinus of Valsalva: A Novel Echocardiographic Screening Method

Anomalous origin of the left main coronary artery from the right sinus (ALMCA) is a rare entity associated with an increased risk for sudden cardiac death. Although transthoracic echocardiography often is the primary screening tool for the diagnosis, its accuracy remains undefined, resulting in the use of more expensive methods such as cardiac catheterization and magnetic resonance imaging when clinical suspicion exists. This report aims to describe a novel echocardiographic screening method for detecting ALMCA and to apply it retrospectively for patients with confirmed findings intraoperatively and/or on autopsy. All patients with a confirmed diagnosis of ALMCA who presented to our institution from 2004 to 2012 were included in the study. Eight patients had adequate images, including two patients with an initial diagnosis of normal coronary origins. A control group consisted of 35 patients with normal coronaries shown by echocardiogram. Five of these patients had normal coronary artery origins confirmed by magnetic resonance imaging (MRI). Echocardiographic images were reviewed, and the left main coronary was identified in the parasternal long-axis view between the aorta and pulmonary trunk. The angle of the left main coronary course was measured. In patients with ALMCA, the proximal course of the vessel was steeper as it coursed posteriorly. In contrast, the course was almost horizontal in patients with normal coronary origins. Based on these findings, a cutoff angle of 28° is proposed. In the parasternal long-axis view, ALMCA can be identified by its anomalous proximal course. This screening method is reliable and increases the accuracy of transthoracic echocardiograms.

Transcatheter Aortic Valve Replacement With Coronary Artery Protection Performed in a Patient With an Anomalous Left Main Coronary Artery

![Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5][![Graphic][6] ][6] An 88-year-old woman with critical aortic stenosis was evaluated for transcatheter aortic valve replacement (TAVR) with the Sapien (Edwards Inc., Irvine, California) balloon-