Contralateral Aortic Sinus Research Articles

Anomalous Origin of Coronary Artery from the Contralateral Aortic Sinus - Case Report

Congenital coronary artery anomalies are rare heart defect that has been associated with myocardial ischemia and sudden death. Only 1-2% of population having variation in the origin, course or distribution of the epicardial coronary arteries. Anomalous origin of coronary arteries may be present as isolated defect or as a part of complex congenital heart disease. The clinical presentation, diagnostic work up, prognosis and treatment of these anomalies are highly variable. Most of the patients are asymptomatic but manifestation of these patients are chest pain, dyspnoea, palpitation, dizziness, ventricular fibrillation, syncope and sudden death. It is the second most common cause of sudden death in young athletes. Selective coronary angiography is the gold standard for identification of such type of anomaly. Patients of anomalous origin of coronary artery from the opposite sinus may require medical treatment, coronary angioplasty with stenting or surgical repair.University Heart Journal Vol. 12, No. 2, July 2016; 98-101

Coronary CTA assessment of coronary anomalies

Coronary anomalies occur in <1% of the general population and can range from a benign incidental finding to the cause of sudden cardiac death. The coronary anomalies are classified here according to the traditional grouping into those of origin and course, intrinsic arterial anatomy, and termination. Classic coronary anomalies of origin and course include those in which a coronary artery originates from the contralateral aortic sinus or the pulmonary artery with anomalous course. Single coronary artery anomalies, in which single coronary artery branches to supply the entire coronary tree, are also included in this category. Anomalies of intrinsic arterial anatomy are a broad class that includes myocardial bridges, coronary ectasia and aneurysms, subendocardial coursing arteries, and coronary artery duplication. Coronary anomalies of termination are those in which a coronary artery terminates in a fistulous connection to a great vessel or cardiac chamber. In the case of those anomalies associated with a risk of sudden cardiac death, the relevant imaging features on CT angiography (CTA) associated with poorer prognosis are reviewed. Recent guidelines and appropriateness criteria favor the use of coronary CTA for the evaluation of coronary anomalies. Although invasive angiography has historically been used to diagnose coronary anomalies, multidetector CT imaging techniques have now become an accurate noninvasive alternative. Cardiac CTA provides excellent spatial and temporal resolution, allowing accurate anatomical assessment of these anomalies.

In Vivo Intravascular Ultrasonic Assessment of Anomalous Right Coronary Artery Arising from Left Coronary Sinus

Anomalous coronary arteries with origins from the contralateral aortic sinus and coursing between the aorta and pulmonary trunk have received much attention because of their association with sudden death. These morphologic features have not been well assessed in vivo. The investigators describe 3 cases of anomalous right coronary arteries arising from the left coronary sinus with intravascular ultrasound findings. In the present patients, characteristic vessel distortion was consistently observed at the ostium of the anomalous right coronary arteries, as well as systolic compression of the intra-arterial segments. In conclusion, the slitlike ostium might be associated with the higher incidence of sudden death under strenuous exercise and exercise-induced myocardial ischemia.

Coronary angiography and dual-source computed tomography are complementary methods in diagnosis of significant stenosis of the right coronary artery originating from the left aortic sinus

Abstract Anomalous origin of the right coronary artery from the contralateral aortic sinus is a rare but potentially fatal congenital abnormality. We analyzed 8.066 consecutive coronary angiograms and found 4 cases demonstrating this anomaly. In 2 cases the right coronary artery was without significant atherosclerotic lesions and coursed between the aorta and pulmonary trunk. In the 2 other cases the right coronary artery was significantly stenosed. In the last case, diagnosis was based on angiographic and dual-source computed tomographic examinations. Dual-source computed tomography showed precisely the origin and course of the right coronary artery between the ascending aorta and pulmonary artery. Moreover, stenoses of the anomalous coronary artery were depicted. Subsequent coronary interventions required modification of the Amplatz left guiding catheter, which enabled a sufficient support even for coronary artery stenting. Both methods seem to be complementary in the diagnostic and therapeutic process of this coronary anomaly.

Aberrant coronary arteries: a reliable echocardiographic screening method

Background Aberrant origin (ABO) of a coronary artery (CA) from the contralateral aortic sinus with a subsequent interarterial course is a life-threatening condition. It carries a 28% to 55% risk for a sudden coronary event or death, but there are no reliable screening methods. Objective We sought to determine whether imaging a cross section of a coronary segment in the anterior aortic wall on the long-axis view may be used as an echocardiographic screening sign for ABO CA. Methods The echocardiograms of all patients with ABO CA were evaluated for the screening sign and compared with those of age-matched control patients. Results Between January 1989 and October 2002, we identified 8 patients with ABO CA (median age: 15 years). Of these patients, 4 were symptomatic and 4 were discovered incidentally. The electrocardiogram produced normal findings in 5 of 8 patients, maximal stress test produced normal findings in 5 of 6 patients, and thallium perfusion test produced negative results in 2 of 3 patients. There were 4 patients with ABO in the main left CA, 3 with ABO in the right CA, and 1 with ABO in the circumflex CA branch. The screening sign was readily visible in 7 of the 8 patients (88%), and all 7 of these patients had ABO in a main CA. Only in the ABO in the circumflex CA branch was the screening sign not detected. The 1743 control patients (median age: 14 years) showed normal anterior aortic wall, which was void of any CA segment. In 5 control patients (0.3%, P < .001) the normal right CA was visible on the long-axis view, but was not confused for a false-positive screening sign. Conclusion We concluded that the proposed screening sign for ABO CA is reliable and easily recognizable, and should prompt a comprehensive assessment of the CA.

Congenital Coronary Artery Abnormalities in Children.

After a significant coronary artery abnormality is recognized in a pediatric patient, surgery or appropriate transcatheter intervention should be performed. The risk of fatality from a congenital coronary abnormality far outweighs the small risks of surgical or transcatheter intervention. Angiography, although considered the state-of-the-art method of diagnosis, has significant spatial limitations and is not always diagnostic of aberrant coronary origins from the contralateral aortic sinus. In the hands of an experienced coronary imager, color flow Doppler echocardiography is one of the best diagnostic tools for congenital coronary abnormalities. Symptoms of a coronary abnormality vary from none to a sudden coronary event that may result in death. Awareness of subtle as well as obvious symptoms is essential for a timely intervention. Surgical or transcatheter intervention in an asymptomatic child with a coronary abnormality is controversial, but it is becoming more acceptable due to a better understanding of the risks involved in unrepaired congenital coronary abnormalities. Surgical reimplantation is the treatment of choice for a patients with a pulmonary origin of a coronary artery. Surgical unroofing of the intramural segment is preferable in an aberrant coronary origin from the contralateral aortic sinus. Surgical enlargement of a stenotic ostium is recommended for ostial stenosis. Transcatheter coil embolization is becoming the treatment of choice of large coronary artery fistula.

Main Coronary Artery and Coronary Ostial Stenosis in Children: Detection by Transthoracic Color Flow and Pulsed Doppler Echocardiography

Coronary artery stenosis (CAS) and coronary ostial stenosis (COS) are potentially life-threatening conditions. The echocardiographic diagnosis of CAS and COS in children has not been described. We report on the transthoracic echocardiography (TTE) findings of CAS and COS in children. Six patients, aged 1 week to 12 years, with clinically confirmed COS (n = 5) and CAS (n = l) were diagnosed by TTE. Their echocardiographic findings were compared with 26 healthy control subjects of a similar age range. Left COS was associated with an aberrant left coronary artery (CA) from the contralateral aortic sinus (n = 2), an intramural left CA with d-transposition of the great vessels (n = l), and supravalvular aortic stenosis (n = l). Right COS was present in a patient with aortic valvular stenosis. Acquired left main CAS was diagnosed in the sixth patient 3 years after orthotopic heart transplantation. Coronary ostial stenosis was recognized when a color flow acceleration signal was present proximal to and extending into the coronary ostium (CO). Coronary artery stenosis was detected when a coarctated color flow stream was present within the stenosed CA segment with turbulent distal flow. These findings were not detected in the control cohort who demonstrated laminar CA and CO flow signals. All patients had increased spectral velocity in the CA distal to the stenosed segment (patients = 50 ± 5 cm/s, controls = 24 ± 6 cm/sec; P <.01). Delayed peak diastolic velocity seemed to indicate severe stenosis. We conclude that (1) CO acceleration signals and turbulent coarctated CA flow signals are abnormal findings in TTE coronary Doppler assessment. They indicate COS and CAS, respectively. (2) Knowledge of the normal TTE CA flow velocity patterns is essential so that abnormal velocity signals such as seen with CAS and COS can be recognized and a timely diagnosis made. (J Am Soc Echocardiogr 2000;13:255-63.)

Coronary arteries arising from the contralateral aortic sinus: Electron beam computed tomographic demonstration of the initial course of the artery with respect to the aorta and the right ventricular outflow tract

operations, but none of our patients had undergone such operations. The apparent association of thymic cysts with infection (e.g., syphilis or tuberculosis) has been reported 2 but was not present in our cases. If hemorrhage occurs, fluid in the cyst becomes brownish and more viscid. In two of our patients, the cysts had such findings. Microscopic examination did not show a definite epithelium. The walls showed fibrocollagenous scar tissue formation. Malignant degeneration, although rare, has been reported 5 but was not seen in this review. Some malignant tumors, particularly thymoma, Hodgkin's disease, and seminoma, can show prominent cystic changes. We therefore made every effort to detect any malignant tissue on pathologic examination. A diffuse goiter was seen in three of five patients. However, this finding may be coincidental because goiter is endemic in Turkey. This relationship should be investigated further. Operative excision of thymic cysts seems both diagnostic and curative. Except in case 1, the thymic cysts were not localized in the midline and all were large. Therefore we preferred thoracotomies to explore and excise the cysts rather than median sternotomies. The cysts were completely removed to prevent a recurrence and to eliminate the risk of malignant transformation. Thoracotomy in patients with large cysts allows for easy removal of the cysts. Neither aspiration nor decompression of the cysts was necessary.