Opposite Sinus Of Valsalva Research Articles

Echocardiographic Findings of an Anomalous Origin of the Left Coronary Artery in Children and Adolescents: Real or Fake?

An anomalous origin of the left coronary artery (LCA) is a relatively uncommon congenital heart defect that can lead to myocardial ischemia and sudden cardiac death. An LCA arising from the pulmonary artery and an LCA arising from the opposite sinus of Valsalva are the common types of anomalous origins of the LCA. Echocardiographic assessment of the coronary arteries is an important component of the routine cardiovascular evaluation, but echocardiographic "pseudo images" of LCA origination can be present in some patients. Detection of an anomalous origin of the LCA remains a challenge to sonographers.

Surgical Unroofing for Anomalous Aortic Origin of Coronary Arteries

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

Anomalous Aortic Origin of a Coronary Artery Is Not Always a Surgical Disease.

Anomalous aortic origin of the coronary artery (AAOCA) from the opposite sinus of Valsalva with an interarterial course has become a high-profile lesion as a result of its association with sudden cardiac death in otherwise young and healthy individuals. Despite our incomplete knowledge of its pathophysiology and natural history, surgical intervention is often recommended. Evidence now shows AAOCA to be relatively common, with lower than previously suspected rates of sudden cardiac death. Analysis of this information reveals that AAOCA is not always a surgical disease. Future multi-institutional studies will continue to define those subgroups best served by observation or surgery.

Prevalence and characteristics of coronary artery anomalies in an adult population undergoing multidetector-row computed tomography for the evaluation of coronary artery disease.

BackgroundCongenital coronary anomalies are uncommon with an incidence ranging from 0.17 % in autopsy cases to 1.2 % in angiographically evaluated cases. The recent development of ECG–gated multi–detector row computed tomography (MDCT) coronary angiography allows accurate and noninvasive depiction of coronary artery anomalies.MethodsThis retrospective study included 2572 patients who underwent coronary 64-slice MDCT coronary angiography from January 2008 to March 2012. Coronary angiographic scans were obtained with injection of 80 ml nonionic contrast medium. Retrospective gating technique was used to synchronize data reconstruction with the ECG signal. Maximum intensity projection, multi-planar reformatted, and volume rendering images were derived from axial scans.ResultsOf the 2572 patients, sixty (2.33 %) were diagnosed with coronary artery anomalies (CAAs), with a mean age of 53.6 ± 11.8 years (range 29–80 years). High take-off of the RCA was seen in 16 patients (0.62 %), of the left main coronary artery (LMCA) in 2 patients (0.08 %) and both of them in 2 patients (0.08 %). Separate origin of the left anterior descending artery (LAD) and left circumflex artery (LCx) from left sinus of Valsalva (LSV) was found in 15 patients (an incidence of 0.58 %). In 9 patients (0.35 %) the right coronary artery (RCA) arose from the opposite sinus of Valsalva with a separate ostium. In 6 patients (0.23 %) an abnormal origin of LCX from the right sinus of Valsalva (RSV) was found with a further posterior course within the atrioventricular groove. A single coronary artery was seen in 3 patients (0.12 %). It originated from the right sinus of Valsalva in one patient and from LSV in two patients. In two other patients (0.08 %) the left coronary trunk originated from the RSV with separate ostium from the RCA. LCA originating from the pulmonary artery was found in one patient (0.04 %). A coronary artery fistula, which is a termination anomaly, was detected in 4 patients (0.15 %).DiscussionAlthough these anomalies, which are remarkably different from the normal structure, exist as early as birth, they are incidentally encountered during selective angiography or at autopsy. The incidence in reported angiographic series ranges from 0.6 % to 1.3 %. Variations in the frequency of primary congenital coronary anomalies may possibly have a genetic background. The largest angiographic series of 126595 patients, by Yamanaka and Hobbs, reported a 1.3 % incidence of anomalous coronary artery.ConclusionThe results of this study support the use MDCT coronary angiography as a safe and effective noninvasive imaging modality for defining CAAs in an appropriate clinical setting, providing detailed three-dimensional anatomic information that may be difficult to obtain with invasive angiography.

Dynamic Evaluation of Coronary Anomalies Originating from the Opposite Sinus of Valsalva (ACAOS).

Coronary anomalies originating from the opposite sinus of Valsalva (ACAOS) are a rare anomaly associated with sudden cardiac death. Dynamic, invasive evaluation using coronary angiography, intravascular ultrasound, and fractional flow reserve can more clearly identify important pathophysiologic variants and guide treatment. This dynamic evaluation can assist the clinician in the appropriate surgical and percutaneous treatment options and aid in patient counseling. Long-term outcomes data regarding treatment and prognosis is still lacking.

Why can a case report be so important? The case of sudden cardiac death, caused by a coronary anomaly.

Coronary artery anomalies (CAA) are one of the most common causes of sudden cardiac death (SCD) in the young, in athletes and in military recruits [1–3]. Essentially, anomalous origin of a coronary artery from the opposite sinus of Valsalva (ACAOS, when featuring intramural proximal course of the ectopic artery [3]) is the only type of CAA that is a recognized culprit [1–3]. Current understanding of the patho-physiology of these conditions is still tentative, and the students of such active field of clinical investigations are quite interested in the exact clinical circumstances, during the development of such unusual, unexpected tragedies. Effective treatment requires such understanding. The accompanying article by Kutreti et al. [4] presents in remarkable, unusually available details the case of a 14-year-old girl, who succumbed to one of such cases of SCD.

Origin of the right coronary artery from the opposite sinus of Valsalva in adults: characterization by intravascular ultrasonography at baseline and after stent angioplasty.

ObjectivesWe attempted to characterize the anatomy, function, clinical consequences, and treatment of right-sided anomalous coronary artery origin from the opposite side (R-ACAOS).BackgroundAnomalous aortic origin of a coronary artery is a source of great uncertainty in cardiology. A recent study by our group found that ACAOS had a high prevalence (0.48%) in a general population of adolescents.MethodsSixty-seven consecutive patients were diagnosed with R-ACAOS according to a new definition: ectopic right coronary artery (RCA) with an intramural proximal course. We used intravascular ultrasonograms of the RCA to quantify congenital stenosis (in patients with potentially serious clinical presentations), and we correlated these measurements with clinical manifestations.ResultsAll patients had some proximal intramural stenosis (mean 50%, range 16–83% of the cross-sectional area). Forty-two patients (62%) underwent stent-percutaneous coronary intervention (PCI) of R-ACAOS because of significant symptoms, positive stress tests, and/or significant stenosis. Stent-PCI was successful in all cases and correlated with improved symptoms at >1-year follow-up in 30 patients (71%) who were available for clinical follow-up. No ACAOS-related deaths occurred. The instent restenosis rate was 4/30 (13%) at a mean follow-up time of 5.0 years.ConclusionsThis preliminary, but large and unprecedented observational study shows that cases angiographically identified as R-ACAOS universally feature an intramural aortic course but only occasionally severe stenosis on resting IVUS imaging. Our data suggest that stent-PCI with IVUS monitoring ameliorates patients’ presenting symptoms. © 2015 Wiley Periodicals, Inc.

A review of anomalous origination of a coronary artery from an opposite sinus of Valsalva (ACAOS) impact on major adverse cardiovascular events based on coronary computerized tomography angiography: a 6-year single center review.

Anomalous origination of a coronary artery from an opposite sinus of Valsalva (ACAOS) is a rare finding that is typically found on autopsy in a person with sudden cardiac death or during routine cardiovascular testing. The true prevalence is unknown for this reason. There is also question to the specific anatomy of the anomalies themselves and how best to correct them. We performed a retrospective chart review of all coronary computed tomography angiography (CCTA) studies to evaluate the incidence of all-cause mortality, nonfatal myocardial infarction, stroke and late revascularization (>90 days following CCTA) from January 2005 until July 2012. We describe the origin of the artery, its course, slit-like appearance and treatment in this population. We reviewed 1518 CCTA reports and identified 22 patients with ACAOS with an incidence of 1.4% of our original study population over a review period of 6 years with a resultant median follow-up period of 25 months [interquartile range (IQR)25,75 12-34 months]. The indication for CCTA was for chest pain in the majority of patients (73%). We had one patient undergo surgical repair and one with coronary bypass grafting for unrelated symptomatic coronary artery disease. ACAOS continues to be a rare but presumed fatal condition in subsets identified to carry high risk features. As the characteristics of the anomalous vessels that increase risk are still debated, over an intermediate to long follow up in a single large center, none of the different anomalous findings with varying degrees of high risk findings were associated with sudden death.

The distribution and prognosis of anomalous coronary arteries identified by cardiovascular magnetic resonance: 15 year experience from two tertiary centres.

BackgroundAberrant coronary arteries represent a diverse group of congenital disorders. Post-mortem studies reveal a high risk of exercise-related sudden cardiac death in those with an anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) with an inter-arterial course. There is little documentation of lifetime history and long-term follow-up of patients with coronary artery anomalies.MethodsPatients with anomalous coronary arteries undergoing cardiovascular magnetic resonance over a 15-year period were identified and classified by anatomy and course. Medical records were reviewed for major adverse cardiovascular events (MACE). Revascularisation or myocardial infarction counted only if occurring in the distribution of the anomalous artery.ResultsConsecutive patients with coronary artery anomalies were retrospectively identified (n = 172). Median follow-up time was 4.3 years (IQR 2.5–7.8, maximum 15.6). 116 patients had ACAOS of which 64 (55%) had an inter-arterial course (IAC) and 52 (45%) did not. During follow up 110 ACAOS patients were alive, 5 died and 1 lost to follow-up.ACAOS patients experienced 58 MACE events (5 cardiovascular deaths, 5 PCI, 24 CABG and 24 had myocardial infarction). 47 MACE events occurred in ACAOS with IAC and 11 in those without (p < 0.0001), the statistical difference driven by surgical revascularisation and myocardial infarction.ConclusionsIn life, patients with an anomalous coronary artery originating from the opposite sinus of Valsalva taking an IAC have higher rates of both myocardial infarction and surgical revascularisation during long-term follow up, compared to those without IAC.

104 PROGNOSIS OF ANOMALOUS CORONARY ARTERIES ORIGINATING FROM THE OPPOSITE SINUS OF VALSALVA (ACAOS): 15 YEAR EXPERIENCE FROM TWO LARGE CMR CENTRES

IntroductionAberrant coronary arteries represent a diverse group of congenital disorders, many of which may have no clinical significance. Post mortem studies show a high risk of exercise related sudden cardiac...

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

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

Prevalence and Characteristics of Coronary Anomalies Originating from the Opposite Sinus of Valsalva in 8,522 Patients Referred for Coronary Computed Tomography Angiography

Although coronary computed tomographic angiography has the ability to depict potentially malignant features of anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS), there are limited data on the significance of ACAOS in the computed tomography population. The aims of this study were to assess the prevalence of ACAOS and to correlate its anatomic features with patients' symptoms among 8,522 consecutive subjects who underwent coronary computed tomographic angiography from February 2008 to May 2012. The ACAOS proximal course was classified into anterior, interarterial, septal, and retroaortic subtypes. Malignant ACAOS was recorded if a slitlike ostium, an acute angle of takeoff, an intramural course, and significant compression between the aorta and pulmonary trunk were present simultaneously. The prevalence of ACAOS was 0.84% (72 of 8,522), including right-sided origins of the left main coronary artery (n = 11), left anterior descending coronary artery (n = 9), and left circumflex coronary artery (n = 33) and left-sided origin of the right coronary artery (n = 20). Of the 24 ACAOS (0.28%) with an interarterial course, 12 (0.14%) showed significant vessel compression, of which 6 (0.07%) were classified as malignant. The presence of significant interarterial compression and malignant ACAOS type were observed in left-sided right coronary arteries only, and interarterial compression correlated with patients' symptoms at a median of 15-month follow-up. In conclusion, the computed tomographic prevalence of ACAOS seems to be comparable with that of previous angiographic studies. The malignant features of ACAOS in the adult computed tomography population might be exclusively associated with left-sided right coronary arteries.

Prognosis of anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS): 15 year experience from two large CMR centres

Background Aberrant coronary arteries represent a diverse group of congenital disorders, many of which may have no clinical significance. Post mortem studies show a high risk of exercise related sudden cardiac death in those with an anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) that takes an interarterial (anterior) course. However, there is little documentation in life of the long term natural history of anomalous coronary arteries.

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

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

Aortic Valve Replacement and Concomitant Coronary Artery Bypass Grafting in a Patient with Infective Endocarditis and Anomalous Origin of the Right Coronary Artery from the Opposite Sinus of Valsalva

A 69-yrs-old woman with anomalous origin of the right coronary artery from the opposite sinus of Valsalva (ACAOS) was diagnosed as having infective endocarditis affecting the aortic valve. Transthoracic echocardiography showed severe aortic stenosis and vegetations on the cusp of the aortic valve, which necessitated aortic valve replacement. Before the operation, computed tomography showed a right-ACAOS, with the artery running an interarterial course between the aorta and pulmonary artery. ACAOS running an interarterial course has been reported to be associated with an increased risk of ischemic cardiac events and sudden death. The patient was treated successfully by the aortic valve replacement with concurrent coronary artery bypass grafting using a saphenous vein graft for the right coronary artery.

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.

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.

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 …

Intramural Coronary Length Correlates With Symptoms in Patients With Anomalous Aortic Origin of the Coronary Artery

Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus of Valsalva is a rare congenital anomaly with the potential for myocardial ischemia and sudden death. This review evaluated our series of AAOCA patients, who underwent coronary artery unroofing, to test our hypothesis that the intramural length of the anomalous coronary artery correlates with symptoms. A retrospective analysis of symptoms, preoperative imaging (computed tomography and magnetic resonance imaging), intraoperative assessment, perioperative course, and follow-up were reviewed. From 2005 to 2010, 27 patients (70% male) underwent surgical AAOCA repair. Mean age was 14.3±12 (range, 6 to 52) years. In 25 patients with right AAOCA, 14 had chest pain and 4 had syncope. Both patients with left AAOCA had chest pain. AAOCA unroofing was done in 25 and side-to-side anastomosis in 2. The intramural coronary artery length measured intraoperatively correlated with preoperative symptoms (symptoms=10±3.58 mm, no symptoms=5.2±1.5 mm, p<.002), as did preoperative imaging measurements (symptoms=7.8±2.8 mm, no symptoms=5.3±0.8 mm, p<.001). Preoperative imaging strongly predicted the intraoperative measurement (r=0.81, p=0.00001). There were no deaths, significant morbidity, or recurrence of symptoms. Coronary unroofing for AAOCA is a safe method of enlarging the coronary orifice and eliminating the intramural course. Symptomatic patients had a longer intramural course than asymptomatic patients, as assessed by preoperative imaging and intraoperative measurements. These results may have important clinical implications in determining indications for operation.