Interarterial Course Research Articles

Abstract 18489: Abnormal Coronary Findings on Non-Invasive Computed Tomography Coronary Angiography in Adult Patients with Transposition of the Great Arteries Corrected by Arterial Switch Operation

Purpose: Early mortality and long-term outcome in patients with congenital transposition of the great arteries (TGA) corrected by arterial switch operation (ASO) mainly depend on the perfusion of the myocardium provided by the transferred coronary circulation. This study aimed to assess the prevalence of potential unfavorable coronary findings in adult patients after ASO using non-invasive computed tomography coronary angiography (CTA). Methods: The study population consisted of 30 adult patients after ASO (22 male, 22±3 yrs.) referred for non-invasive evaluation of the coronary anatomy by CTA. First, the post-operative coronary anatomy pattern was described using the classification of Gittenberger-de Groot. Furthermore, all scans were reviewed on the presence of (1) significant coronary stenosis, defined as ≥50% luminal narrowing, (2) an inter-arterial coronary course, and (3) an acute angled coronary origin. Results: A post-operative anatomy patterns of 1R-2LCx was observed in 24 patients (80%), 1RCx-2L in 5 patients (17%) and 2RLCx in 1 patient (3%). A total of 13 patients (43%) had abnormal coronary findings of which 1 patient (3%) had a significant stenosis in the proximal LAD, 5 patients (17%) had an inter-arterial coronary course (case examples in Figure 1) and 7 patients (23%) had an acute angled coronary origin. All 16 patients with a normal CT results had a post-operative coronary pattern of 1R-2LCx, whereas this pattern was only observed in 8/14 (57%) patients with abnormal coronary findings on CTA (P<0.005). Conclusions: The current study demonstrated that abnormal coronary findings are frequently observed in adult patients with TGA corrected by ASO. Moreover, a significant association between the coronary anatomy and the presence of coronary abnormalities on CTA was observed, indicating that patients with a post-operative coronary anatomy pattern other than 1R-2LCx may be at higher risk to have potential malignant coronary findings on CTA.

Sudden cardiac death after repair of anomalous origin of left coronary artery from right sinus of Valsalva with an interarterial course : Case report and review of the literature.

Anomalous aortic origin of the coronary artery from the opposite sinus with interarterial course (AAOCA) is a rare condition with a high risk of sudden cardiac death (SCD) during or after strenuous exertion. SCD after repair of this anomaly is extremely rare. Here we present a 15-year-old athlete who collapsed on the basketball court in whom an anomalous origin of the left coronary artery from the right sinus of Valsalva with interarterial course (ALCA) was diagnosed. In spite of extensive pre-sport participation testing, SCD occurred shortly after surgical correction. We reviewed the literature to establish an evidence-based recommendation to aid physicians in conducting the optimal pre-sport participation management for the prevention of SCD in patients with a surgically corrected AAOCA/ALCA, especially for those who participate in strenuous exercise. Review of the literature (60 articles with 325 patients) reveals that post-surgical, pre-sport participation testing varies greatly but that mortality after surgical repair is extremely low (1.5%). In conclusion, SCD can still rarely occur after repair of AAOCA despite extensive pre-sport participation testing. This should raise awareness among physicians treating these patients and raises the question whether or not return-to-play guidelines need to be revised.

Anomalous aortic origin of coronary arteries from the opposite sinus: A critical appraisal of risk

BackgroundAnomalous aortic origin of the coronary artery (AAOCA) from the opposite sinus of Valsalva with an interarterial course has received much attention due to its association with sudden death in otherwise healthy individuals. AAOCA is relatively common and may have significant public health implications. While our knowledge of its pathophysiology and natural history remains incomplete, an emphasis has been placed on surgical correction.DiscussionIn 2005 we published a review examining the rates of sudden death with AAOCA, as well as complications of surgical management. Evidence now points even more strongly to lower rates of sudden death, while surgical outcomes data now better documents associated risks.SummaryArmed with this updated information, we agree with the need for a national registry to better track patients with AAOCA. We submit that the risks of surgical management outweigh any benefits in the asymptomatic patient with anomalous right coronary artery, and expectant management should also be strongly considered even in asymptomatic patients with anomalous left coronary artery.

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 ...

Anomalous origin of left coronary artery: A malignant interarterial variant with a benign clinical course

Anomalous origin of coronary arteries represents a clinical challenge because of the anatomical variability and possible functional consequences, the pathophysiological mechanisms involved, and the lack of large published series that would provide evidence to guide the clinical and therapeutic approach. The authors describe the case of a 55-year-old male patient with a long history of atypical chest pain who was considered to have a low to intermediate likelihood of coronary artery disease. Therefore, and also bearing in mind his physical limitations (congenital left leg atrophy), he was referred for cardiac CT to rule out coronary artery disease. The exam showed a left coronary artery arising from the right coronary cusp and with an interarterial course, between the aorta and pulmonary trunk. Although this is a potentially malignant anatomical variant with surgical indication, a conservative approach was chosen, considering the late diagnosis and particular risk-benefit profile.

Absent Left Main with Anomalous Origin of All Three Coronary Arteries From Left Aortic Sinus: A Previously Undescribed Combination of Coronary Anomalies

Coronary artery anomalies resulting in all three coronary arteries arising separately from single sinus of Valsalva is very rare. We report a patient with two coincidental coronary anomalies: absent left main with left anterior descending, and left circumflex arteries arising separately from left sinus of Valsalva along with anomalous origin of right coronary artery from left sinus of Valsalva. Computed tomography angiogram and conventional coronary angiogram showed anomalous right coronary artery from left sinus with an interarterial course, but with no significant lesions. However, there was significant stenosis of left anterior descending and circumflex arteries that was treated with angioplasty and stenting. To the best of our knowledge, absent left main with all three major coronary arteries arising separately from left aortic sinus has never been reported previously.

Origem anómala da coronária esquerda: variante interarterial maligna com evolução clínica benigna

Anomalous origin of coronary arteries represents a clinical challenge not only because of the anatomical variability, but also the possible functional consequences, pathophysiological mechanisms involved and the absence of large series in the literature that would provide evidence for clinical and therapeutic orientation.The authors describe the case of a 55-year-old male patient with a long history of atypical chest pain who was considered to have a low to intermediate likelihood of coronary artery disease. Therefore, and also bearing in mind his physical limitations (congenital left leg atrophy), he was referred for cardiac CT to rule out coronary artery disease. The exam showed a left coronary artery arising from the right coronary cusp and with an interarterial course, between the aorta and pulmonary trunk. Although this is a potentially malignant anatomical variant with surgical indication, a conservative approach was chosen, considering the late diagnosis and particular risk-benefit profile.

Coronary artery anomalies: Role of contrast enhanced MDCT coronary angiography

ObjectiveThe purpose of this study is to evaluate the role of MDCT in the depiction of coronary artery anomalies. Patients and methodsSixteen patients were included in this study. Retrospectively gated coronary CT angiography was performed in 11 patients and prospectively gated CT coronary angiography was performed in 5 patients. Post-processing techniques as maximum-intensity projection, curved multiplanar reconstruction, and volume rendering were applied to assess the origin and course of the coronary vessels. ResultsOrigin and course anomalies of the central coronary artery segments were seen in 11 patients (67%), anomalies of only coronary artery origin in 2 patients (13%), origin and course anomalies of the peripheral coronary segments in 2 patients (13%) and coronary arterio-venous fistula in one patient (7%). The origin and course anomalies of the central coronary artery segment were more common in the left coronary artery involving 8 patients (73%). Malignant inter-arterial course between aortic root and pulmonary artery or the right ventricle outflow tract was seen in 3 anomalous arteries. ConclusionMDCT coronary angiography can precisely depict the origin and course coronary artery anomalies and is recommended in young patients and before cardiac intervention or surgery to prevent possible complications.

Anomalous origin of coronary arteries: When one sinus fits all

A right coronary artery origin from the left coronary sinus and a left coronary origin from the right sinus although rarely encountered during routine cardiac catheterization, they represent two relatively common autopsy findings in young patients suffering sudden cardiac death. The interarterial course of the aberrant artery, between the aortic root and the pulmonary artery has been considered as a malignant variant, because of the higher risk of myocardial ischemia and sudden death. We present two rare cases of ectopic coronary origin from the opposite sinus of Valsalva.

Identifying, Characterizing, and Classifying Congenital Anomalies of the Coronary Arteries

The clinical manifestations of coronary artery anomalies vary in severity, with some anomalies causing severe symptoms and cardiovascular sequelae and others being benign. Cardiovascular computed tomography (CT) has emerged as the standard of reference for identification and characterization of coronary artery anomalies. Therefore, it is important for the reader of cardiovascular CT images to be thoroughly familiar with the spectrum of coronary artery anomalies. Hemodynamically significant anomalies include atresia, origin from the pulmonary artery, interarterial course, and congenital fistula. Non-hemodynamically significant anomalies include duplication; high origin; a prepulmonic, transseptal, or retroaortic course; shepherd's crook right coronary artery; and systemic termination. In general, coronary arteries with an interarterial course are associated with an increased risk of sudden cardiac death. Coronary artery anomalies that result in shunting, including congenital fistula and origin from the pulmonary artery, are also commonly symptomatic and may cause steal of blood from the myocardium. Radiologists should be familiar with each specific variant and its specific constellation of potential implications.

Malignant Single-Origin Coronary Arteries Arising From a Left Coronary Sinus

A 2-month-old boy with a heart murmur and suspected coronary artery anomalies presented for cardiac computed tomography to delineate the origin and course of these anomalies. A single-origin coronary artery was discovered, which arose from the left coronary sinus and coursed between the two outflow vessels, giving this single origin a potentially malignant course. This vessel then went on to split into right and left coronary arteries with normal anatomic distribution. Without the ability for collateral flow, this vessel was located in an extremely precarious position prone to compression during times of stress or exercise. Very rarely has a single-origin coronary artery supplied both ventricles, and even more astonishing was the presence of its interarterial course. This patient will need long-term follow-up care and undoubtedly will be a candidate for surgery to correct this rare potentially malignant anomaly to lessen the boy's chances of sudden cardiac death.

An interarterial course of anomalous coronary artery and an alternative surgical option

An interarterial course of anomalous left main coronary artery originating from the right aortic coronary sinus of valsalva is a rare condition among anomalous aortic origin of the coronary artery. Various surgical options are available. We performed an alternative procedure, that is, mobilisation of the pulmonic root, pulmonary bifurcation, and plication of the pulmonic root adjacent to the left main coronary artery, in a 12-year-old boy. Favourable results were achieved after 43 months of follow-up.

Symptomatic anomalous right coronary artery originating superior to the left aortic sinus with interarterial course in a young adult. Diagnosis with multislice computed tomographic coronary angiography

Anomalous origination of a coronary artery from the opposite (improper) aortic sinus with interarterial course comprises the group of coronary anomalies with the greatest risk for sudden cardiac death (SCD) in the young. SCD in such settings is consistently related with exercise and driven by ischemia. The proximal ectopic vessel is intussuscepted at the aortic wall and such an anatomy has been documented to be the culprit one. We present a 26-year-old male patient with exercise-induced angina and syncope due to an anomalous right coronary artery, which originated from the tubular ascending aorta superior to the left aortic sinus and followed an interarterial course. Diagnosis was reached with multislice computed tomographic (MSCT) coronary angiography. This case highlights the utility of MSCT to depict the ectopic coronary artery origin and course as

Malignant anomalous right coronary artery detected by multidetector row computed tomography coronary angiography

We report a case of an anomalous origin of a right coronary artery from the left coronary sinus with an inter-arterial course, between the aorta and the main pulmonary artery. This variant has been called malignant because of its association with sudden death, especially in young asymptomatic athletes. Although these variants are rare, knowledge of cross sectional anatomy of the coronary arteries and their variants is critical, especially because some variants are associated with sudden death.

Rare coronary anomaly: Common origin of major coronary arteries from the right sinus of Valsalva and a small ramus branch originating from the left sinus of Valsalva

We present a clinical case where coronary computed-tomography angiogram (CTA) findings on admission had crucial role for clinical diagnosis and management of the patient. A 67-year-old woman with no prior history of coronary artery disease (CAD) was admitted with chest pain and dyspnea for past several weeks. Her initial electrocardiogram and cardiac biomarkers were unremarkable. She was referred for a coronary CTA to rule obstructive CAD as a reason for her symptoms. The coronary CTA showed a common origin of all three major epicardial arteries from right sinus of Valsalva forming a trifurcation, and a small ramus intermedius branch originating from left sinus of Valsalva. The right coronary artery gave rise to the left circumflex artery which had a retroaortic course, and the left anterior descending artery demonstrated an interarterial course (highrisk variant). There was an occlusion of the mid right coronary artery, with associated inferior wall motion abnormality and borderline reduced left ventricular systolic function (Fig. 1). These findings were confirmed on invasive coronary arteriography (Fig. 2, Video 1–4). The patient subsequently underwent coronary artery bypass surgery with a saphenous venous graft to posterior descending artery, and a left internal mammary arterial graft to left anterior descending artery. At 9-month follow-up, the patient denied angina or dyspnea and was doing well.

Two circumflex arteries originating from both right and left coronary sinuses of Valsalva

A 75-year-old woman with a history of chest discomfort was referred to our clinic. Following physical examination and initial tests, a diagnostic coronary arteriography was planned. Left coronary arteriography revealed a normal left main coronary artery (LMCA) originating from the left sinus of Valsalva. The LMCA was branching into the left anterior descending (LAD) and left circumflex (Cx) arteries (Fig. 1). When the right coronary ostium was cannulated, another Cx artery was noticed in addition to a right coronary artery (RCA) (Fig. 2). Most of the cases with anomalous origin of the Cx artery, the initial course is posterior to the aorta. An interarterial course of a Cx artery is a very rare condition. In this case, mild ectasia or interarterial course might be responsible for her symptoms. A multislice computed tomography was planned to show the course, but she refused to take additional radiation. In cases of double Cx artery, origination of the Cx artery as a proximal branch of the RCA or separate branch from right sinus of Valsalva has been previously reported [1]. This case illustrates dual Cx artery with a common ostium with RCA. Fig. 1 Coronary angiogram in the right caudal view shows the left coronary artery tree with a circumflex artery Fig. 2 Coronary angiogram in the left anterior oblique caudal view shows the circumflex artery originating from right sinus of Valsalva

Anomalous Origin of the Right Coronary Artery from the Left Coronary Sinus with an Interarterial Course: Subtypes and Clinical Importance

To classify anomalous origins of the right coronary artery (RCA) from the left coronary sinus (AORL) with an interarterial course into two subtypes and to evaluate the clinical importance of each. Institutional review board approval was obtained for this retrospective study, and informed consent was waived. Through a retrospective review of 22,925 consecutive cardiac computed tomographic (CT) scans, 124 cases of AORL with an interarterial course were identified. These anomalies were classified into two subtypes according to the location of the anomalous RCA ostium: high interarterial course (between the aorta and the pulmonary artery) and low interarterial course (between the aorta and the right ventricular outflow tract). The clinical records were evaluated, and differences in prevalence of typical angina and major adverse cardiac events (MACEs) between the subtypes were analyzed through the χ(2) contingency tables or Fisher exact test. After excluding patients with combined cardiac disease, 87 patients (51 [59%] men, 36 [41%] women; mean age, 56.0 years) were enrolled. Of the 87 patients, 53 had a high interarterial course and 34 had a low interarterial course. A significant difference in the prevalence of typical angina (high [43%] vs low [6%], P = .001) and MACE (high [28%] vs low [6%], P = .012) was observed between the two subtypes. For patients with a high interarterial course, the odds ratio for typical angina was 12.3 (95% confidence interval: 2.7, 56.6), and the odds ratio for MACE was 6.3 (95% confidence interval: 1.3, 29.7). The prevalence of typical angina and that of MACE were significantly higher in patients with a high interarterial course than in those with a low interarterial course.

Anomalous origination of a coronary artery from the opposite sinus

Anomalous origination of a coronary artery from the opposite sinus (ACAOS) is estimated to be present in 0.2-2.0% of the population. In the majority of individuals, ACAOS has no hemodynamic or prognostic implications, but in a minority of cases, typically where the anomalous coronary artery takes an interarterial course to reach its correct myocardial territory, it can precipitate ischemia and sudden cardiac death (SCD). With the growing use of CT coronary angiography (CTCA) in the investigation of ischemic heart disease, we can expect increasing rates of incidental detection of this anomaly. Although CTCA and magnetic resonance coronary angiography can effectively characterize these lesions anatomically, they fail to describe and quantitatively assess the basic defect that leads to coronary insufficiency, such as mural intussusception. The key challenge lies in the identification of which patients are at risk of SCD and, therefore, who should be offered corrective surgical or (potentially) percutaneous intervention. Conventional, noninvasive stress testing has limited sensitivity, but emerging, invasive stress tests, which utilize intravascular ultrasonography and measurements of fractional flow reserve, show the potential to provide more-accurate hemodynamic and prognostic assessment.

Response to Letter Regarding Article, “Long-Term Outcome and Impact of Surgery on Adults With Coronary Arteries Originating From the Opposite Coronary Cusp”

We appreciate Dr Angelini's insights. The prevalence of anomalous coronary artery from the opposite sinus of Valsalva (ACAOS) that he reports from our article, however, was ACAOS with interarterial course (IAC). The actual prevalence of ACAOS was 0.14% (301 cases in 210 700 angiograms),1 a number consistent with several large, recently published series. For comparison, a Turkish group found a prevalence of 0.08% (11 cases in 12 457 angiograms),2 and recent series from India and China found prevalence to be 0.3% and 0.5%, respectively. We actually found that angiographers overreported rather than underreported this anomaly, and that only 57% of those patients initially coded as ACAOS in our registry were eventually confirmed. We agree that there are significant limitations …

Letter by Angelini Regarding Article, “Long-Term Outcome and Impact of Surgery on Adults With Coronary Arteries Originating From the Opposite Coronary Cusp”

To The Editor: I read with interest the recent article by Krasuski and colleagues,1 which acknowledges that our understanding of coronary artery anomalies remains inadequate, and that advances in this field are slow to come. The authors report data from their 35-year experience at the Cleveland Clinic. Their review of coronary angiograms from a database that included 210 700 patients yielded 310 cases of anomalous origin of the coronary artery from the opposite sinus of Valsalva (ACAOS), including 54 cases with an interarterial course (IAC), of which 28 were treated surgically. I congratulate the authors for undertaking such large-scale research into …