Left Sinus Of Valsalva Research Articles

253 EXCERCISE-INDUCED PULMONARY HYPERTENSION AND CORONARY ARTERY ANOMALY: AN UNUSUAL ASSOCIATION

Abstract A healthy 55-year-old competitive sportsman, with familial history of early sudden cardiac death, came to our attention following the finding of asymptomatic exercise-induced myocardial ischemia (ST depression in V3- V6). Computed tomography (CT) coronary angiogram excluded atherosclerotic disease but showed a dominant right coronary artery (RCA) originating from left Valsalva sinus and with an interarterial course between the ascending aorta and the pulmonary artery. Both the trunk of the pulmonary artery and the right ventricle were reported as mildly dilated Transthoracic echocardiography showed a normal left ventricle (LV), while confirmed right ventricle (RV) dilatation, moderate tricuspid regurgitation (TR) and interatrial septal aneurysm. Stress echocardiography excluded inducible ischemia, but highlighted exercise-induced pulmonary hypertension (PH) (PAPs 25 → 70 mmHg), while a transesophageal echo confirmed a left-to-right shunt due to a 8-mm Patent Foramen Ovale (PFO). Rheumatological, thromboembolic and parenchymal lung diseases were excluded as possible causes of exercise-induced PH; a rest right heart catheterization (RHC) showed a Qp/Qs ratio at the upper limits of normal range without PH. Nuclear stress testing identified trivial asymptomatic septal ischemia. The patients started medium dose of beta-blockers and early follow-up was planned. This clinical case raises some questions: why is RV dilated? What role does PFO play? What is the cause of the inducible ischemia? What is the pathogenesis of exercise-induced PH? Pulmonary Arterial Hypertension, in early stages, often manifests only under exertion, but it is usually characterized by exercise dyspnea and low oxygen saturation. Moreover, intracardiac shunts may be involved in developing PH. In this specific case, pulmonary trunk may be expanded by pressure overload, causing the compression of aberrant RCA and consequent ischemic abnormalities. RV dilatation might be explained by exercise-induced PH itself, but it was not severe and has to be demonstrated by exercise right heart catheterization. The main questions are: which is the primary etiology of right chamber enlargement and myocardial ischemia? Which is the most appropriate therapeutic approach (i.e. conservative vs interventional)?

1056 AN OUT OF ORDINARY CASE OF ACUTE SEVERE AORTIC REGURGITATION IN SPONTANEOUS AORTIC VALVE LACERATION

Abstract A 77-year-old male presenting with acute chest pain and syncope was sent to our emergency room by ambulance. An echocardiogram revealed severe pericardial effusion, thoracic aortic ectasia, and mild aortic regurgitation (AR). Computed tomography (CT) scan did not demonstrate aortic dissection. He underwent emergency pericardiocentesis for acute cardiac tamponade. After three hours of clinical monitoring, the transthoracic echocardiogram revealed de-novo severe AR, and CT scan showed a probable laceration of left ventricular wall at the level of left sinus of Valsalva. The lesion was confirmed during urgent cardiac surgery and it was successfully repaired using stitches intertwined with double pledglet and aortic bioprosthesis implant.

Coronary Angiography and Percutaneous coronary Intervention in Anomalous Origin of Right Coronary Artery Arising from the Left Sinus of Valsalva

Background and Aims: To assess the difficulties encountered while performing coronary angiography and percutaneous coronary intervention in anomalous right coronary artery arising from the left sinus of Valsalva.
 Methods: Between January 2016 and December 2020, a total of 23 patients underwent coronary angiography and eight underwent percutaneous coronary intervention for an angiographic significant lesion in the anomalous right coronary artery arising from the left sinus of Valsalva. The vascular approach, usage of catheters, fluoroscopic time, and the amount of contrast used were also assessed.
 Results: Among 6000 coronary angiography and 1500 percutaneous coronary intervention performed, 33 patients (0.55%) had right coronary artery arising from the left sinus of Valsalva. Altogether, 14 patients had type-A, seven had Type-B, eight had Type-C, and four had Type-D anomalous right coronary artery arising from the left sinus of Valsalva. Coronary Angiography was accomplished with the Tiger catheter in 13 patients, Judkins left JL in 8 patients, and Extra-backup (XB3) in one patient. In the percutaneous coronary intervention group, cannulation was done with Judkins left (JL), Amplatz left (AL), and XB in five, two, and one patient respectively and among five type-A patients, four were cannulated with JL and one with XB; one Type-B with JL4; and two Type-C with AL2. The mean fluoroscopic time and contrast volume consumption for coronary angiography and percutaneous coronary intervention were 9.9 minutes and 47 minutes respectively and 63ml and 229 ml respectively.
 Conclusion: Coronary intervention of anomalous right coronary artery arising from the left sinus of Valsalva is difficult due to inappropriate selection of guide catheter and is associated with a higher both mean fluoroscopic time and contrast volume. Radial route is equally effective for successful procedure.

Abstract 15162: Anomalous Right Coronary Artery From the Left Sinus of Valsalva With an Interarterial Course: Impact on Clinical Outcomes in the Adult Population

Introduction: Anomalous right coronary arteries (RCA) arising from the left sinus of Valsalva with an interarterial course (lAC) may cause sudden cardiac death in children and adolescents. However, the natural history and management of patients in whom this anomaly is first detected during adulthood remains uncertain. Methods: Database review identified patients ≥35 years old with anomalous coronary arteries diagnosed by cardiac catheterization or coronary computed tomographic angiography. The outcomes of patients with anomalous RCA with IAC treated conservatively were compared to patients with anomalous left circumflex (LCX) coronary arteries with retroaortic course (an anomaly not associated with ischemic events). The primary outcome was all-cause mortality. Secondary outcomes included survived cardiac arrest and myocardial infarction. Results: The study population consisted of 185 patients (115 men, 70 women) aged 59 ± 12. Clinical characteristics were similar in the RCA (n=88) and LCX (n=97) groups. At follow-up of 6.6 ± 4.4 years there were no statistically significant differences between the 2 groups in mortality (p=0.11) or in secondary outcomes (P=0.89). Conclusions: The outcome of adult patients who had an anomalous RCA with lAC were similar to patients who had anomalous LCX with a known benign course. These results suggest that most patients who survive this anomaly into adulthood may be managed conservatively without intervention.

Right internal mammary artery for the management of anomalous right coronary artery from the left sinus of Valsalva; a case report

Background: Anomalous origin of the right coronary artery from the left sinus of Valsalva (ARCA) is a rare anomaly. Surgery is recommended in symptomatic patients, while the optimal surgical approach is controversial.
 Case presentation: We present a case of an ARCA in a 56-year-old male who was managed with coronary artery bypass grafting using the right internal mammary artery and ligation of the proximal right coronary artery. The patient remained asymptomatic after 1 year of follow-up.
 Conclusions: ARCA can be managed using the right internal mammary artery with ligation of the proximal right coronary artery to prevent the competitive flow.

Origin of the Right Coronary Artery From the left Sinus of Valsalva in a Donor Heart With Unsuccessful Repair

Described herein is a 62-year-old man who had orthotopic heart transplantation (OHT) because of severe heart failure secondary to idiopathic dilated cardiomyopathy. Because of continued symptoms of heart failure, a coronary angiogram was performed 3 years after the OHT and it showed anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva. As a consequence, an operation was performed to transfer the origin of the RCA to the right sinus of Valsalva. Unfortunately, the lumen of the RCA clotted off shortly after the operative procedure. Because of clinical evidence of rejection, the donor heart was replaced 4 years later providing the opportunity to study the previously transferred anomalous RCA.

Prevalence and Patterns of Coronary Artery Anomalies in a Tertiary Cardiac Center of Nepal: A Coronary Angiographic Study

Introduction: The prevalence of coronary artery anomalies (CAAs), though rare, is nonetheless globally found in 0.2% to 1.3% of patients undergoing coronary angiography (CAG). We aimed to investigate the prevalence and patterns of CAAs. Methods: The data was collected retrospectively by analyzing the coronary angiographic data of 6000 consecutive adult patients undergoing coronary angiography between January 2016 to December 2020 at the Manmohan Cardiothoracic Vascular and Transplant Center. Results: Among 6000 patients, 89 (1.4%) had CAAs, with anomalies in the right coronary artery (RCA) being the most common (73%). The presence of a dominant RCA was found in 48 (53.9%) patients. The anomalous origin of RCA arising from the left sinus of valsalva was present in 33 (37.1%) patients. The left main (LM) anomaly was present in 49 (55%) patients with absent LM in 29 (32.6%) and a short LM in 20 (22.5%) patients, respectively. The left anterior descending (LAD) artery anomalies were present in 42 (47.2%) patients - out of which 29 (32.6%) had a separate origin of LAD from the left coronary sinus and 13 (14.6%) had a dual LAD. The left circumflex artery (LCx) anomalies were evident in 32 (35.9%) patients including separate origin from left coronary sinus in 29 (32.6%) and anomalous origin from the right coronary sinus in 3 (3.4%) patients, respectively. Two patients (2.2%) had coronary artery fistulas, both arising from LAD. Conclusion: Though rare, our study did discover the prevalence of CAAs to be1.4%.

Evaluation of Prevalence and Features of Coronary Artery Anomalies using Multidetector-row Computed Tomography

Aim: To evaluate the course, origin and termination of coronary artery anomalies in subjects demonstrating various symptoms and undergoing multidetector CT coronary angiography for evaluation of coronary disease. Study Design: Retrospective study Place and duration: Ch.Pervaiz Elahi Institute of Cardiology Multan from January 2021 to January 2022. Methodology: The study included patients who were referred to the radiology department because of suspicion of coronary artery disease. The data of these patients were reviewed for the course and origin of coronary artery anomalies. A 64-slice scanner was used for MDCT coronary angiography. At the start of acquisition contrast arriving coronary arteries were synchronised using the bolus tracking technique. The whole heart was imaged during apnea using 80-90ml iodinated contrast material administered intravenously. Coronary arteries were evaluated using 3-D and multiplanar reformatted images Results: Total of 600 patients who were referred for MDCT coronary angiography. The subjects underwent screening because of various risk factors, chest pain, or similar symptoms. Coronary artery anomalies were diagnosed in 21 out of 600 (3.5%) patients, whose mean age was 52.6±10.8 years and 504 (84%) were male. 3(14%) patients had high take-off of RCA (right coronary right) and 4(19%) of LMCA (left main coronary artery). In 5(24%) patients left circumflex artery (LCx) and left anterior descending artery (LAD) originated separately from the left sinus of Valsalva (LSV). In 3(14%) patients RCA originated from the opposite sinus of Valsalva.RCA anomaly in 1 patient had a malignant course. Conclusion: The study shows that evaluation of coronary artery anomalies can viably be done using CT. Right diagnosis and treatment planning are based upon an understanding of the clinical significance and CT characteristics of different CAAs. Keywords: Coronary artery angiography, MDCT, prevalence

Giant Aneurysm of the Left Valsalva Sinus Revealed by Left Coronary Ischemia Successfully Treated with Aortic Root Remodeling

Giant Aneurysm of the Left Valsalva Sinus Revealed by Left Coronary Ischemia Successfully Treated with Aortic Root Remodeling

A rare case of dual left anterior descending arteries arising from left main coronary artery and right sinus of Valsalva

Duplication of left anterior descending (LAD) artery is an uncommon coronary anomaly. Type IV dual LAD is the rarest variety where short LAD arises from left main stem and long LAD arises from right coronary artery or right sinus of Valsalva. I present a case of 60-years-old lady with dilated cardiomyopathy with incidental detection of type IV dual LAD during coronary angiography. The patient was treated conservatively

An Atypical Anomalous Aortic Origin of the Left Coronary Artery With Intra-Arterial Wall Course Pretending a Normal Migration on Imaging Screening: A Case Report

BackgroundAn anomalous aortic origin of a coronary artery (AAOCA) has been considered as a dominant cause of sudden cardiac death (SCD) among young age children. Therefore, it is critical to identify AAOCA timely to avoid lethal events. Recently, accumulating cases of right or left coronary arteries originating from inappropriate locations at the sinus of Valsalva have been identified. Here, we report a rare case of AAOCA with an intra-arterial wall course pretending normal migration on imaging screening in a patient who suffered from syncope.Case summaryA 7-year-old male without a previous history of cardiovascular and cerebrovascular diseases suddenly suffered from sharp chest pain and syncope after intensive exercise. The electrocardiogram showed that the ST segment of multiple leads was depressed by more than 0.05 mV, and biomarkers indicated severe myocardial injuries. The left ventricular ejection fraction (LVEF) decreased dramatically to 23%. Fulminant myocarditis and cardiomyopathy were therefore excluded. However, a relatively normal coronary artery origin, which arose from the left coronary sinus, presented on echocardiography and cardiac CT angiography (CTA). It is difficult to draw an association between severe clinical manifestations and slight malformations on echocardiography and CTA. Furthermore, selective coronary angiography revealed that an anomalous left coronary artery arose from the superior margin of the inappropriate sinus, developed an intramural wall course and finally exits the left sinus of Valsalva and migrated between the aorta and the pulmonary artery, which induced severe myocardial infarction during exercise. Then, the patient received surgical correction with a modified unroofing procedure. After 2 months of intensive treatment, the patient was discharged and remained asymptomatic through 18 months of follow-up.ConclusionAAOCA, especially anomalous left coronary artery (ALCA), represents a major potential risk of SCD. We reported an atypical manifestation of ALCA arising from the inappropriate sinus of Valsalva and merging into the intra-arterial wall to develop a strange course and then sprout between the aorta and the pulmonary artery. The diversity of AAOCA might present as a relatively normal course under non-invasive radiological imaging scanning.

Cardiac Arrest in an Adolescent Boy Due to the Anomalous Origin of the Left Main Coronary Artery: Emergency Department Perspective

Congenital anomalies of the origin of the coronary arteries are rare. Multiple anomalies have been reported where the common one is left circumflex arising from the right sinus of Valsalva (RSV). Other anomalies are a single coronary artery from the left sinus of Valsalva, both coronary arteries originating from RSV, and the left anterior descending from RSV. The left main coronary artery originating from RSV is significant as it carries a high risk of sudden cardiac death. We report here the case of one child who was brought in a cardiac arrest to the emergency department of our hospital. After successful resuscitation and further workup during his stay in the hospital, it was found that he had the left main coronary artery originating from the right Valsalva sinus.

Dysphagia Caused by the Unruptured Aneurysm in the Left Sinus of Valsalva.

Dysphagia Caused by the Unruptured Aneurysm in the Left Sinus of Valsalva.

P159 AN INSIDIOUS CASE OF VENTRICULAR STRESS EXTRASYSTOLES IN A YOUNG ATHLETE

Abstract VEBs in young people and athletes are generally benign; however, in some cases, they can be a sign of underlying heart disease and predispose to the risk of SCD during sports. Clinical Case A 14–year–old boy arrives for renewal of competitive sports eligibility. He practices competitive football; always eligible according to previous checks; not familiar with heart disease or SCD; asymptomatic; with normal cardiac objectivity. Basic ECG: RS conduction and repolarisation within normal limits. ECG during exercise: 2 monomorphic VEBs, RBB type with superior axis (Fig. 3). For this reason, he performs TT Echocardiogram and ECG sec. Holter. Holter ECG: 1 SVEB 0 VEB. MB Color Doppler Echocardiogram: LV of normal size and wall thickness with a normal pump function; no alterations of the regional dynamics, undamaged valve systems, RV in the standard; suspected image due to anomaly of coronary origin (right coronary artery from the left sinus of Valsalva). Fig. 1 shows a modified PSAX. In particular, the image highlights the origin of the right coronary and left coronary from the left sinus of Valsalva. The course of the right coronary is parallel to the anterior aortic wall. The cardiac CT confirmed the anomalous origin of the right coronary from the left coronary sinus with a course between the aorta and pulmonary artery. In the proximal section, the right coronary would seem to run for about 12 mm within the adventitia of the aortic wall (Fig. 2) Hence, myocardial scintigraphy was performed on stress testing, given a possible corrective strategy. Discussion Anomalies involving the origin of the coronary arteries and among these, the right coronary artery originating from the left represent one of the leading causes of SCD in athletes under 35 years of age. It is a pathology challenging to diagnose. Indeed, the affected subjects, in most cases, are healthy at the sports doctor visit. Early identification is a priority in the diagnostic classification of a young athlete. In this case, the evidence of extra systolic beats on the exercise stress test and the subsequent ultrasound demonstration of the anatomical anomaly proved significant. The importance of echocardiography in recognizing coronary anomalies in young athletes, as highlighted in our report, should also suggest introducing this method as a screening test for their early identification and, consequently, the prevention of MCI.

Valve-sparing Aortic Root Replacement for a Patient With Filamin A Mutation

A 47-year-old woman with the filamin A mutation and marked obstructive respiratory impairment required admission for lung transplantation. During her perioperative examination, enhanced computed tomography revealed markedly enlarged (80-mm) aortic sinuses, especially the left sinus of Valsalva (Figures 1A, 1B); other arterial abnormalities included localized thrombosed aortic dissection of the infrarenal aorta and right common femoral artery dilatation (Figure 1A, arrows). Preoperative echocardiography showed severe enlargement of the Valsalva sinus and moderate to severe aortic valve regurgitation (Figure 1C, asterisk).

Clustered Origin of the Left Coronary Artery from the Left Sinus of Valsalva: Uncharacteristic Developmental Event in the Temporally Regulated Process

Coronary artery development is a sequential and progressively regulated process. However, there are a number of reports available on the disturbance to this temporal process resulting in variations of the artery. In these instances, the function of the coronary arteries was normal in providing blood supply to the heart. The normal and abnormal coronary artery development has been studied using a variety of approaches and the knowledge continues to evolve. The cadaveric specimen was obtained from the “willed body program” for the purpose of student dissection. During the cadaveric dissection of a 94-year old male Caucasian we observed that the left coronary artery arose from the coronary ostium in a cluster of multiple branches. A detailed study of the origin of the left coronary artery showed that there is one ostium from which multiple branches arose. The right coronary artery arose normally from the right coronary ostium. The coronary veins were normal and returned the blood through the coronary sinus to the right atrium. The anomalous finding is discussed in the light of what is already known about the normal coronary artery development and rationalize a possible explanation. We conclude that the abnormal development of the coronary artery is rarely detrimental and provides adequate blood circulation to the heart. However, knowledge of such malformation is important in clinical practice. KEY WORDS: Coronary Artery, Clustered Left Coronary Artery, Normal Coronary Development, Anomalous Developmental Process, Clinical Significance.

Prevalence and patterns of coronary artery anomalies in 28,800 adult patients undergoing angiography in a large tertiary care centre in India.

Coronary artery anomalies (CAAs) are a diverse group of disorders with varied clinical presentation and pathophysiological mechanisms. A majority of these anomalies are asymptomatic and often an incidental finding on coronary angiogram or autopsy. This retrospective study included 28,800 patients who underwent coronary angiography from 2016 to 2020. The coronary angiograms were reviewed by two independent reviewers and CAAs were documented. CAAs were classified into i) anomalies of coronary artery connection, ii) anomalies of intrinsic coronary arterial anatomy and iii) anomalies of myocardial/coronary artery interaction as proposed by the European Society of Cardiology. Of the 28,800 coronary angiograms, CAAs were present in 4.12% with anomalies in the left coronary artery (LCA) being most common. Anomalies of coronary artery connection were most common (48.48%) followed by anomalies of myocardial/coronary artery interaction (34.49%) and anomalies of intrinsic coronary artery anatomy (17.03%). Among anomalies of coronary artery connection, absent left main trunk or split LCA with separate origins of left anterior descending coronary artery and left circumflex coronary artery from the left coronary sinus of Valsalva (22.59%) was most common. An intramural course or "myocardial bridge" had an incidence of 1.16% while incidence of coronary artery fistulae (CAF) was 0.115%.

Is the Prevalence of Coronary Artery Anomalies Different in Countries with Small Populations? - A Retrospective Study in Northern Cyprus.

Although the prevalence of coronary artery anomalies (CAA) is due to accidental and rare discoveries, it varies between different countries or geographies. CAA are rare congenital disorders having various clinical definitions. Its prevalence varies in angiographic and autopsy series in adult populations and is approximately 1% in average. While the incidence ranges from 0.2% to 5.64% in coronary angiographic (CAG) studies, it is around 0.3% in autopsy series. We aimed to estimate the frequency of CAA in our patient population. The coronary angiographic data of 4099 consecutive adult patients, who underwent CAG between January 2019 and December 2020, were analyzed and retrospectively studied. The mean age of the total patients who underwent CAG was 61.59 ± 13.67 years (range, 18-98 years). CAA were found in 76 patients (1.85% incidence), origin and course anomaly in 62 patients (81.6%), and coronary artery termination anomaly in 14 patients (18.4%). Separate exits of the left anterior descending (LAD) and left circumflex (LCX) coronary artery from the left sinus of Valsalva (LSV) were the most common anomalies (36.84%). Coronary artery fistulas were seen in 14 (18.42%) patients. Abnormal origin of left circumflex artery (LCX) from the right coronary artery (RCA) or right sinus valsalva (RSV) was seen in 13 (17.11%) patients. Outflow anomalies from the contralateral coronary sinus were detected in 10 (13.16%) patients. The incidence and pattern of CAA in our patient population showed similarity with previous studies. Physicians should be aware of CAA that may be associated with potentially serious cardiac incidents, because recognition of these CAA is important for the decision of treatment procedures.

Predictors and Long-Term Outcome of Ablation of Discrete Pre-potentials in Patients With Idiopathic Ventricular Arrhythmias Originating From the Aortic Sinuses of Valsalva.

Background: The predictability and long-term outcome of the discrete pre-potential (DPP) of idiopathic ventricular arrhythmias (VAs) arising from the aortic sinuses of Valsalva (ASV) have not been fully identified.Methods: Of 687 consecutive patients undergoing ablation of outflow tract VAs, there were 105 (15.3%) patients with VAs originating from the ASV region who were included. Detailed mapping was performed within the ASV in all patients. Electrocardiographic, electrophysiological parameters, and long-term success rate were compared between patients with and without the DPPs.Results: A DPP was recorded in 67 of 105 (63.8%) patients, including 38 left sinus of Valsalva (LSV)-VAs (38/105, 36.2%) and 29 right sinus of Valsalva (RSV)-VAs (29/105, 27.6%). The patients with DPPs had wider QRS duration (152 ± 17 vs. 145 ± 14 ms, p < 0.001). The average of earliest activation time was significantly earlier in patients with DPPs (−38.6 ± 8.5 vs. −27.7 ± 5.7 ms, p < 0.001). Mean time from the first lesion to elimination of VAs was shorter in patients with DPPs (2.3 ± 2.1 s vs. 4.9 ± 1.0 s, p < 0.001). A stepwise logistic multivariable analysis identified only younger age as a significant predictor of DPP (age ≤ 35.5 years predicted DPP with 92.9% positive predictive value). During a follow-up duration of 42.5 ± 22.3 months, 63 (94.0%) patients with DPPs and 30 (78.9%) patients without DPPs remained free of recurrent VAs (p = 0.027).Conclusion: Discrete pre-potentials were observed in 63.8% of patients with VAs arising from the ASV. Ablation in patients with DPPs was associated with higher long-term success. DPPs were seen more commonly in younger (age ≤ 35.5 years) patients.

Ectopic right coronary artery arising from the left sinus of Valsalva: A rare variant

An ectopic coronary artery is observed in 0.05–0.1% of angiographic series, may be of tangential origin or proximal endocardial pathway, may result in a slit hole that interferes with flow, and is associated with sudden death.