Left Sinus Of Valsalva Research Articles

Intraconal Left Main Coronary Artery Originating From the Left Sinus of Valsalva.

Anomalous left main coronary artery (LMCA) with an intraconal course is a relatively rare form of anomalous coronary artery. Intraconal LMCA typically originates from the right sinus of Valsalva. However, this report describes the very unusual circumstance of an intraconal LMCA originating from the left sinus.

Safety and efficacy of ultra-long intermediate-power ablation for outflow tract ventricular arrhythmia arising from the left ventricular summit

Abstract Background Radiofrequency ablation (RFA) has been effective in managing premature ventricular contractions (PVCs). Despite improvement in ablation techniques, recurrence remains high for LV summit PVCs. Epicardial ablation here is often precluded due to fat and proximity to coronaries, thus, aggressive but safe endocardial options are needed. Purpose To evaluate the safety and effectiveness of ultra-long ablation (>240 seconds) duration for refractory LV summit PVCs. Methods Patients with deep intramural LV summit PVCs were identified by lack of PVC elimination or late (>60 s suppression) and recurrence post-lesion under the left aortic sinus of Valsalva. We included patients who received the longest RFA of at least 240 seconds (maximum 15 minutes). RFA power was titrated slowly from 20 to 35W, carefully ensuring that the impedance drop did not exceed 12 ohms. Acute procedure success was defined as clinical PVC suppression for ≥60 minutes after the last lesion. Short-term success was defined as symptom improvement, ejection fraction (EF) recovery, and drop in PVC burden at 3 months. Results Twenty patients (59.5 ± 16.4 years, 55% male) were included. Baseline features are shown in Table 1. All RFA were delivered endocardially. No steam pops were noted. PVC burden was significantly lower at 3-month follow-up (P< 0.01), Figure 1A. Most patients had a normal ejection fraction (EF) at baseline; thus, no significant difference change in EF was observed (Figure 1B). One complication was recorded, which was tamponade likely caused by coronary sinus dissection requiring pericardiocentesis. Acute success was achieved in 95.0% of the cases, and all cases followed at 3 months (18/18) achieved short-term success. Conclusion Ultra-long duration RFA with lesions ≥ 240 seconds at 35W per lesion for LV summit PVCs appeared to be safe and effective in achieving acute and short-term success. The lack of acute suppression should not discourage operators, as there seems to be delayed suppression in some cases. Careful monitoring of biophysics is paramount when attempting this technique.

A Case Report of Aberrant Origin of the Right Coronary Artery from thePulmonary Artery in an Adult Male: The Role of Multi-modality Imaging

Background: The normal anatomy of the coronary arteries consists of the right coronary artery and the left main coronary artery, which originate from the right and left sinuses of Valsalva in the aortic root separately. In general, congenital anomalies of the coronary artery are uncommon in adults. The ectopic origin of a coronary artery from the pulmonary trunk is part of a group of infrequent coronary artery anomalies. The Anomalous origin of the Right Coronary Artery from the Pulmonary Artery (ARCAPA) is thought to be an extremely rare congenital coronary artery anomaly. Most of our knowledge and experience about this congenital coronary malformation is derived from published case reports and series. Case Presentation: We have, herein, reported the case of a 68-year-old male who was discovered to have ARCAPA after he presented to our center with chest pain. The patient underwent multiple invasive and non-invasive diagnostic imaging modalities, including an echocardiogram, a coronary angiogram, a multislice-gated coronary computed tomographic angiogram, and stress perfusion cardiovascular magnetic resonance imaging. The clinical decision was to continue with conservative non-surgical management along with close follow-up. Conclusion: The ARCAPA anomaly is considered to be one of the rare congenital coronary artery variances that can be discovered in late adulthood as a patient may remain asymptomatic for many decades.

An unusual cause of cardiac arrest in a young infant

BackgroundAnomalous aortic origin of a coronary artery from the inappropriate sinus of Valsalva (AAOCA) is a rare congenital heart lesion. It is uncommon for patients with AAOCA to present with severe symptoms at a very young age.Case presentationWe describe a very rare but critical presentation in a young infant with AAOCA that requires surgical repair and pacemaker placement. A three-month-old infant was referred because of syncope. Cardiac arrest occurred shortly after admission. The electrocardiogram indicated a complete atrioventricular block and a transvenous temporary pacemaker was implanted. A further coronary computed tomographic angiography (CTA) showed the anomalous origin of the right coronary artery from the left sinus of Valsalva. Coronary artery unroofing was performed due to an interarterial course with the intramural component, and a permanent epicardial pacemaker was implanted. The postoperative recovery was uneventful, and this patient was thriving and asymptomatic at the nine-month follow-up. However, the electrocardiogram still indicated a complete pacing rhythm.ConclusionsBy timely diagnosis and treatment, this patient is successfully rescued. Although rare, AAOCA may be fatal even in infants.

Changes in aortic root dimensions post aortic root enlargement with Y-incision and modified aortotomy.

Lifetime management in aortic stenosis (AS) can be facilitated by aortic root enlargement (ARE) to improve anatomy for future valve-in-valve (ViV) procedures. A mitral valve-sparing ARE technique ("Y-incision") and sinotubular junction (STJ) enlargement ("roof" patch aortotomy) allow upsizing by 3-4 valve sizes, but quantitative analysis of changes in root anatomy is lacking. Among 78 patients who underwent ARE by Y-incision technique (± roof aortotomy closure) we identified 45 patients with high-quality pre- and post-operative computed tomography angiography (CTA) scans to allow analysis of change in aortic root dimensions. Detailed measurements of the annulus/basilar ring and sinuses were performed by an expert imager on both pre- and post-operative CTAs. The basal ring was defined as the functional annulus when a bioprosthetic valve was present. Average age was 65±11 years, the majority were female (29, 64%), and 9 (20%) had undergone prior aortic valve replacement (AVR). Valve upsizing was ≥3 sizes in 41 (91%). Post-operative mean basal ring diameter was larger compared to the native annular diameter (26.3 vs. 25.3 mm, P<0.01) and substantially larger than prior prosthetic valve in redo AVR (25.6 vs. 19.3 mm, P<0.001). Diameters of the sinuses at pre-operative computed tomography (CT) increased by +7.7±2.8 [right sinuses of Valsalva (R SVS)], +6.7±3.0 [left sinuses of Valsalva (L SVS)], and +6.6±2.9 mm [non-coronary sinuses of Valsalva (N SVS)]. Mean diameter of the STJ increased to 38.3±3.7 post-operative (+8.1±3.2 mm). Left main (LM) and right coronary artery (RCA) heights decreased by -6.3±3.3 and -3.7±3.4 mm respectively due to the supra-annular position of the valve, however, the post-operative valve-to-coronary (VTC) artery distances were 6.6±2.3 and 4.9±2.0 mm, respectively. The Y-incision root enlargement technique significantly enlarges the sinus and STJ diameters by 6-7 mm while preserving VTC distances despite upsizing by 3-4 valve sizes, resulting in post-operative anatomy that is favorable for future transcatheter aortic valve-in-surgical aortic valve (TAV-in-SAV).

Cracking The Case of The Cryptic Coronary: Diagnostic Strategies for Anomalous RCA Originating from LAD

Background: Coronary artery anomalies are typically congenital, though they may remain undetected until routine cardiac catheterization is performed. With a detection rate of only 1.3%, these anomalies often go unnoticed. In rare cases, the right coronary artery may originate from the left coronary system, but this anomaly is generally benign. Case presentation: A 55-year-old male patient was diagnosed with NSTEMI and underwent coronary angiography. However, despite multiple attempts, the medical team could not cannulate into the right coronary ostium. The left coronary ostium was located in the left sinus of Valsalva. Selective left coronary arteriography revealed normal courses of the left main and LAD but identified a critical stenosis in the LCx and a possible CTO at the RCA ostium. The patient received a stent in the LCx and returned the following month for another angiography, during which he received a stent in the proximal LAD. However, during cine angiography, it was found that the patient had an anomalous RCA that originated from the mid-portion of LAD, coursing anteriorly to the pulmonary artery and down to the right atrioventricular groove. Subsequent CCTA confirmed the RCA's origin from the mid-LAD. Conclusion: The report finds a rare RCA origin in the mid-LAD. The heart and its complex arterial network may be examined thoroughly, appreciate to coronary CTA, a non-invasive imaging approach. This allows for effective interventional cardiovascular therapy and is helpful for medical cardiac abnormality detection and assessment. Keyword: Anomalous Right Coronary Artery, CT Coronary Angiography, RCA from LAD, Single Coronary Artery.

A report of fifty cases with incidental diagnosis of anomalous origin of the right coronary artery from the left sinus of Valsalva

IntroductionAnomalous origin of the right coronary artery from the left sinus of Valsalva (R-ACAOS) is a relatively rare condition that can potentially lead to devastating outcomes. The current study aims to investigate the cardiac-related disorders among patients with incidental R-ACAOS diagnosis through computed tomography angiography (CTA). MethodsThe current cross-sectional study has been conducted on 50 patients diagnosed with R-ACAOS who underwent CTA. Based on CTA, the patients' were categorized as R-ACAOS with interarterial course and non-interarterial course. The demographic and medical characteristics, any history of cardiac intervention and New York Heart Association (NYHA) Functional Classification at the time of diagnosis were recruited. Patients were revisited to assess cardiac-associated variables, including symptoms, the presence of heart failure and current NYHA function class. ResultsThe variables including the history of cardiac intervention (P-value<0.001), the presence of heart failure (P-value = 0.010) and NYHA function class at the time of diagnosis (P-value = 0.006) were remarkably higher among those with interarterial course of R-ACAOS; while, the other variables including chest pain at rest (P-value = 0.55) or on exertion (P-value = 0.12), current NYHA function class, current cardiac-associated symptoms except for dyspnea at rest (P-value = 0.012), mortality and coronary calium score did not differ (P-value>0.05). coronary interventions led to significantly improved NYHA function class (P-value<0.05). ConclusionBased on the findings of the current study, R-ACAOS with interarterial course leads to significantly higher rates of atherosclerotic-related symptoms and events compared with the other types of RCA anomalies. Moreover, coronary interventions led to significantly improved NYHA functional class regardless of R-ACAOS category.

Cardiac magnetic resonance in the assessment of the anomalous right coronary artery originating from the left sinus of Valsalva.

Cardiac magnetic resonance in the assessment of the anomalous right coronary artery originating from the left sinus of Valsalva.

Diagnosis and surgical treatment of high-risk anomalous aortic origin of coronary artery

Objective: To analyze the diagnosis and surgical treatment of high-risk anomalous aortic origin of coronary artery (AAOCA). Methods: This is a retrospective case series study. From January 2016 to July 2023, 24 cases of high-risk AAOCA underwent surgical treatment in Department of Cardiac Surgery, Guangdong Provincial People's Hospital. There were 18 males and 6 females, operatively aged (M (IQR)) 13 (26) years (range: 0.3 to 57.0 years). They were confirmed by cardiac ultrasound and cardiac CT, all of which had anomalous coronary running between the aorta and the pulmonary artery. There were 15 cases of the right coronary artery from the left aortic sinus of Valsalva, 6 cases of left coronary artery from the right aortic sinus of Valsalva, 3 cases of the sigle coronary artery. Only 3 patients had no obvious related symptoms (2 cases were complicated with a positive exercise stress test and 1 case with other intracardiac malformations), 21 cases had a history of chest tightness, chest pain, or syncope after exercise. Three patients suffered syncope after exercise and underwent cardiopulmonary resuscitation (2 cases were treated with an extracorporeal membrane oxygenerator (ECMO)). The gap from the first symptom to the diagnosis was 4.0 (11.5) months (range: 0.2 to 84.0 months). The detection rate of coronary artery abnormalities suggested by the first cardiac ultrasound was only 37.5% (9/24). Seven patients were complicated with other cardiac diseases (4 cases with congenital heart defects, 2 cases with coronary atherosclerotic heart disease, 1 case with mitral valve disease). Results: All 24 patients underwent surgical treatment (23 cases underwent abnormal coronary artery unroofing, 1 case underwent coronary artery bypass grafting), and 5 patients underwent other intracardiac malformation correction at the same time. There were no death or surgery related complications in the hospital for 30 days after the operation. A patient with preoperative extracorporeal cardiopulmonary resuscitation was continuously assisted by ECMO after emergency AAOCA correction and had complications such as limb ischemia necrosis and renal dysfunction after the operation. During the follow-up of 2.2 (3.3) years (range: 1 month to 7.2 years), one patient who previously underwent percutaneous transluminal coronary angioplasty with a stent implant experienced significant postoperative symptomatic relief, and the other discharged patients had no related symptoms. Conclusions: The accurate rate of initial diagnosis for high-risk AAOCA is still low, but the risk of cardiovascular accidents is high. For sports-related chest pain and other symptoms, more attention should be paid to the detection of AAOCA, especially for adolescents. Exercise stress testing can be helpful in evaluating the cardiovascular risk of asymptomatic AAOCA. Instant surgical treatment can achieve satisfactory curative effects.

Left Valsalva sinus isolation with Vieussens' arterial ring.

Left Valsalva sinus isolation with Vieussens' arterial ring.

Anomalous origin of the right coronary artery arising from the left coronary sinus of valsalva in a Nigerian adult: a case report

Anomalous origin of the right coronary artery arising from the left coronary sinus of valsalva in a Nigerian adult: a case report

Potential Clinical Usefulness of Post-Valvular Contrast Densities to Determine the Severity of Aortic Valve Stenosis Using Computed Tomography.

Different methods are established for the changes in aortic valve stenosis with cardiac computed tomography angiography (CCTA), but the effect of the grade of stenosis on contrast densities around the valve has not been investigated. Using the information from flow dynamics in cases of increased velocity through narrowed lumen, the hypothesis was formed that flow changes can alter the contrast densities in stenotic post-valvular regions, and the density changes might correlate with the grade of stenosis. Forty patients with severe aortic stenosis and fifteen with a normal aortic valve were enrolled. With echocardiography, the peak/mean transvalvular gradients, peak transvalvular velocity, and aortic valve opening area were obtained. With CCTA, densities 4-5 mm above the aortic valve; at the junction of the left, right, and noncoronary cusp to the annulus; at the middle level of the left, right, and noncoronary sinuses of Valsalva in the center and the lateral points; at the sinotubular junction; and 4 cm from the sinotubular junction at the midline were measured. First, a comparison of the densities between the normal and stenotic valve was performed, and then possible correlations between echocardiography and CCTA values were investigated in the stenotic group. In all CCTA regions, significantly lower-density values were detected among stenotic valve patients compared to the normal aortic valve population. Additionally, in both groups, higher densities were measured in the peri-jet regions than in the lateral ones. Furthermore, a good correlation was found between the aortic valve opening area and the densities in almost all perivalvular areas. With regard to the densities at the junction of the non-coronary leaflet to the fibrotic annulus and at the most lateral point of the right sinus of Valsalva, a high level of correlation was found between all echocardiography and CCTA parameters. Lastly, with receiver operating characteristic curve measurements, area under the curve values were between 0.857 and 0.930. Certain CCTA density values, especially 4-5mm above the valve opening, can serve as auxiliary information to echocardiography when the severity of aortic valve stenosis is unclear.

Three-step surgical management algorithm for annular rupture in transcatheter aortic valve replacement

ObjectiveWhereas transcatheter aortic valve replacement is widely implemented, annular rupture is a devastating complication and could be highly mortal. However, owing to its rare incidence, the optimal treatment algorithm has not been established. Thus, we evaluated the feasibility and effectiveness of a 3-step algorithm to treat annulus rupture. MethodsFrom 2009 to 2022, 8 patients of 1083 transcatheter aortic valve implantation (0.8%) developed annulus rupture and were treated with the three-step algorithm. The algorithm was composed of a first step (pericardial drainage and protamine neutralization with blood pressure control), second step (manual hemostatic compression via full/partial sternotomy), and a third step (conservative treatment or radical surgical correction). ResultsThe median age at the procedure was 85 (78-88) years and 7 female patients were included in this study. Two (25%) patients had end-stage renal failure under hemodialysis, and median Society of Thoracic Surgeons score was 8.9% (2.1%-23.2%). The implanted transcatheter heart valves (THVs) were 7 balloon-expandable THVs and 1 self-expandable THV with balloon postdilatation. Under this strategy, 8 (100%) patients underwent pericardial drainage as first step and 5 patients achieved hemostasis. Of these, patient 1 demonstrated bleeding from left sinus of Valsalva and required a Bentall procedure. Although the etiology of this phenomenon was not investigated by contrast-enhanced computed tomography, it might be derived from pseudoaneurysm rupture or delayed annular rupture. In 2 patients, the second step treatment was needed for hemostasis. Third-step treatment was conducted in 1 patient. Postoperatively, 6 patients could be discharged without critical complications whereas 2 patients died during the hospitalization. There were no other complications during the followed-up (584 [7-1614]) days. ConclusionsIn accordance with the three-step algorithm, 6 patients, including those with high-risk or inoperative status, survived.

Clinical Outcomes in Adult Patients With an Anomalous Right Coronary Artery from the Left Sinus of Valsalva

An anomalous origin of the right coronary artery from the opposite sinus of Valsalva with an intramural course (R-ACAOS-IM) may cause sudden cardiac death in children and adolescents. However, the natural history and management of patients in whom this anomaly is detected later during adulthood remains uncertain. The goals of this study were to assess the impact of an R-ACAOS-IM on the clinical outcomes in an adult population and to determine if adult patients with this anomaly who do not have significant coronary artery disease (CAD) can be managed safely without surgical intervention. A database review identified patients aged >35 years with anomalous coronary arteries diagnosed by cardiac catheterization or coronary computed tomography angiography. The outcomes of patients with R-ACAOS-IM were compared with patients with anomalous left circumflex coronary arteries with retroaortic course (LCx-RA) (an anomaly not associated with ischemic events). The primary outcome was all-cause mortality. The study population consisted of 185 patients aged 59 ± 12 years. Clinical characteristics were similar in the R-ACAOS-IM (n=88) and LCx-RA (n=97) groups. At a follow-up of 6.6 ± 4.5years, there was no difference in mortality (hazard ratio 0.64, 95% confidence interval 0.32 to 1.28, p=0.20) when adjusted for gender, age, and CAD. A subgroup analysis of 88 patients with no obstructive CAD managed nonoperatively found no difference between the LCx and R-ACAOS-IM groups in mortality (hazard ratio 2.45, 95% confidence interval 0.45 to 13.40, p=0.30). There was no significant difference between the 2 groups in the composite outcome of death, nonfatal myocardial infarction, or survived cardiac arrest. The outcome of adult patients who have anomalous R-ACAOS-IM are similar to patients who have anomalous LCx-RA with a known benign course. In conclusion, these results suggest that most patients who survive this anomaly into adulthood may be managed conservatively without intervention.

Complicated catheter ablation of premature ventricular contractions from the left sinus of Valsalva in a young female. Case presentation.

Idiopathic premature ventricular complexes (PVCs) are usually benign and are often treated conservatively. Data regarding radiofrequency catheter ablation (RFA) of PVCs from the aortic sinus of Valsalva are spare. Furthermore, there are limited data regarding complications and their solutions during RFA of PVCs from the aortic sinus of Valsalva. Here we describe a clinical case of symptomatic PVCs in a 27yrold young woman with reduced exercise tolerance and dyspnea. The patient had taken anti-arrhythmic group Ic, II, and III drugs with no significant effect. Successful catheter ablation of PVCs from the left sinus of Valsalva was complicated by acute occlusion of the left main coronary artery (LCA) followed by polymorphic ventricular tachycardia and ventricular fibrillation. Cardioversion and intravenous antiarrhythmic administration restored the sinus rhythm. The LCA was stented with a bioresorbable Magmaris stent with the support of extracorporeal membrane oxygenation that was required due to severe hypotension and ineffectiveness of vasopressors. After the procedure, a favorable angiographic effect was noted. The result of stenting was monitored with IVUS intravascular navigation. The patient was discharged in a satisfactory condition on the 10th day after the procedure. Special attention should be applied to prevent complications and to careful patient selection for RFA in the left sinus of Valsalva, and care must be taken to avoid injury to the LCA. Timely and correct procedures can result in patient survival even after acute LCA injury and occlusion.

Is it possible to determine arrhythmogenic focus localization of ventricular ectopic complexes detected by ambulatory electrocardiogram monitoring?

Aim. To study the possibility of using algorithms (developed using resting ECG as a mapping tool) for localization arrhythmogenic focus of ventricular arrhythmias (VA) detected by ambulatory 12-lead ECG monitoring (AECGM) with the identification of predominant origins of VA.Material and methods. The study included 54 patients aged 45 to 80 years with high frequency VA evaluated during AECGM: 29 — with coronary artery disease (CAD), 25 — w ithout CAD, who underwent radiofrequency ablation (RFA). The study included patients with effective ablation based on AECGM performed 6 months after RFA. Verification localization of VA exit site was carried out during endocardial mapping and AECGM («Cardiotechnika-04, СT-07», «Incart»). The following algorithms were considered in the study: D. Kuchar; O. Segal; J. Miller; A. S. Revishvili, R. Y. Snegur (2006, 2007); A. B. Weinstein; M. V. Noskova. It was assessed the percentage of matches applying the comparative analysis of results of the invasive and non-invasive methods, and it was revealed the predominant localization of VA.Results. The following algorithms had the highest percentage of matches: D. Kuchar in patients with CAD; A. S. Revishvili, R. Y. Snegur (2007) and M. V. Noskova in patients without CAD. The predominant origins of VA in patients without CAD were the left sinus of Valsalva, right ventricular outflow tract, and in patients with CAD — b asal inferior left ventricular wall, right ventricular outflow tract.Conclusion. Algorithms for arrhythmogenic focus localization of VA, developed using resting ECG, can be used to determine the origin of VA detecting by 12-lead AECGM, taking into account patient’s medical history (CAD, myocardial infarction).

Accuracy of 3D-Printed Models of Aortic Valves – a Comparative Analysis Between Planimetric and Photogrammetric Measurements

Abstract Background 3D printing has changed the paradigm of personalized medicine. Similarly to fingerprints, there are no two identical hearts; consequently, in cardiology, diagnosis and treatment, either medical, interventional or surgical, must be individualized according to the specific problem of a particular patient. The aim of this proof-of-concept study was to analyze two measurement methods, the planimetric and the photogrammetric method, in the process of creating a 3D-printed model from cardiac computed tomography angiography images and to evaluate the accuracy of an aortic valve anatomical model. Material and methods Cardiac computed tomography images, obtained from 20 patients with severe aortic stenosis, underwent stereolithographic reconstruction using 3D Slicer to create digital 3D models of the aortic valves. Serial measurements of six key elements of the aortic valvular apparatus were measured on the 3D model and compared to the measurements taken on the 2D computed tomography images. Results The differences between the two measurement methods were sub-millimetric in case of the left ventricular outflow tract and the sinotubular junction, and 1.386 mm for the left sinus of Valsalva (p = 0.0412), 0.3476 mm for the right sinus of Valsalva (p = 0.1874), and 0.6905 mm for the non-coronary Valsalva sinuses (p = 0.1353). Sinus heights were also similar, with a difference of 0.0119 mm (p = 0.6521). Conclusion In this study, the results of digital photogrammetry were superimposable to those of computed tomography scan measurements. The accuracy of each 3D-printed model depends on geometric complexity, the level of training of the personnel, and on the resources of each 3D printing laboratory.

Percutaneous coronary intervention of anomalous right coronary arteries arising from the left sinus of Valsalva: a single-centre experience from Northern India

An anomalous right coronary artery (ARCA) arising from the left sinus of Valsalva is an uncommon congenital anomaly. The unusual location, take-off and intramural courses of ARCA pose a considerable technical challenge during percutaneous coronary intervention (PCI). We sought to report our experience of PCI of ARCA in 35 cases of atherosclerotic occlusion. The PCI database of 35 cases of ARCA was retrospectively analysed. The details about demography, clinical presentation, PCI procedure and clinical follow-up were noted. The mean age was 56.7±13.5 years. The clinical presentation included stable angina in 45.7%, unstable angina in 20% and acute myocardial infarction in 34.3% of patients. Vascular access was transradial in 37.1% of cases, transfemoral in 60% of cases, and transbrachial in 1 case (2.9%). Judkins left and Amplatz left were commonly used guide catheters. Two patients with balloon-uncrossable, calcified lesions required rotablation-assisted PCI. Intravascular imaging was performed in 12 patients (34.3%). Optical coherence tomography demonstrated a proximal intramural course in 3 patients, and a slit-like orifice in 4 patients. The mean radiation dose and fluoroscopy time were 877±687.3 mGy and 18.8±11.6 minutes, respectively. Twenty-eight (80%) patients had an asymptomatic median follow-up of 49 (interquartile range: 29.0-97.5) months. We performed successful PCI in a cohort of 35 patients with ARCA, with favourable long-term clinical outcomes. The selection of an appropriate guide catheter and technical skills were important factors in achieving favourable results.

Unroofing of an anomalous right coronary artery originating from the left coronary sinus

Coronary abnormalities, including the anomalous aortic origin of a coronary artery, coronary fistula and myocardial bridge, are among the most common congenital cardiovascular anomalies. A left coronary artery arising from the right cusp is less common than the right coronary artery arising from the left cusp but is more often found in autopsy series of sudden cardiac deaths. A slit-like/fish-mouth-shaped orifice, acute angle take-off, intramural course, interarterial course and hypoplasia of the proximal coronary artery have all been proposed as reasons for symptoms, ischaemia and sudden cardiac death. Surgical intervention is recommended for those patients with signs or symptoms of myocardial ischaemia. Intervention in asymptomatic patients with an interarterial/intramural left coronary artery from the right sinus of Valsalva is recommended due to the higher calculated risk of sudden cardiac death. In asymptomatic patients with an intramural right coronary artery from the left sinus of Valsalva, provocative testing is recommended. The slit-like orifice is more commonly seen in an anomalous right coronary artery arising from the left sinus, and we believe it is the major factor responsible for myocardial ischaemia. Our unroofing technique focuses on: (i) transecting the endothelial tissue flap to create a neo-ostium; (ii) limiting the flap resection to the intramural portion to avoid extra-aortic incision; and (iii) marsupialization of a neo-ostium with interrupted sutures to reapproximate the endothelium and prevent aortic dissection.

Right Coronary Artery Origin from Left Sinus of Valsalva with an Inter-arterial Course: Case Report and Review of Literature

Introduction: Overally the anomaly of the coronary arteries are rare. Its incidence according to angiographic, autopsy and echocardiographic findings, are about 1%, 0.29% and less than 0.1% respectively. Usually these are the incidental finding during angiography without clinical presentation. These anomalies may be accompanied by myocardial ischemia, arrhythmia, syncope and sudden death. Case Presentation: We present a 14-year-old Iranian boy who experienced chest pain and shortness of breath after engaging in physical activity. The right coronary artery (RCA) had an intramural and inter-arterial course and was proven to have originated from the left sinus of Valsalva by computed tomographic coronary angiography (CTCA). The RCA began adjunct to the ostium of the left main coronary artery and coursed intramural at first and then continued between the aorta and pulmonary artery. The patient underwent corrective surgery. The RCA was cut from origin and reanastomosd to the right coronary sinus after preparing the sinus. The patient recovered well and he was discharged with the ability to perform sports activity. One year Follow up of the patient was uneventful. Conclusions: Even though single ostium coronary artery abnormalities are uncommon, they have become more frequently identified in recent years using non-invasive techniques such transthoracic echocardiography, which is then followed by CT angiography or conventional angiography. These patients are susceptible to sudden death, so attention to symptoms of the patients and comprehensive approach to them can be lifesaving.