Coronary anatomy in congenitally corrected transposition of the great arteries

BACKGROUND: The advent of double switch procedures for the treatment of transposition of the great arteries with L-looped ventricles, e.g. typical congenitally corrected transposition of the great arteries, has made delineation of the coronary artery anatomy in these hearts important. Previous studies have suggested a consistently inverted coronary arterial pattern. METHODS: A morphologic study was conducted of the coronary arterial anatomy of all heart specimens in our registry of approximately 2600 hearts with segmental anatomy [S,L,L] (situs solitus of the viscera and atria, ventricular L-loop, and levoposition of the aorta), with anatomical features to permit such repair. RESULTS: Twenty specimens collected between 1965 and 1993 ranged in age from 1 day to 23 years. Transposition of the great arteries or double outlet right ventricle was seen in 12 (60%). One had a single coronary artery that arose from the right anterior sinus and trifurcated. Another had the anterior descending artery arise from the right ventricular coronary artery while the circumflex arose alone, directly above the intercoronary commissure. Eccentric ostia were seen in another four, with one left ventricular coronary artery originating directly above the intercoronary commissure. Right ventricular aorta with pulmonary atresia was in eight of the total (40%). Three had eccentric ostia: one with both arteries from the left posterior sinus, and one with the left ventricular coronary over the intercoronary commissure. None of these specimens had additional coronary anomalies that would further complicate surgery. CONCLUSION: Nearly half of the specimens (45%) had coronary artery abnormalities that could have complicated, but not necessarily precluded, anatomic surgical repair.     

Evaluation of coronary artery anatomy in patients with tetralogy of Fallot by two-dimensional echocardiography

A major coronary artery crossing the right ventricular outflow tract in patients with tetralogy of Fallot interferes with a transannular patch, and preoperative detection of this artery is important. We evaluated the ability of two-dimensional echocardiography to define noninvasively the coronary artery anatomy in 37 consecutive patients (age range, 1 day to 18 years; mean age, 40.9 months). The origin and distribution of the right anterior descending and circumflex coronary arteries, as well as any anteriorly coursing vessel, were examined from parasternal views. Complete studies were obtained in 29 (78%) of the 37 patients. Coronary artery anatomy was determined to be normal by echocardiography in 20 (69%) of the 29 patients. An anterior vessel across the right ventricular outflow tract was detected in the remaining nine patients. Six patients had an anterior descending artery from the left main coronary artery (paired anterior descending arteries in three patients, a right anterior descending artery from the left main coronary artery in two patients, and a right coronary-to-pulmonary artery fistula in one patient). Three patients had no anterior descending artery from the left main coronary artery (anterior descending artery from the right main coronary artery in two patients, and anterior descending and circumflex arteries from the right main coronary artery in one patient). Angiography, surgery, or autopsy confirmed the diagnoses in all but the final patient in whom the anterior descending artery arose from the right main coronary artery as observed at surgery, but the circumflex artery was not seen. Accurate evaluation of coronary artery anatomy is possible by echocardiography in the majority of patients with tetralogy of Fallot. Noninvasive identification of a major coronary artery coursing anteriorly can influence the timing of cardiac catheterization and surgery and the need for angiography.     

Myocardial bridging of obtuse marginal branch of the left circumflex artery associated with congenital corrected transposition of the great arteries

A 54-year-old male was admitted to the emergency department with progressive dyspnea and chest pain during exercise. Congenital corrected transposition of the great arteries was detected on echocardiography. Coronary angiography revealed myocardial bridging on the obtuse marginal branch of the left circumflex coronary artery. Being a rare complex cardiac anomaly we discussed the congenitally corrected transposition of the great arteries (CCTGA) in association with myocardial bridging.     

A quantitative study of the anatomy and distribution of coronary arteries in swine in comparison with other animals and man

The coronary circulation of swine was studied to establish adequate baseline information for using swine in cardiovascular research. Of 65 hearts from domestic and miniature pigs, 45 were injected with a methacrylate plastic and prepared as coronary artery casts whose branches were described and measured, and 20 were injected with different coloured dyes in the right, left anterior descending, and circumflex coronary arteries so that horizontal sections of the heart showed the distribution of each artery and the source of blood supply to particular areas or structures of the heart. Like man, the swine had a left coronary artery that was larger in diameter and longer than the right coronary artery. The right coronary artery was almost always dominant (78%), supplying the posterior septum and atrioventricular node via the posterior descending coronary artery. Eight (17%) of the hearts possessed a balanced blood supply. Two (5%) hearts had a left dominant supply. The intracoronary artery dye injections showed that 72.4% of the right ventricular mass was supplied by the right coronary artery and 27.6% by the left anterior descending coronary artery. In the left ventricle 49% of the mass was supplied by the left anterior descending coronary artery, 25.5% by the right coronary artery, and 25.5% by the circumflex coronary artery. The left anterior descending coronary artery supplied 58% of the interventricular septal mass, while the posterior descending coronary artery supplied 42%. The distribution of the left anterior descending coronary artery branches to the ventricular wall varied inversely in number and size of its diagonal branches (2-9) with the obtuse marginal branches of the circumflex coronary artery which were occasionally more numerous or extended to the apex. The blood supply to the sinoatrial node was always by a branch of the right coronary artery. This analysis shows that not only the coronary anatomy but also the distribution of blood supply to particular areas or structures of the swine heart are very similar to that of humans.     

Single Coronary Ostium in Right Coronary Sinus: Previously Unreported “One for All” Configuration

We report our identification of a single coronary ostium arising from the right coronary sinus of Valsalva, in a 63-year-old woman who presented with chest pain atypical of angina. Coronary angiograms showed that the left anterior descending coronary artery arose from a right ventricular branch and that the left circumflex coronary artery arose from a right posterolateral branch. Both arteries reconstituted themselves in a backward fashion from the apex to the base of the heart—a configuration that to our knowledge has not been reported. The patient was treated conservatively and reported no chest pain 24 months later.     

Spontaneous Termination of Ventricular Fibrillation in a Patient with Congenital Coronary Anomaly

Sudden death is common in patients with congenital coronary artery anomalies mainly when the left main coronary artery originates from the right coronary sinus. Ventricular fibrillation in these patients is irreversible unless defibrillation can be rapidly performed. We describe a 57‐year‐old male with an anomalous origin of circumflex and the left anterior descending coronary arteries from the right coronary sinus. He developed two episodes of ventricular fibrillation that terminated spontaneously, 10 hours after percutaneous revascularization of the circumflex coronary artery. Computed tomography angiography, in addition to confirming the anomalous origin of the coronary arteries, showed a muscle bridge over the midportion of the left anterior descending coronary artery. This is the first report of spontaneous termination of ventricular fibrillation in a patient with congenital anomaly of the coronary arteries.     

Effects of acute, transient coronary occlusion on global and regional right ventricular function in humans.

OBJECTIVES. The aim of this study was to investigate the changes in right ventricular function during acute coronary occlusion produced by inflating a coronary angioplasty balloon catheter. BACKGROUND. Alterations in right ventricular function are well known to occur in patients with acute myocardial infarction or ischemic cardiomyopathy. However, the changes in right ventricular function resulting from acute, transient coronary occlusion of each of the major coronary arteries have been scantily studied, perhaps because of serious limitations of currently available technology. METHODS. A newly designed, mobile, multiwire gamma camera, in combination with generator-produced tantalum-178, affords high count rate first-pass radionuclide angiography and is thus ideal for studying right ventricular function at the bedside. Accordingly, 46 patients underwent first-pass radionuclide angiography at baseline and during transient coronary occlusion induced by a coronary angioplasty balloon catheter. RESULTS. A significant, albeit modest, decrease in global right ventricular ejection fraction occurred during occlusion of the left anterior descending (from 42.9 +/- 9.3% to 39 +/- 8.7%, p < 0.05) and left circumflex (from 44 +/- 9.1% to 38.8 +/- 7.9%, p = 0.03) coronary arteries, but diagonal artery occlusion caused no significant change in right ventricular ejection fraction. Occlusion of the right coronary artery proximal (but not distal) to the acute marginal branch caused a significant decrease in right ventricular ejection fraction (from 42.6 +/- 4.7% to 35.7 +/- 7.2%, p < 0.01). Although occlusion of the left anterior descending, left circumflex and proximal right coronary arteries all caused significant deterioration in regional right ventricular function, only proximal right coronary occlusion caused right ventricular dilation (p < 0.005). CONCLUSIONS. Significant impairment of right ventricular function occurs during transient occlusion of the left anterior descending, left circumflex and proximal right coronary arteries, but only occlusion of the latter causes acute right ventricular dilation, probably as a result of ischemia.     

Selective coronary arteriography in congenitally corrected transposition of the great arteries.

Three cases of congenitally corrected transposition of the great arteries in adults who underwent selective coronary arteriography are presented. The morphologic features of the epicardial coronary anatomy are distinctive and are identifiable angiographically as morphologically right and left coronary arteries that are specifically concordant with the morphologically right and left ventricles. This relation is constant in the presented cases, in previously published coronary arteriograms of congenitally corrected transposition of the great arteries and in a review of the anatomic studies of congenitally corrected transposition of the great arteries that identify the coronary arterial pattern. Thus the angiographic characteristics of the epicardial coronary arterial pattern permit identification of the morphologic features of the underlying ventricle regardless of other spatial relations.     

The independent origins of the anterior descending, circumflex and right coronary arteries from the right coronary sinus]

We present a patient with chronic ischaemic cardiac disease and anomalous left anterior descending and circumflex coronary arteries with independent origin from the right Valsalva sinus. Each one had his own ostium and the left anterior descending artery followed an intramyocardial pathway through the interventricular septum whereas the circumflex artery had a retrocardiac pathway. The clinical picture of the patient was related to the presence of atherosclerotic obstructive lesions in right, whose origin and curse were normal, and circumflex coronary arteries. He was treated medically at first but without obtaining complete control therefore he needed surgical treatment which was undertaken without technical difficulties. We reviewed the anomalies of the main coronary arteries, in the origin and course, with its clinical signification, diagnosis and therapeutics topics.     

Complete proximal occlusion of all three main coronary arteries complicated with a left main coronary aneurysm: a case report

A 68-year-old woman with recurrent chest pain was referred to our institution. Coronary angiography showed 100% obstruction of the left main trunk, the proximal right coronary artery with good collaterals to the left anterior descending artery and left circumflex artery along the conus artery. Emergency surgical revascularization was undertaken with two saphenous vein grafts. The saphenous vein grafts were placed in the left anterior descending artery, obtuse marginal branch and the posterolateral and posterior descending coronary arteries with excellent flow. The postoperative course was uneventful and follow-up angiography was obtained 20 days after the surgery. Coronary angiography demonstrated a saccular aneurysm (10 x 9 mm) originating at the distal segment of the left main coronary artery with 90% stenosis, and excellent patency of both saphenous vein grafts. Follow-up angiography was performed 1 and 3 years after the surgery. The size of the left main coronary aneurysm remained unchanged at both examinations. The patient did well with no further cardiac symptoms after 5 years.     

Origin of three coronary arteries from the right sinus, ramus intermedius from the left sinus and hybrid distribution

A 72-year-old hypertensive man with diabetes had a previously undiagnosed pattern of coronary artery distribution: the ramus intermedius from the left sinus, and the separate origin of the left anterior descending artery, left circumflex artery and right coronary artery from the right sinus. A unique form of branching, a hybrid distribution, was also noted: the left anterior descending artery giving off a right ventricular branch and septals arising from the ramus. No intervention was planned due to the minimal disease observed with angiography and the absence of an interarterial course.     

An unusual case of congenitally corrected transposition of the great arteries associated with noncompaction-like remodeling of the morphological right ventricle

Congenitally corrected transposition of the great arteries is a rare disease characterized by atrio-ventricular and ventriculo-arterial discordance (double discordance) and is associated with other cardiac anomalies in the majority of cases. The important associated anomalies include ventricular septal defect, abnormalities of left atrioventricular valve, subpulmonary stenosis, and conduction abnormalities. However, the noncompaction-like remodeling of the subaortic, morphologic right ventricle is not a commonly reported association. We, report a case of congenitally corrected transposition of the great arteries in a 40-year-old male patient, who had noncompaction-like remodeling of the morphologic right ventricle with severe ventricular dysfunction. He also had, left-sided Ebstein's anomaly, severe left atrioventricular valve regurgitation and a 2:1 atrioventricular conduction block.     

Noninvasive assessment of left and right ventricular filling in myocardial infarction with a two-dimensional Doppler echocardiographic method

Inflow characteristics of left and right ventricular filling were assessed in 40 patients with myocardial infarction and in 10 normal subjects by pulsed Doppler echocardiography. Patients with myocardial infarction were subdivided into four groups, focusing on the involvement of right ventricular and septal branches of the coronary arteries. Group I consisted of 11 patients with anterior infarction who showed an obstructive lesion of the proximal left anterior descending branch involving the first septal perforator with a patent right coronary artery. Group II consisted of 10 patients with inferior infarction who showed an obstructive lesion of the proximal right coronary artery involving the right ventricular branch. Group III consisted of 12 patients with both anterior and inferior infarction who showed obstructive lesions of both the proximal left anterior descending branch and the right coronary artery involving the right ventricular branch. Group IV consisted of seven patients with lateral infarction who showed an obstructive lesion of the diagonal branch or branches of the circumflex coronary artery with a patent left anterior descending branch and right coronary artery. Three measurements were performed from the transmitral and transtricuspidal inflow velocity patterns to assess the left and right ventricular diastolic behaviors. These measurements were: acceleration half-time, deceleration half-time of early diastolic rapid inflow, and the ratio of the peak velocity of early diastolic rapid inflow to that of the late diastolic inflow due to the atrial contraction. Impaired diastolic filling of the left ventricle compensated by enhanced left atrial contraction was observed in patients with myocardial infarction from groups I, II, III and IV.(ABSTRACT TRUNCATED AT 250 WORDS)     

Corrected transposition of the great arteries simulating coronary heart disease in adults.

Two middle-aged adults with corrected transposition of the great arteries presented with chest pain and dyspnea, initially attributed to coronary arterial disease with left ventricular dysfunction and mitral regurgitation. The clinical diagnosis of coronary arterial disease was supported in these patients by electrocardiographic changes of probable old anteroseptal myocardial infarction and by an abnormal cardiac silhouette on the chest x-ray film suggestive of ventricular aneurysm. Coronary arteriographic studies in both patients showed that the morphologic left coronary artery supplied the venous ventricle, and the right coronary artery supplied the systemic ventricle. Neither patient had coronary arterial luminal narrowing. We propose that anginal chest pain in these patients resulted from inadequate coronary reserve of the morphologic right ventricle functioning as a systemic ventricle.     

A case of type IV dual left anterior descending artery associated with anomalous origin of the left circumflex artery in the presence of coronary atherosclerosis

Double origin of the left anterior descending coronary artery (LAD) from the left and right coronary arteries (type IV dual LAD) is a rare coronary anomaly. We report an unusual case of type IV dual LAD associated with anomalous origin of the left circumflex artery from the right coronary artery in a patient with a recent history of myocardial infarction. The first diagonal branch originating from the short LAD demonstrated 70-80% stenosis and the posterior descending artery was totally occluded. We believe that this unusual variance of the coronary arteries in association with atherosclerosis has not been previously reported.     

Coronary arterial and left ventriculographic findings in patients with double-vessel disease and angina pectoris

The distribution and severity of coronary artery disease and left ventricular wall abnormalities are described in 119 patients with double-vessel disease and angina pectoris. The coronary arterial patterns were divided into right (84), mixed (17), and left (18) systems, depending upon the blood supply to the inferior surface of the left ventricle. Patterns of double-vessel disease were separated into those with 50% or greater reduction of luminal diameter involving the left anterior descending and circumflex/obtuse marginal arteries (2-LC), circumflex/obtuse marginal and right coronary arteries (2-CR), and left anterior descending and right coronary arteries (2-LR). The following relationships were noted: (1) Left anterior descending and right coronary artery disease occurs with twice the frequency of 2-LC or 2-CR disease, supporting the thesis that of the three major coronary arteries, the circumflex/obtuse marginal arteries contribute least to angina pectoris. (2) The mid portion of the left anterior descending artery is most commonly involved and the left main coronary artery least commonly involved in patients with double-vessel disease. (3) Left ventricular wall motion abnormalities are found in one-half of patients with double-vessel disease and angina pectoris with hypokinesis usually found in all areas except at the apex where dyskinesis is usually seen.     

Exercise-induced S-wave prolongation in left anterior descending coronary artery stenosis.

Myocardial ischemia may decrease conduction velocity and produce QRS prolongation in the surface electrocardiogram. In cases with normal intraventricular conduction, areas of the myocardium contributing to the development of the S wave receive blood from all 3 major coronary arteries, whereas in left anterior hemiblock or right bundle branch block, most of the blood supply to the areas of the myocardium contributing to the development of the S wave is from the left anterior descending (LAD) coronary artery. To test the hypothesis that the S wave will be prolonged with exercise only in patients with LAD coronary artery stenosis and left anterior hemiblock or right bundle branch block, 88 patients with normal intraventricular conduction, 66 with left anterior hemiblock and 36 with right bundle branch block were studied. Sixty-four, 32 and 21 patients had LAD, right and left circumflex coronary artery stenoses, respectively. In patients with normal coronary arteries, S-wave duration decreased with exercise regardless of the status of ventricular conduction. In patients with coronary artery disease and normal intraventricular conduction, the S wave was prolonged slightly with exercise, but in those with left anterior hemiblock and right bundle branch block, it was prolonged significantly (12.5 +/- 6 and 10.4 ms, respectively) only in those with LAD, but not in those with circumflex or right coronary artery stenosis. S-wave prolongation in patients with LAD coronary artery stenosis and left anterior hemiblock or right bundle branch block most likely is related to exercise-induced ischemia in the areas of the myocardium contributing to the development of the S wave.     

Catheterization laboratory events and hospital outcome with direct angioplasty for acute myocardial infarction

To assess the safety of direct infarct angioplasty without antecedent thrombolytic therapy, catheterization laboratory and hospital events were assessed in consecutively treated patients with infarctions involving the left anterior descending (n = 100 patients), right (n = 100), and circumflex (n = 50) coronary arteries. The groups of patients were similar for age (left anterior descending coronary artery, 59 years; right coronary artery, 58 years; circumflex coronary artery, 62 years), patients with multivessel disease (left anterior descending coronary artery, 55%; right coronary artery, 55%; circumflex coronary artery, 64%), and patients with initial grade 0/1 antegrade flow (left anterior descending coronary artery, 79%; right coronary artery, 84%; circumflex coronary artery, 90%). Cardiogenic shock was present in eight patients with infarction of the left anterior descending coronary artery, four with infarction of the right coronary artery, and four with infarction of the circumflex coronary artery. Major catheterization laboratory events (cardioversion, cardiopulmonary resuscitation, dopamine or intra-aortic balloon pump support for hypotension, and urgent surgery) occurred in 10 patients with infarction of the left anterior descending coronary artery, eight with infarction of the right coronary artery, and four with infarction of the circumflex coronary artery (16 of 16 shock and six of 234 nonshock patients, p less than 0.001). There was one in-laboratory death (shock patient with infarction of the left anterior descending coronary artery).(ABSTRACT TRUNCATED AT 250 WORDS)     

Anomalous septal artery originating from the right coronary sinus and detection of the interarterial course using multislice computed tomography (MSCT)

Anomalies of the coronary arteries are uncommon but may produce life-threatening symptoms and myocardial ischemia. Multislice computed tomography (MSCT) has become a major technique for imaging the coronary arteries. We present a case of a patient with a septal and a circumflex arteries originating from the right coronary sinus and a duplicate left anterior descending artery. The interarterial course of the septal branch is clearly demonstrated with MSCT technique as the abnormal circumflex artery that coursed posterior to the aortic root.     

Aberrant right ventricular branch of right coronary artery with mitral valve prolapse

A 37-year-old man presented with a three-week history of chest pain. Transthoracic echocardiography demonstrated a mitral valve prolapse and mild mitral insufficiency. Coronary angiography showed normal left main, circumflex, left anterior descending and right coronary arteries; however, the right ventricular branch of the right coronary artery had a separate ostium. Concomitant congenital heart abnormalities have been observed with coronary artery anomalies. Primary congenital coronary and valvular anomalies may have genetic heredity. In the present case, mitral valve prolapse was accompanied by a right ventricular coronary artery origin anomaly which, to the best of our knowledge, is the first report in the literature in which both anomalies presented together.