Right Coronary Artery Ostium Research Articles

LEFT MAIN TRACT AND RIGHT CORONARY ARTERY OSTIAL DISEASE

Association of the left main ostium (LMO) and right coronary artery ostium (RCAO) disease was considered as one of the worst coronary artery disease (CAD) scenarios. Locating at the transition zone between coronary vessels and aorta suggest possibility of a different pathophysiology and risk factors

TCT-240 Impact of Coronary Ostial lesions for Clinical Outcomes After Percutaneous Coronary Intervention

It is well known that right coronary artery ostium (RCA-os) is anatomically different from unprotected left main ostium (ULM-os). However, there is a little data regarding the comparison of clinical outcome of percutaneous coronary intervention (PCI) between RCA-os and ULM-os. Therefore, to clarify

Surgical Unroofing of Anomalous Aortic Origin of a Coronary Artery: A Single-Center Experience

Anomalous aortic origin of a coronary artery (AAOCA) has been associated with myocardial ischemia and sudden death. The optimal management of patients with AAOCA is controversial. We examined our experience with surgical unroofing of AAOCA to determine the midterm effect of surgical repair. From October 1992 through December 2011, 75 patients with AAOCA underwent surgical unroofing. Mean age was 39.6 ± 19.6 years; 23 patients (32%) were aged younger than 30 years. Angina, shortness of breath, or syncope was present in 55 patients (72%); 2 (3%) had history of sudden cardiac arrest. Of 40 patients (53%) who had preoperative stress tests, results were abnormal in 20 (50%). Coronary or computed tomography angiography demonstrated an anomalous right coronary artery (RCA) arising from the left sinus in 69 patients (92%) and the left main coronary artery arising from the right sinus in 6 (8%). Two patents (3%) were referred for recurrent anginal symptoms after previous RCA bypass with the right internal mammary artery. Minimally invasive partial upper sternal split was performed in 17 patients (22%). Two patients (3%) needed right internal mammary artery-to-RCA grafting due to flow acceleration at the RCA ostium. There were no early deaths. One late death (1%) occurred related to noncardiac causes. At follow-up (mean, 18 months; maximum, 7 years), all patients remained free of cardiac symptoms. Surgical unroofing of AAOCA is associated with low morbidity and mortality. At intermediate follow-up, resolution of symptoms and freedom from sudden death can be expected. The threshold for offering intervention should be low.

Acute aortic dissection debut as STEMI: A case report

We submit a case report of a 66-year-old male, with hypertension and family history of cerebrovascular disease, who was referred to our department for right-inferior STEMI.According to the current ESC (European Society of Cardiology) guidelines for the management of STEMI, the patient was conducted to the cath lab to perform primary PCI. Despite the identification of the culprit lesion we had many difficulties during the procedure of angioplasty, so we decided to perform aortography that showed a Stanford type A acute aortic dissection involving the ostium of right coronary artery causing the right-inferior STEMI.In the early phase of a STEMI, exclusion of the presence of aortic dissection using further image investigations is actually not recommended, as reported by the latest ESC STEMI guidelines.In uncommon presentation of Acute Aortic Dissection and in every case of Acute Coronary Syndrome associated with neurological symptoms and nonspecific clinical presentation, we suggest and strongly recommend the use of diagnostic algorithm proposed in the thoracic aortic disease national guidelines and a rapid echocardiographic evaluation.

Sirolimus-eluting stent implantation for ostial right coronary artery lesions: five-year outcomes from the j-Cypher registry

Ostial right coronary artery (RCA) lesions are associated with a high restenosis rate after bare-metal stent implantation. However, long-term outcomes after drug-eluting stent (DES) implantation for ostial RCA lesions have not been adequately evaluated. Among 12824 patients enrolled in the j-Cypher registry, 5-year outcomes were compared between 397 patients with ostial RCA lesions, and 3716 patients with non-ostial RCA lesions treated with sirolimus-eluting stents (SES). Through 5-year follow-up, patients with ostial RCA lesions had a significantly higher cumulative incidence of target lesion revascularization (TLR) (28.2 versus 13.7%, P<0.0001) than those with non-ostial RCA lesions. After adjusting for confounders, excess TLR risk of the ostial group relative to the non-ostial group was significant for both early TLR within 1-year and late TLR beyond 1-year (HR 2.14 [95% CI 1.59-2.84], P<0.0001, and HR 1.58 [95% CI 1.06-2.26], P=0.02, respectively). Although the cumulative incidence of death was also significantly higher in the ostial group than in the non-ostial group (25.7 versus 14.4%, P<0.0001), the excess risk of the ostial group relative to the non-ostial group was no longer significant after adjusting for confounders (HR 1.25 [95% CI 0.99-1.57], P=0.07). SES implantation for ostial RCA lesions was associated with higher risk for TLR as compared with that for non-ostial RCA lesions. Restenosis, both early and late, remains an issue in coronary DES implantation for ostial RCA lesions.

GW24-e2526 Clinical characteristics, coronary angiographic and intravascular ultrasound appearances in the patients with ectopic right coronary artery originating from left coronary sinus

ObjectivesTo study clinical characteristics, coronary angiography appearance and the effect of drug-eluting stent implantation in the patients with ectopic right coronary artery (RCA) originating from left sinus and passing between...

Side branch ostium stenting with main vessel drug-eluting balloon kissing (BOMB): An innovative approach for isolated coronary stenosis at side branch ostium

Side branch ostium stenting with main vessel drug-eluting balloon kissing (BOMB): An innovative approach for isolated coronary stenosis at side branch ostium

A novel parasternal transthoracic echocardiographic window for detecting coronary ostial dilation after modified Bentall surgery

BackgroundDuring the modified Bentall surgery (aortic root replacement), a cuff of native aorta is implanted, together with the coronary ostium, into the aortic graft. Multi-detector computed tomography (MDCT) imaging can accurately assess the coronary ostial anastomosis site post-surgery. In this study, we assessed the feasibility of imaging the coronary ostial anastomosis site using transthoracic echocardiography (TTE).MethodsPatients (n = 14, mean age 65 ± 12 years, 79% males) with previous Bentall surgery underwent TTE study, with MDCT (64-slice) as the reference standard. TTE used conventional and novel acoustic windows to interrogate the coronary ostia.ResultsAll coronary ostia (n = 28) were well-visualized with MDCT. The optimum TTE acoustic window for visualizing the coronary ostia was a superiorly positioned parasternal short-axis view with the probe tilted towards the left shoulder, medially angulated for the right coronary artery ostia (RCAos) and laterally angulated for the left main coronary artery (LMAos). In this off-axis position, 10 (71%) LMAos and 13 (93%) RCAos could be visualized. In the conventional parasternal views, only 5 (36%) RCAos and no LMAos could be visualized. TTE underestimated the diameter of the LMAos (10.0 ± 2.4 mm TTE vs. 13.4 ± 2.7 mm MDCT, p = 0.007), but was similar to MDCT for the RCAos (9.8 ± 3.1 mm TTE vs. 11.1 ± 3.2 mm MDCT, p = 0.10).ConclusionsWe report a novel TTE acoustic window to image the coronary ostia of post-Bentall surgery patients. Although TTE underestimates the left coronary ostium size, recognition of the ostial dilation with TTE appears feasible in most patients. Those that cannot be imaged will require alternative imaging modality such as MDCT.

Hypertrophic obstructive cardiomyopathy and anomalous origin of the right coronary artery. A rare coexistence

We present the case of a 65 year-old patient with a history of hypertension and hypertrophic obstructive cardiomyopathy (HOCM) in whom anomalous origin of the right coronary artery (RCA) was diagnosed. Echocardiography measured left ventricular outflow tract (LVOT) gradient ranged between 80 and 123 mm Hg. Systolic anterior motion (SAM) of the mitral valve was visualised. The angiography showed favorable coronary anatomy for alcohol septal ablation (Fig. 1). Additionally, anomalous RCA origin from the left coronary sinus (CS) in sub-selective contrast injection was diagnosed. Cardiac magnetic resonance (CMR) showed asymmetrical left ventricular hypertrophy up to 22 mm of the base anterior segment, base and mid segments of the interventricular septum and inferior segment. Stress CMR revealed reversible, dipyridamole induced ischaemia in the base segment of the lateral wall, apex segments of the inferior and septal wall, and within papillary muscles. Computed tomography (CT) scan revealed RCA ostium angulation and moderate compression at rest of the proximal RCA segment (Fig. 2). Corrective surgery for HOCM was performed. Based on intraoperative assessment of the anomalous RCA course, no surgical correction was done. The anatomical course of a coronary artery that passes between the aorta and pulmonary artery in a young person is a major risk factor for adverse events, even without symptoms. The co-existence of HOCM with marked LVOT obstruction at rest may potentially increase the sudden cardiac death risk. Recently Moza et al. (Am J Med Sci, 2011; 342: 341–342) reported a similar case, but in a much younger patient, who presented with a two-week history of exertional chest pain. Additionally, the combination of HOCM with left coronary artery originating from the right CS was described. Invasive treatment for asymptomatic patients remains controversial, with growing advocacy for patients with ‘left from right’ as opposed to ‘right from left’ origins. CMR provides relevant information on the extent and functional relevance of ischaemia in HOCM patients, mainly attributed to microvascular dysfunction. The value of CT in assessing anomalous coronary arteries has been established. Miller et al. (Int J Cadiovasc Imag, 2012; 28: 1525–1532) presented a series of 15 patients with abnormal origin of coronary arteries, who were examined by CT. This modality proved to be very accurate in showing the anatomical details, confirmed later during corrective surgery. Accurate depiction of the RCA course can be helpful in planning the operative strategy. Interventional treatment of the LVOT obstruction and SAM is discussed elsewhere. Surgical correction of anomalous course of coronary artery is recommended for all adult patients who are symptomatic or who have clear evidence of exercise-induced myocardial ischaemia and the mid-term results are encouraging.

S Chronic total occlusion in ostium of right coronary artery – retrograde approach as the first-choice method of revascularization?

Recanalization of chronic total occlusion (CTO) located in the ostium may require the operator's ability to use the retrograde approach. We present a case of opening a chronically occluded right coronary artery (RCA) by the retrograde approach after an unsuccessful attempt of recanalization by classic antegrade technique.

Necropsy Findings Early After Transcatheter Aortic Valve Implantation for Aortic Stenosis

Although transcatheter aortic valve implantation has been available for 10 years, reports of cardiovascular morphologic studies after the procedure are virtually nonexistent. The investigators describe such findings in 2 patients, both 86 years of age, who died early (hours or several days) after transcatheter aortic valve implantation. Although the prosthesis in each was seated well, and each of the 3 calcified cusps of the native aortic valves was well compressed to the wall of the aorta, thus providing a good bioprosthetic orifice, the ostium of the dominant right coronary artery in each was obliterated by the native right aortic valve cusp. Atherosclerotic plaques in the common iliac artery led to a major complication in 1 patient, who later died of hemorrhagic stroke. The other patient developed fatal cardiac tamponade secondary to perforation of the right ventricular wall by a pacemaker catheter.

Intravascular ultrasound-guided coronary stenting without contrast medium for the treatment of catheter-induced aortocoronary dissection

Catheter-induced aortocoronary dissection is a rare, but serious complication during diagnostic coronary catheterization or percutaneous coronary intervention (PCI). Immediate coronary artery stenting of the entry point is one of therapeutic options. However, PCI itself may worsen the dissection, because contrast injection has been reported to be a risk factor for the extension of dissected aorta. We present a case of 79-year-old male suffering from inferior acute myocardial infarction due to the catheter-induced aortocoronary dissection. Multi-slice computed tomography (MSCT) revealed an intramural hematoma of the ascending aorta and an intimal tear from the proximal portion of right coronary artery (RCA) to the intramural hematoma. We attempted intravascular ultrasound (IVUS)-guided coronary stenting without contrast injection. IVUS revealed that thrombus distributed from the ostium to middle portion of RCA. A 3.0×30mm bare-metal stent was deployed to cover the distal end of thrombus, and a 3.5×30mm bare-metal stent was deployed to cover the entry point and ostium of RCA. All procedures were done without contrast injection. Follow-up MSCT confirmed the patency of stents and the disappearance of the intimal tear. As contrast injection may cause the expansion of the dissected aorta, IVUS-guided stenting of the entry point without contrast injection can be a promising solution for such lesions.

Anomalous Right Coronary Artery Originating From the Left Anterior Descending Artery

A69-year-old man with diabetes mellitus presented at our hospital with exertional chest pain. An exercise test showed a horizontal ST depression in the lateral leads. Multidetector computed tomography revealed a single coronary artery arising from the left sinus of Valsalva and an anomalous branch originating from the midportion of the left anterior descending (LAD) artery that traversed to the right side of the heart along the course of the right coronary artery (RCA). Diffuse calcification in the midportion of the LAD artery indicated stenosis in this section (Fig 1). Coronary angiography revealed severe stenosis in the ostium of the anomalous RCA and around the bifurcation of the LAD artery (Fig 2). He underwent off-pump coronary artery bypass grafting for the LAD artery and anomalous RCA. The left internal thoracic artery (LITA) was anastomosed to the LAD artery, and a saphenous vein graft (SVG) was anastomosed to the proximal portion of the anomalous RCA. The postoperative course was uneventful, and all grafts were patent (Fig 3). An anomalous RCA arising from the LAD artery is extremely rare, and few surgical interventions have been reported. Multidetector computed tomography can provide an accurate diagnosis and valuable information for preoperative planning.

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.

Severe Aortic Regurgitation After Transradial Percutaneous Coronary Intervention

A 60-year-old man presented to a community hospital with new-onset shortness of breath after a 2-hour episode of typical chest pain. The ECG showed anteroseptal and inferior wall Q-waves. Serum troponin T levels were negative. An echocardiogram revealed anterior wall hypokinesia with left ventricular ejection fraction of 40% and no signs of valvular disease. The patient was transferred to our center for coronary angiography. Arterial access was obtained from the right radial artery. The angiogram showed mild disease of the left coronary artery and a right coronary artery (RCA) arising from the left coronary sinus. The RCA was extremely difficult to cannulate; nonselective injections revealed a long and severe stenosis of the mid segment (Figure 1 and Movie 1). After many unsuccessful attempts to cannulate the RCA with different guiding catheters, the operator decided to engage first the left coronary artery with an Amplatz 2 guiding catheter. A BMW Universal II guide wire was advanced into the left anterior descending artery (LAD) for better stability. This approach …

Giant right coronary artery aneurysm presenting as cardiac tamponade

Fig. 2. (A) Coronary angiogram demonstrating diffuse left coronary artery disease. Due to the cath lab results and general medical condition patient was not deemed a suitable candidate for surgical revascularization. A successful attempt was made to exclude RCA from coronary circulation by percutaneous embolization. (B) The angiogram following successful insertion of microcoil into the ostium of right coronary artery (white arrow). The first microcoil embolized into the aneurismal sack (black arrow). Patient subsequently made an uneventful recovery and was transferred back to the referring hospital.

Occlusion of the right coronary artery ostium by an aortic cusp attachment

Occlusion of the right coronary artery (RCA) ostium by an aortic cusp is a rare anomaly and can be a cause of sudden death. We report the case of a child with progressive stenosis of the right coronary ostium caused by a hypoplastic right coronary cusp that adhered to the aortic wall resulting in severe myocardial ischemia. The patient underwent a Ross-Konno operation with mitral valvuloplasty for congenital aortic valvular stenosis and mitral regurgitation caused by ischemia-induced posteromedial papillary muscle dysfunction. The myocardial ischemia was relieved by resection of the deformed pouch-like cusp to disclose the RCA ostium. Postoperative myocardial scintigraphy demonstrated no myocardial ischemia and multidetector computed tomography showed no coronary ostial stenosis.

Stenting of right coronary ostial occlusion due to thrombosed type A aortic dissection: One-year follow-up results

A 52-year-old man experienced acute chest pain and was transferred to our hospital. An electrocardiogram showed ST-segment elevation in leads II, III, aVf, and V1 through V3. The diagnosis at the emergency room was inferior acute myocardial infarction (AMI), and emergent coronary angiography (CAG) was performed. While CAG showed subtotal occlusion of the right coronary artery (RCA) ostium, aortic dissection was suspected due to staining of the contrast agent distal to the occluded site of RCA. Intravascular ultrasound showed compression of the RCA ostium due to aortic dissection. We performed bare metal stent implantation, and contrast-enhanced computed tomography (CT) after stenting showed a thrombosed type A aortic dissection. The patient received medical treatment along with repeated CT and echocardiographic examinations, and was discharged without any events one month after admission. CAG six months after stenting and 64-multislice CT angiography one year later showed a patent RCA. Contrast-enhanced CT at six months showed complete resorption of the ascending aortic intramural hematoma, and 64-multislice CT at one year showed a descending aortic intramural hematoma. The patient is doing well one year after the onset. This is a rare case of successful medical treatment for acute type A aortic dissection complicated with AMI.

Multidetector Computed Tomography for Evaluation of Ischemic Etiology and a Post-Unroofing Procedure for an Anomalous Origin of the Right Coronary Artery From the Left Sinus of Valsalva

An anomalous origin of the right coronary artery (RCA) is a rare congenital anomaly. If it runs between the pulmonary artery and aorta, it may cause acute myocardial infarction (AMI) and sudden death.1-4) Identification of coronary anomalies is sometimes difficult by coronary angiography because of the lack of three-dimensional information. A 34-year old male patient presented with an inferior wall AMI. Coronary angiography showed that the RCA originated from the left sinus of Valsalva close to the left main coronary artery (Fig. 1). Coronary spasm was considered as the etiology of the AMI. Ten months after the first attack, the patient was readmitted due to an inferior wall AMI. Multidetector computed tomography (MDCT) showed that the RCA originated from the left sinus of Valsalva, and ran between the aortic root and the main pulmonary trunk (Fig. 2A). The axial image showed an acute-angled takeoff of the RCA from the ascending aorta and a small orifice of the RCA which was thought to be the main mechanism for the ischemia (Fig. 2B). Findings during surgery showed the RCA ostium with a small slit-like orifice that originated at the left sinus of Valsalva with an acute angle and the proximal portion of the RCA was located beside the commissure, between the right and left cusps, which were embedded in the aortic wall (Fig. 2C). After the operation, MDCT and coronary angiography showed good patency of the RCA and the patient was doing well and was free of symptoms (Fig. 2D and E). Our case showed that when a coronary anomaly, especially an anomalous origin of the RCA, is noted on coronary angiography, MDCT may provide important information about ischemic mechanisms. Fig. 1 Coronary angiography showed there were no significant lesions at LAD and LCX (A). However, RCA could not be found at its usual location. It originated from left sinus of Valsarva (white arrow) close to the left main coronary artery with diffuse minimal ... Fig. 2 MDCT showed RCA originated from left sinus of Valsalva (white arrow), separate from the left main coronary artery, and courses anteriorly between aortic root and main pulmonary trunk (A). The maximum intensity projection image showed an acute-angled takeoff ...

High Origination of the Right Coronary Artery in a 58‐Year‐Old Woman: An Unusual Congenital Coronary Artery Anomaly

A 58-year-old woman underwent coronary angiography because of exertional angina pectoris (New York Heart Association class II). She had a history of arterial hypertension for 13 y. The right coronary artery (RCA) was not visualized during diagnostic angiography. Ascending aortography showed that an ectopic RCA ostium located on the left surface of the ascending aorta several centimeters above the sinotubular junction (Figure 1A). On the basis of aortographic data, we were able to selectively cannulate the RCA ostium using a left Amplatz-type catheter (Figure 1B) (Asahi Intecc CD., LTD Akatsuki-cho, Scto-chi, Aichi, Japan). Anomalous RCA, as well as, the left coronary arterial tree were found to be normal.