Myocardial infarction in the distribution of a patent anomalous left circumflex coronary artery

Anomalous origin of the left circumflex coronary artery is the most common congenital coronary artery anomaly. Myocardial infarction has been seen in the distribution of this anomalous vessel. This has been noted most typically when the vessel is atherosclerotic. Sudden death and myocardial infarction, however, also have been seen in a case without atherosclerotic involvement. This is a case report of a 45-year-old man who suffered a myocardial infarction after strenuous and sustained physical effort and who was found to have nonatherosclerotic coronary arteries with an anomalous left circumflex coronary artery arising from the right sinus of Valsalva.     

Anomalous origin of the left circumflex coronary artery: A case report

The anomalous origin of the left circumflex coronary artery from the right sinus of Valsalva is a relatively common anatomical variation. Difficulties may occur in the diagnostic procedure, but recognition and adequate visualization of the anomaly is essential for proper patient management, especially in patients undergoing evaluation for percutaneous coronary intervention, coronary artery surgery or prosthetic valve replacement. In the present report, a patient who had undergone percutaneous coronary intervention for a right coronary artery lesion after inferior myocardial infarction is described. The anomalous origin of the left circumflex coronary artery arising independently from the right sinus of Valsalva was previously undetected.     

Anomalous circumflex coronary artery: benign or predisposed to selective atherosclerosis

Anomalous origin of the circumflex coronary artery from the right sinus of Valsalva is the most common coronary anomaly and is usually considered benign. Although several researchers in the past believed that aberrancy predisposes this vessel to accelerated atherosclerosis, this could not get wide acceptance owing to lack of convincing data. To examine the suggestion that atherosclerosis affects the anomalous circumflex artery more severely, the authors reviewed the clinical and angiographic features of patients with this anomaly identified from 2,684 coronary angiography procedures performed between January 1998 and March 2000 at their institution. The degree of atherosclerotic narrowing in the anomalous artery was compared with that in other coronary arteries in the same patient as well as in the nonanomalous circumflex arteries in controls. For comparison 3 control subjects were selected for each patient with anomalous circumflex artery, matched by age, sex, and clinical presentations. The results showed earlier and greater degree of atherosclerotic narrowing of the anomalous artery as compared to the other coronary arteries in the same patients as well as to nonanomalous circumflex arteries of age- and gender-matched control subjects with similar clinical characteristics. However, this predilection for atherosclerosis was evident only in anomalous vessels arising from the right side and pursuing a retroaortic course. The anomalous artery was responsible for myocardial infarction in 3 patients, all of whom were 60 years or older. Two of the patients with this anomaly and myocardial infarction underwent successful angioplasty with stent placement for symptomatic relief.     

冠状动脉起源异常的检出率与冠状动脉狭窄

目的　评价国人冠状动脉(冠脉)起源异常的冠脉造影检出率,并探讨其与冠脉狭窄之间的关系。方法　回顾性分析2001年1月至2004年6月在我院接受选择性冠脉造影的患者,观察并记录冠脉起源异常的检出频度和类型,以及合并冠脉狭窄的情况。结果　4094例患者中,共检出冠脉起源异常者32例,检出率为0 78%,其中右冠脉异常起源最为多见,占总数的65 6%;合并冠脉狭窄者共11例(占34 3% ), 其中仅5例(占15 6% )累及起源异常的冠脉,且无1例冠脉狭窄单独累及起源异常的冠脉。结论　国人冠脉起源异常的检出率与国外文献报道结果相似,其中以右冠脉起源异常最为多见,冠脉起源异常与冠脉狭窄不具有相关性。     

Morbidity associated with anomalous origin of the right coronary artery from the left sinus of Valsalva

Anomalies of the coronary arteries occur infrequently, but can have major clinical consequences. Many reports have described an association between sudden death and origin of the left coronary artery from the right sinus of Valsalva, but origin of the right coronary artery from the left sinus of Valsalva is thought to be benign. Herein, we describe a patient in whom anomalous origin of the right coronary artery from the left sinus of Valsalva was associated with significant cardiovascular morbidity. A 25-year-old man developed complete heart block and myocardial infarction in the distribution of a dominant anomalous right coronary artery free of atherosclerotic lesions. Systolic compression at the origin of the anomalous artery was demonstrated. The left coronary artery was normal. We conclude that anomalous origin of the right coronary artery from the left sinus of Valsalva may be associated with significant cardiovascular morbidity in the absence of atherosclerosis.     

Anomalous origin of all three coronary arteries from right sinus of Valsalva in a patient with angina pectoris

Anomalous origin of coronary arteries is uncommon, and all 3 coronary arteries arising from a single sinus of Valsalva is very rare. The anomaly has been associated with myocardial infarction and sudden cardiac death in particular when the anomalous left coronary artery courses between the great vessels. Imaging modalities have a complementary role to angiography in the diagnosis. Percutaneous interventions are technically difficult. Surgical options like direct repair of anomalous artery or coronary artery bypass graft can be helpful. We report a case of a patient who presented with chest pain and was found to have all 3 coronary arteries arising from the right sinus of Valsalva.     

Origin of all major coronary arteries from left sinus of Valsalva as a common coronary trunk: single coronary artery--a case report

Coronary anomalies are divergent and can occur in up to 1% to 2% of patients. The most common of these anomalies is separate ostia of the left anterior descending and left circumflex arteries, followed by origin of the circumflex coronary artery from the right coronary artery and the left coronary artery from the right sinus of Valsalva, either as a separate ostium or as a part of single coronary artery. Anomalous origin of right coronary artery from the left sinus of Valsalva with a separate ostium or from the left main coronary artery is very rare. These coronary anomalies may be incidentally diagnosed on routine angiography or may present with myocardial ischemia, infarction, or sudden death. A case is described in which all 3 coronary arteries were originating from the left sinus of Valsalva as a common trunk (single coronary artery), which trifurcated to left anterior descending, left circumflex, and right coronary artery.     

Successful angioplasty of an occluded aberrant coronary artery: a rare cause of acute myocardial infarction

A 48-year-old woman was admitted for an acute infero-lateral myocardial infarction (AMI). The coronary angiography showed an occluded aberrant left circumflex artery taking off from the right sinus of Valsalva of the aortic root. This rare coronary anomaly represents a challenge for interventional cardiologists, especially in the setting of AMI, since it may be difficult to identify an aberrant occluded vessel, to predict its origin and course and finally to choose the material which offers an adequate support during the revascularization procedure. In this particular case, the percutaneous treatment of initially occluded aberrant circumflex artery was performed successfully.     

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.     

Aberrant course of the left anterior descending coronary artery assoicated with anomalous left circumflex origin from the pulmonary artery.

We have presented a two year nonoperative follow-up of an asymptomatic 14-year-old girl with an unusual anomaly of the coronary arteries. Systolic and diastolic murmurs heard preoperatively did not change following severance of a patent ductus arteriosus. Postoperative selective coronary arteriography revealed (1) anomalous orgin of the left anterior descending artery from the right aortic sinus of Valsalva crossing between the aorta and pulmonary artery, (2) aberrant circumflex artery orgin from the pulmonary artery and (3) collaterals from the left anterior descending and right coronary arteries to the circumflex artery. This combination of coronary anomalies has never been described previously.     

Successful angioplasty of an occluded aberrant coronary artery: A rare cause of acute myocardial infarction

A 48‐year‐old woman was admitted for an acute infero‐lateral myocardial infarction (AMI). The coronary angiography showed an occluded aberrant left circumflex artery taking off from the right sinus of Valsalva of the aortic root. This rare coronary anomaly represents a challenge for interventional cardiologists, especially in the setting of AMI, since it may be difficult to identify an aberrant occluded vessel, to predict its origin and course and finally to choose the material which offers an adequate support during the revascularization procedure. In this particular case, the percutaneous treatment of initially occluded aberrant circumflex artery was performed successfully.     

Abnormal origin of the left circumflex coronary artery: clinical, angiographic and prognostic aspects. Apropos of 30 cases]

The object of this study of 30 patients with an anomalous origin of the left circumflex coronary artery was to define the clinical and angiographic features of this condition and to assess its influence on morbidity and survival. The 30 patients were 24 men and 6 women with ages ranging from 29 to 76 years. An anomalous origin of the left circumflex coronary artery should be suspected when two angiographic signs are present: firstly, the visualisation of a spur of opacification in the 30 degrees LAO view of left ventriculography, present in 93% or our patients; secondly, during selective left coronary angiography in the transverse view, an ascular zone is observed where the normal left circumflex artery should be. Confirmation of the diagnosis depends on opacification of the left circumflex arising from the right anterior sinus of Valsalva with a separate (37%) or common (23%) orifice with the right coronary artery or arising from a proximal segment of the right coronary artery/(40%). Five patients (17%) had a significant stenosis of the anomalous left circumflex coronary artery but this was always associated with lesions of the other coronary narrowing was observed. Of these patients, one had electrocardiographic signs of myocardial ischaemia and no other cause apart from the anomalous origin of the left circumflex to explain this ischaemia. The 30 patients were followed up for an average of 6.1 +/- 3.9 years. During this period, 1 cardiac death, 1 infarction, 5 cases of angina, 4 coronary bypass procedures, and 6 coronary angioplasties were observed. Nine patients (30%) had no cardiac event during follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)     

Myocardial ischemia caused by anomaly at the origin of the left coronary artery

The case of a 68 years old man admitted because of angina "de novo" and submitted to coronariography is reported. The rest ECG showed abnormalities of the ST-T suggesting myocardial ischemia. The coronariography showed: No significant atherosclerotic lesions. The left coronary artery had an anomalous origin; the left descending coronary artery originated from an independent ostium located at the right Valsalva sinus, the circumflex artery had its origin at the same ostium as the right coronary artery.     

Coronary artery anomalies in 126,595 patients undergoing coronary arteriography

Coronary artery anomalies were found in 1,686 patients (1.3% incidence) undergoing coronary arteriography at the Cleveland Clinic Foundation from 1960 to 1988. Of the 1,686 patients, 1,461 (87%) had anomalies of origin and distribution, and 225 (13%) had coronary artery fistulae. Most coronary anomalies did not result in signs, symptoms, or complications, and usually were discovered as incidental findings at the time of catheterization. Eighty-one percent were "benign" anomalies: 1) separate origin of the left anterior descending and circumflex from the left sinus of Valsalva; 2) ectopic origin of the circumflex from the right sinus of Valsalva; 3) ectopic coronary origin from the posterior sinus of Valsalva; 4) anomalous coronary origin from the ascending aorta; 5) absent circumflex; 6) intercoronary communications; and 7) small coronary artery fistulae. Other anomalies may be associated with potentially serious sequelae such as angina pectoris, myocardial infarction, syncope, cardiac arrhythmias, congestive heart failure, or sudden death. Potentially serious anomalies include: 1) ectopic coronary origin from the pulmonary artery; 2) ectopic coronary origin from the opposite aortic sinus; 3) single coronary artery; and 4) large coronary fistulae. Coronary artery anomalies require accurate recognition, and at times, surgical correction.     

冠状动脉起源异常的冠状动脉造影分析

目的探讨冠状动脉起源异常(anomalous origin of coronary artery,AOCA)的冠状动脉造影特征及其临床意义。方法2000年10月~2006年12月在我院行冠状动脉造影的患者1560例,检出有AOCA患者29例,并对其临床资料进行回顾性分析。结果29例AOCA患者检出率为1.9%,其中23例(79.3%)为良性AOCA,包括:前降支和回旋支分别开口于左冠窦15例,回旋支起源于右冠窦3例,右冠状动脉起源于无冠窦1例和高位开口于升主动脉4例;6例(20.7%)为有潜在临床危险AOCA,分别为左主干起源于右冠窦1例,单支左冠状动脉2例,右冠状动脉起源于左冠窦3例。起源异常冠状动脉有明显狭窄患者9例(31.0%),但仅2例为狭窄只累及起源异常动脉。结论AOCA无特征性临床表现,通常在冠状动脉造影时被发现;某些类型有导致严重心脏事件的潜在危险。AOCA与冠状动脉狭窄无相关性。     

Anomalous origin of the circumflex coronary artery--two case reports.

As shown in many series, congenital coronary artery anomalies are found in 0.6 to 1.5% of patients undergoing coronary angiography. Various types of coronary anomalies have been described, many involving the circumflex artery. The second most common anomaly is of the circumflex arising from the right sinus of Valsalva, while origin in the right coronary artery is also frequent. The most common anomaly is absence of the left main coronary artery, the anterior descending and circumflex arteries originating separately in the left coronary sinus. Such anomalies are usually benign, although earlier and more aggressive atherosclerosis is more likely than in normal coronaries and myocardial ischemia can result. Although rare, this can manifest as sudden death. Conventional coronary angiography may be unable to determine the three-dimensional course of the anomalous vessel. The development of multislice computed tomography and its application to cardiac imaging mean that it is now possible to visualize the coronary arteries non-invasively and to obtain more accurate information on their proximal course. We present two cases of congenital anomaly of the circumflex coronary artery diagnosed with the aid of multislice computed tomography.     

Congenital coronary anomalies of origin and distribution in adults: a coronary arteriographic study

BACKGROUND: Coronary anomalies should be recognized to avoid problems during coronary intervention and cardiac surgery. METHODS AND RESULTS: We retrospectively reviewed 7400 coronary angiograms to find out the pattern and incidence of coronary anomalies of origin and distribution. We excluded patients with congenital heart diseases, coronary artery fistulae and patients with separate origin of the conus artery. and found 34 cases (0.46%) (22 males), mean age 50.7 +/- 12 years with coronary anomalies. Six cases underwent angiography prior to valve replacement and the rest were part of the evaluation for atherosclerotic coronary artery disease. The most common anomaly was separate origins of the left anterior descending coronary artery and left circumflex coronary artery [n=12 (35.3%)]. The next most common anomalies were origins of the right coronary artery from the left coronary sinus [n=7 (20.6%)] and left circumflex artery from the right sinus [n=6 (20%)]. A single coronary artery was seen in 3 cases (8.8%) which included one case of postmyocardial infarction ventricular septal rupture with triple-vessel disease, and another with two small coronary fistulae. One case each of the following coronary anomalies was found: (i) double right coronary artery, (ii) left anterior descending coronary artery from the right coronary sinus, (iii) all three coronary arteries originating separately from the right sinus, and (iv) left main coronary artery from the right sinus. Of these 34 patients, 11 (32.4%) had significant atherosclerotic disease in the anomalous vessel. CONCLUSIONS: The incidence of primary coronary anomaly seems to be less than that in earlier reports, but the pattern of anomalies appears to be similar.     

Acute myocardial infarction caused by "malignant" anomalous right coronary artery detected by multidetector row computed tomography.

Anomalous coronary arteries are usually identified incidentally by angiography or autopsy, but some "malignant" coronary anomalies are associated with a high incidence of syncope, arrhythmia, myocardial infarction, and sudden death. So far, the pathogenesis of the coronary events in such cases has only been revealed by autopsy. In the present case report, a patient with anomalous origin of the right coronary artery from the left sinus of Valsalva developed acute myocardial infarction, and visualization of the anomaly and assessment of the culprit plaque in the artery were done by multidetector row computed tomography and intravascular ultrasound.     

Percutaneous coronary intervention with stent deployment in anomalously-arising left circumflex coronary arteries.

BACKGROUND: Anomalous origin of the left circumflex coronary artery from the right sinus of Valsalva or proximal right coronary artery is the most common congenital coronary anatomical abnormality. Whether such vessels are particularly predisposed to atherosclerotic disease in their proximal portion remains controversial. Successful balloon angioplasty has been described, but thus far only six isolated cases of stent deployment in anomalous circumflex vessels have been described in the interventional literature. METHODS: Single-center retrospective case study of twenty-two patients with anomalous circumflex coronary arteries. Twelve patients (11/12 male, average age (63 +/- 3) years) underwent successful percutaneous coronary intervention (PCI) with stent deployment in the retroaortic segment of the anomalous vessel. RESULTS: Significant obstructive coronary disease in the retroaortic portion was found in the majority of anomalous left circumflex vessels (16/22, 73%), but did not predict the presence of significant two or three vessel coronary disease (P = 0.14, 0.63). PCI was successful in all cases attempted, with favourable short/medium-term event-free survival. CONCLUSIONS: The retroaortic portion of anomalously-arising circumflex coronary arteries is selectively predisposed to atherosclerotic disease. PCI to these vessels is feasible but may be technically challenging.