Separate Ostia Research Articles

Cardiomegaly and Variations in Coronary Arteries “All in One:” A Rare Case Report

Abstract Cardiomegaly with variations in coronary arteries has rarely been reported. We report a case of an enlarged heart noticed during routine dissection. The weight of the heart was 600 g; the length, breadth, and thickness of the heart were 15.1, 10.4, and 7.7 cm respectively. The ventricular walls and interventricular walls were thicker than normal. There was a separate ostium for the right conus branch in Valsalva’s right sinus along with a short main trunk of the left coronary artery (LCA); 2 mm and trifurcation of the LCA. It is important to report such cases, as an enlarged heart poses a risk for heart complications, and the use of advanced image diagnostic and interventional techniques is required, which demand in-depth knowledge of the typical and atypical coronary anatomy.

RIGHT CORONARY ARTERY PERCUTANEOUS CORONARY INTERVENTION IN A PATIENT WITH ANOMALOUS ORIGIN OF LEFT MAIN FROM RIGHT CORONARY SINUS – CASE REPORT”

A 63-year-old male is hospitalized during an episode of NSTEMI and therefore he underwent Coronary Angiography which revealed Two-Vessel coronary artery disease and anomalous origin of Left Main Artery. Left Main Artery and Right Coronary Artery did both originate from right coronary sinus, but with separate ostia. The patient underwent revascularization of Right Coronary Artery with balloon angioplasty and drug eluting stents. The case report is made at the University Hospital Center “Mother Tereza”, Tirana Albania.

Anomalous origin of the left coronary artery from the right sinus of Valsalva with separate ostia and inter-arterial course: MDCT angiography depiction.

We describe a case of anomalous left coronary artery origin from the right coronary sinus with separate ostia of right and left coronary arteries detected by 128-slice computed tomography (CT) coronary angiography. Apart from separate ostia, the left coronary artery had inter-arterial course between the aorta and the pulmonary trunk, also called as a malignant course.

Clinical case of Bow Hunter's Syndrome

Bow Hunter‘s Syndrome (BHS) is a mechanical compression of the vertebral artery during head rotation, leading to partial disruption or complete interruption of the blood flow of the affected artery, causing vertebrobasilar vascular insufficiency. There are no established precise diagnostic and therapeutic behavioral algorithms in patients with BHS. I present a case of an 80-year-old woman with syncopal symptoms, in which a dynamic stenosis of the dominant left vertebral artery was diagnosed, and the same artery originates from the aortic arch with a separate ostium.

Balloon Interrogation of Intervening Tissue: A Novel Method to Decide Strategy for Closing Multiple Atrial Septal Defects.

Two separate ostium secundum atrial septal defects are a challenging substrate for device closure due to lack of a well-described strategy or an adequately evaluated protocol. This is a prospective study comprising 20 patients with 2 atrial septal defects who underwent device closure. All of them underwent balloon interrogation (BI) of the intervening tissue to decide 1- versus 2-device strategy. During BI, if the flow through both the defects could be stopped completely implying adequate mobility of the separating tissue, a single device strategy was used. The size of the device in this subset was determined by BI diameter. In case the flow persisted, 2 devices were used to close the defects separately. The mean age was 24±17 years. The main defect size was (mean 14.5 mm±SD 2.69 mm), whereas the second defect measured (mean 8.5±SD 3.02 mm). The tissue separating the 2 defects was measured (mean 6.1±SD 2.6 mm). In 15 of them, based on the BI results, a single device was used successfully to close both the defects without a residual shunt. In the remaining 5 patients, 2 devices were used. There were no complications during the procedure or at follow-up period of 41.9±16.9 months. BI in patients with 2 atrial septal defects is helpful in defining 1- versus 2-device strategies and in choosing the size of the device to be used. Nearly 3/4 of the patients may get away with a single device for closing both the defects successfully thereby decreasing the cost and complexity of the procedure.

An unusual congenital coronary anomaly: A circumflex coronary artery arising in ``shotgun`` with the right coronary artery in anterior ST – elevation myocardial infarction

Objective: Coronary anomalies do not generate symptoms, it is incidental findings when performing a coronary angiography in a patient with ischemic heart disease or valvular heart disease. The anomalous origin of the circumflex (LCX) of the right coronary artery (RCA) is one of the common anomalies. We describe a case of CX orifice arising from right coronary sinus in a ``shotgun`` manner with orifice of RCA and successful percutaneous coronary intervention (PCI). Case Report: In this case, the anomalous incidental finding was the arising of the CX artery in “shotgun” shape with the RCA (separate ostium) in a clinic scenario of anterior ST-segment elevation myocardial infarction wherein the patient received fibrinolytic therapy with alteplase, presenting reperfusion criteria (&qt;50% ST-segment resolution at 60 minutes and relief angina) and then underwent to successful PCI. Conclusion: The ectopic origin of the CX is a well-recognized variant, which is considered the most common coronary anomaly. Although this anomaly is classified as benign and asymptomatic, a few cases of sudden death, myocardial infarction, and angina pectoris in the absence of atherosclerotic lesion have been reported. We shared successful PCI in such coronary anomaly in a patients with ST elevation anterior myocardial infarction. Such coronary anomalies should be considered as well in patients with STEMI undergoing PCI.

The complementary nature of multimodal imaging in the management of an anomalous aortic origin of the right coronary artery from the left coronary cusp

Anomalous aortic origins of coronary arteries (AAOCA) are congenital abnormalities involving the origin and course of coronary arteries and present with diverse clinical manifestations in patients ranging from asymptomatic incidental findings to sudden cardiac death. The current case describes a patient with an anomalous right coronary artery with an anterior interarterial course originating from a separate ostium at the left coronary cusp. By utilizing complementary multimodality imaging techniques including fractional flow reserve (FFRCT), we obtained a comprehensive functional and anatomic assessment resulting in appropriate surgical therapy and a good clinical outcome.

Prevalence and Pattern of Congenital Coronary Artery Anomalies in Patients Undergoing Coronary Angiography at a Tertiary Care Hospital of Northern India.

Objectives: To evaluate the prevalence and pattern of congenital coronary artery anomalies (CAAs) in the adult population undergoing catheter coronary angiography.Methods: The coronary angiograms done between October 2015 and September 2020 were reviewed for the presence of coronary anomalies based upon Angelini's classification. The medical record of patients with anomalies was reviewed for symptomatology and indication of angiography.Results: CAAs were found in 129 (87 males and 42 females) of 6,258 patients giving a prevalence of 2.06%. The mean age was 57.8 ± 11.8 (range 32-81) years. Among these, the anomalous origin and course of the coronaries were the most common anomaly seen in 81 (1.29%) patients, followed by intrinsic anomalies of the coronary arterial system in 44 (0.7%) patients and anomalies of coronary termination and anomalous anastomotic vessels in 2 (0.03%) patients each. Overall, the absence of the left main trunk with a separate origin of the left anterior descending (LAD) and the circumflex artery was the commonest anomaly seen in 46 (0.74%) patients, followed by dual LAD in 35 (0.56%) patients. The anomalous origin of the right coronary artery (RCA) from the left sinus was seen in 14 patients (0.22%) and that of the circumflex artery from the right sinus or right coronary artery was seen in 11 patients (0.17%). The origin of the left main and RCA from ascending aorta was found in eight (0.13%) patients. One (0.02%) patient had a single coronary artery, and another one (0.02%) had all the three coronary arteries arising from the right sinus; however, with separate ostia. The split RCA was seen in nine (0.14%) patients and there were two (0.03%) patients each of coronary artery fistulae, and of anomalous anastomotic vessels.Conclusions: The prevalence of congenital coronary anomalies in this study was 2.06%. The commonest anomaly was that of origin and courses of the vessels, however, the pattern of anomalies is different from previous studies.

Unusual coronary artery arrangement in D-transposition of the great arteries with ventricular septal defect.

A term female with prenatally diagnosed D-Transposition of the great arteries, large membranous ventricular septal defect with inlet extension, moderate secundum atrial septal defect, and large patent ductus arteriosus (Fig1) was born by scheduled caesarean section. Transthoracic echocardiogram confirmed the anatomy with both coronary arteries arising from a single sinus with separate ostia. The right coronary artery arose from right posterior facing sinus (Fig2). The left coronary artery arose anomalously from the same sinus adjacent to the right coronary artery ostium, coursing posterior to the aorta, with brief intramural and interarterial course before bifurcating into the left anterior descending and left circumflex coronary arteries (Figs3 and 4). As a result of this unique coronary pattern, she underwent unroofing of the intramural left coronary artery noted on opening the aortic root to the coronary ostium. Both coronary buttons were harvested and this large button was then divided into two buttons. The left coronary artery button was implanted with a trapdoor technique, right coronary artery button was implanted, and the remainder of the arterial switch procedure along with LeCompte maneuver was completed uneventfully, with closure of the atrial and ventricular septal defects. The post-operative course was uneventful and the patient was discharged on the seventh post-operative day. At discharge, the patient had normal biventricular systolic function, no residual intracardiac shunt, and robust antegrade flow in the reimplanted coronary arteries. The patient was growing well at the fourth month post-operative visit with normal biventricular function, patent coronaries, and outflow tracts.

Abstract 16079: The Cusp of Life: Anomalous Origin of All Coronary Arteries From a Single Cusp

Introduction: Anomalous origin of coronary arteries has a prevalence of 1% in the population and is independently associated with a risk of sudden cardiac death. While an anomalous coronary artery arising from the opposite sinus is rare, all three coronary arteries arising from separate ostia in a single cusp is an extremely rare phenomenon. Case: A 48-year-old male with history of hypertension presented with fevers, cough and shortness of breath of 3 days duration. CXR demonstrated multi-lobar pneumonia and serology returned positive for Influenza A. Treatment was initiated with oseltamivir, vancomycin and piperacillin-tazobactam. Subcutaneous heparin was initiated for VTE prophylaxis. On day 3, the patient developed acute hypoxic respiratory failure from flash pulmonary edema necessitating intubation and mechanical ventilation. ECG revealed ST segment elevation in leads II, III, aVF, V5 and V6 (Fig. 1A). He was taken for urgent cardiac catheterization. Coronary angiography revealed anomalous origins of the left circumflex (LCX) and left anterior descending (LAD) arteries arising from the right coronary cusp (RCC) (Fig. 1B & 1C). 99% thrombotic occlusion of the distal right coronary artery was identified as the culprit lesion (Fig 1D). Percutaneous coronary intervention with a 4 x 30 mm drug-eluting stent was performed. Discussion: Absence of the left coronary artery originating from the left coronary sinus should raise suspicion for a coronary anomaly. While an anomalous LCX artery originating from the RCC is seen in 0.7% individuals, the LAD artery arises from the RCC is seen in 0.15% of people. All three coronary arteries arising from the RCC is extremely rare. An abnormal take-off angle, compression between the aorta and the pulmonary trunk, slit-like ostia, coronary hypoplasia and accelerated atherosclerosis are responsible for the increased risk of coronary events in this population.

Anomalous Origins of All Three Coronary Arteries from Separate Ostia within the Right Aortic Cusp: A Case Report and Review of the Literature.

Coronary artery anomalies are congenital defects which are found incidentally or after cardiac events. While these are rare abnormalities with the majority of patients remain asymptomatic and largely undiagnosed, it remains to be a major cause of sudden cardiac death (SCD). Anomalous origin of left coronary artery (ALCA) from the opposite right aortic sinus is extremely rare with less than 100 cases reported to-date. These patients are at increased risk for significant cardiac events, including SCD. In this report, we present a 48-year-old man with hypertension and marijuana use who was admitted initially with multi-lobar pneumonia and acute kidney injury, developed respiratory failure and sustained ST elevation myocardial infarction (STEMI). Coronary angiography demonstrated anomalous origin of all three main coronary arteries arising from right aortic sinus. In this report we also discuss the genesis of this rare and potentially fatal congenital abnormality and we highlight the diagnostic and management strategies available to-date.

A single, shared origin for all three coronary arteries from the right coronary cusp: a case report

BackgroundAnomalous coronary arteries occur in less than 1% of the population and have been implicated in sudden cardiac and exercise-related death. The most common variant involves the left circumflex artery arising from a separate ostium than the left coronary artery. This case demonstrates a rare variation in which all three coronary arteries arise from a shared, single, ostium originating from the right coronary cusp.Case presentationWe report the case of a 63-year-old Caucasian man with a history of myocardial infarction, congestive heart failure, and atrial fibrillation who presented for syncope. Inpatient ischemic workup, including coronary angiography, demonstrated a rare coronary anomaly which included all three coronary arteries arising from a shared, single, ostium originating from the right coronary cusp. Our patient was treated conservatively with an option for coronary bypass if symptomatic.ConclusionSurgical management is indicated in high-risk patients, but the optimal management for a nonmalignant, shared origin for all three coronary arteries has not been explored in detail.

Anatomic predictors of recurrence after cryoablation for atrial fibrillation: a computed tomography based composite score.

Effective pulmonary vein isolation (PVI) with cryoablation depends on adequate occlusion of pulmonary veins (PV) by the cryoballoon and is therefore likely to be affected by PV and left atrial (LA) anatomical characteristics and variants. Thus, the objective of this study was to investigate the effect of LA and PV anatomy, evaluated by computed tomography (CT), on acute and long-term outcomes of cryoablation for atrial fibrillation (AF). Fifty-eight patients (64.72+9.44years, 60.3% male) undergoing cryoablation for paroxysmal or early persistent AF were included. Pre-procedural CT images were analyzed to evaluate LA dimensions and PV anatomical characteristics. Predictors of recurrence were identified using regression analysis. 60.3% of patients had two PVs on each side with separate ostia, whereas 29.3% and 10.3% had right middle and left common PVs, respectively. The following anatomic characteristics were found to be independent predictors of recurrence: right superior PV ostial max:min diameter ratio > 1.32, left superior PV ostial max:min diameter ratio > 1.2, right superior PV antral circumference > 69.1mm, right inferior PV antral circumference > 61.38mm, right superior PV angle > 22.7°. Using these factors, LA diameter and right middle PV, a scoring model was created for prediction of "unfavorable" LA-PV anatomy (AUC = 0.867, p = 0.000009, score range = 0-7). Score of ≥ 4 predicted need for longer cryoenergy ablation (p = 0.039) and more frequent switch to radiofrequency energy (p = 0.066) to achieve PVI, and had a sensitivity of 83.3% and specificity of 82.5% to predict clinical recurrence. CT-based scoring system is useful to identify "unfavorable" anatomy prior to cryo-PVI, which can result in procedural difficulty and poor outcomes.

Absence of the Left Main Artery with Separate Ostia of the Left Anterior Descending Artery and Circumflex from the Left Sinus Valsalva: A Case Report

Coronary artery anomalies are diagnosed in approximately 1% of patients who undergo coronary angiography (CAG). Several anomalies are life threatening but are generally asymptomatic and clinically insignificant. Nonetheless, proper recognition and adequate visualization is necessary for proper medical management, especially in patients undergoing percutaneous coronary intervention or cardiac surgery. In this report, a 73-year-old female was admitted for NSTEMI. Coronary angiography revealed a stenotic right coronary artery and separate ostium of the left circumflex artery and left anterior descending artery from the left Valsalva sinus. The patient was treated with percutaneous coronary intervention of the RCA lesion.

Frequency of coronary artery anomalies and relationship between coronary artery with anomalous origin and myocardial bridge

The association between coronary artery with anomalous origin and myocardial bridge is not investigated well yet. We aimed to investigate the incidence of coronary artery anomalies and the relationship between coronary artery with anomalous origin and the presence of myocardial bridge. The coronary angiography records of 6100 patients who undergone coronary angiography in Eskisehir Osmangazi University – school of medicine hospital between 2008 and 2010 were retrospectively assessed. The Angelini classification system was used to classify the coronary artery anomalies. Coronary arteries were classified in three classes: (i) Coronary artery with anomalous origin, (ii) abnormal course (myocardial bridge) and; (iii) termination (fistula). Myocardial bridge is a type of coronary anomaly and is defined as the case where a segment of the epicardial coronary artery is covered by myocardium. The incidence of coronary artery anomalies was 3.1%. Coronary artery with anomalous origin was 1.5%, myocardial bridge was 1.4% and fistula was 0.3%. The frequency of coronary artery anomalies was significantly higher in males (66.7%) than in females (33.3%). Among the coronary arteries with anomalous origin, the circumflex and left descending artery originating from separate ostia in the left aortic sinus was the most common anomaly. Myocardial bridge was significantly higher in males (81.9%) than in females (18.07%). Among the coronary artery with anomalous origin, originating of right coronary artery from left sinus of valsalva was significantly higher with the presence of myocardial bridge (p

Anomalous origin of the three coronary arteries with separate ostia from right sinus of Valsalva in a young patient presenting with myocarditis: a very rare congenital anomaly.

Anomalous origin of the three coronary arteries with separate ostia from right sinus of Valsalva in a young patient presenting with myocarditis: a very rare congenital anomaly.

P1911The impact of pulmonary vein morphology and orientation on the outcomes of cryoballoon ablation in patients with paroxysmal atrial fibrillation

Abstract Background Circumferential contact of cryoballoon and pulmonary vein (PV) ostium is an important factor for pulmonary vein isolation (PVI). PV ostium shape and orientation can make challenges for PV occlusion. Purpose We aimed to assess the impact of pulmonary vein morphology and orientation on cryoablation outcomes in patients with paroxysmal AF. Material and methods The single-center prospective study included 122 patients (males: 46.7% (57), mean age 57 (53; 62) with drug-refractory paroxysmal AF. The mean AF duration was 4 years (2; 4). A multislice cardiac computed tomography (MSCT) was performed prior to CBA in order to evaluate the PV anatomy (maximal and minimal ostium diameters, ovality of PV ostium, angle of PV orientation in the frontal and axial plane (Figure1)). The presence of typical anatomy (4 separate ostia of PVs) was inclusion criteria. Procedures were performed with 28-mm second generation balloon. A procedural endpoint was the achievement of PVI. Outcomes of PVI were defined as freedom from any AF episodes documented by ECG from the end of blanking period to 12 months. Results PVI was achieved in 97.5% of PVs (476/488). Freedom from AF was 78.7%. Difficult occlusion of right inferior PV was observed in 12 patients and associated with a more horizontal PV orientation in the frontal plane: −15.2±6.20 versus −26.5±6.3°, p<0.001. A total of 11 (9%) patients experienced transient phrenic nerve injury (PNI) during ablation of right superior PV (RSPV). PNI was associated with the maximum and minimum diameter of the RSPV 20.0–24.0 mm (OR=13,2; 95% CI: 3.4–51; p<0.05) and 17.5–20.0 mm (OR=12.5; 95% CI: 4.7–41.9; p<0.05), respectively. Patients with AF recurrence had significantly larger maximum and minimum diameters of left superior PV (LSPV): 18.8 versus 17.5 mm, p=0.048, and 13.4 versus 12.5 mm, p=0.05, respectively. Ovality of PV ostium was larger in the recurrence group: 0.36 versus 0.18, p=0.05. Figure 1. Evaluation of PV orientation Conclusions Evaluation of PV morphology and orientation can be used to predict CBA results. AF recurrence was associated with larger diameters and ovality of LSPV ostium. More horizontal RIPV orientation was associated with difficult PV occlusion. RSPV morphology can affect safety of procedure.

Supernumerary coronary artery. Case report

During the routine dissection of a 60‐year‐old male within our university's Department of Anatomy, we identified a peculiar aspect of the coronary blood supply.The heart is normally supplied by two coronary arteries, however in our case, we identified a supernumerary coronary artery. It arose from the aorta, through a separate ostium, anterior of the right coronary artery's point of origin. This third artery descended diagonally along the anterior surface of the right ventricle. At the heart's apex, it then continued for approximately 2cm along the posterior interventricular sulcus.The right marginal branch took a diagonal descending path to the middle of the posterior interventricular sulcus, close to the terminal point of the third artery. At the same time, the right coronary artery was shortened, and only descended to the first third of the posterior interventricular sulcus.The left coronary artery presented with two branches: the circumflex branch, and a common trunk for the anterior interventricular branch and the left marginal branch. The anterior interventricular branch was shortened, only descending two thirds of the way along the anterior interventricular sulcus. Both it and the left marginal branch were partially covered by myocardial bridges. The circumflex branch terminated near the posterior interventricular sulcus through two ventricular branches.The study and knowledge of coronary variants is critical in identifying potential collateral paths, of which a supernumerary coronary artery is a good example.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Prevalence and Types of Anomalous Coronary Anatomy and Future Utilisation of Such Cohorts to Investigate Cause

Background: The incidence of anomalous coronary anatomy is about 1%. The embryonic cause is unknown. Method: We searched cardiac catheterisation cases over 5 years (2013–2017) for the words “anomaly”, “anomalous”, “aberrant”, and common spelling mistake variations. For duplicates, only a patient's earliest procedure was included. A cardiologist reviewed the report and angiogram of each potential case to confirm coronary anomaly. We excluded cases of high take-off anterior right coronary origin, separate origin of LAD and circumflex, and coronary artery fistulae, because our methodology was unlikely to detect all such cases. Results: The incidence was 0.8% (109 of 14295) including: (1) Circumflex origin from right cusp or as proximal branch of right coronary (n = 61, 56%), (2) Right coronary origin from left cusp (n = 36, 33%), (3) Left coronary origin from right cusp (n = 8, 7.3%), and single cases (n = 1, 0.9%) of (4) single coronary from right cusp, (5) single coronary from left cusp, (6) right, circumflex and LAD coronaries with separate ostia from right cusp, and (7) LAD origin from right cusp. There was no difference between cases and non-cases regarding age, procedure duration, screening time, height, weight or gender. Conclusions: 0.8% proportion with coronary anomaly is similar to previous series. The commonest anomaly is circumflex arising from the right cusp or as a branch of the right coronary. Our cohort could be leveraged to perform GWAS or whole genome sequencing to investigate genetic contributions to anomalous coronary anatomy. Genetic studies of this phenotype do not yet appear to have been conducted.

Three Separate Coronary Arteries with Hypertrophic Cardiomyopathy

Coronary arteries anomalies are an uncommon congenital heart disease. Anomalous origin of three separate ostia is the rarest condition. Hypertrophic cardiomyopathy is the most common inherited disease. There have been just few cases of hypertrophic cardiomyopathy in relation with congenital coronary anomaly. In this report, we describe a rare case of anomalous origin of all three coronary arteries from separate ostia with apical hypertrophic cardiomyopathy.J MEDICINE JUL 2018; 19 (2) : 136-137