Anomalous origin of the right coronary artery: diagnosis and treatment

We report the case of a rare anomaly of the right coronary artery (RCA) arising from the left aortic sinus, having a single ostium with the left coronary artery, associated with documented episodes of inferior ischemia, in which surgical treatment with a right internal thoracic artery to RCA bypass graft and the corresponding ligation provided greater stability to the coronary blood flow and good clinical progress.     

Anomalous origin of the right coronary artery: diagnosis and treatment

We report the case of a rare anomaly of the right coronary artery (RCA) arising from the left aortic sinus, having a single ostium with the left coronary artery, associated with documented episodes of inferior ischemia, in which surgical treatment with a right internal thoracic artery to RCA bypass graft and the corresponding ligation provided greater stability to the coronary blood flow and good clinical progress.     

Protective role of collaterals in patients with coronary artery occlusion

We reviewed the clinical, hemodynamic and angiographic data of 105 patients with right coronary artery occlusion and of 82 patients with left anterior descending coronary artery occlusion, subdivided into 3 groups by the presence and quality of collaterals to the occluded coronary (absent, poor or good collaterals). We found that patients with right coronary artery occlusion and good collaterals had a lower frequency of diaphragmatic myocardial infarction (60%) than patients with absent collaterals (100%) (P < 0.01). In addition, in patients with old diaphragmatic myocardial infarction, both poor and good collaterals were associated with a lower frequency of severe asynergy of the diaphragmatic left ventricular segments at left ventriculography (54% and 14%, respectively), compared to patients with no collaterals to the right coronary artery (92%, P < 0.02 vs. poor collaterals, P < 0.001 vs. good collaterals). In contrast, in patients with left anterior descending coronary artery occlusion, the presence of either poor or good collaterals to the left anterior descending coronary artery was not associated with a lower frequency of old anterior myocardial infarction, or, in patients with old anterior myocardial infarction, with a less severe asynergy of the anterior left ventricular segments.Our results suggest that collaterals are effective in protecting the diaphragmatic left ventricular wall in patients with right coronary artery occlusion, but not the anterior left ventricular wall in patients with left anterior descending coronary artery occlusion.     

Three-dimensional reconstruction of computed tomographic images of anomalous origin of the left main coronary artery from the pulmonary trunk in an adult

We present a 49-year-old female case of anomalous origin of the left main coronary artery from the pulmonary trunk. Multidetector computed tomography was performed, and 3-dimensional reconstruction of computed tomographic images found that the left main coronary artery originated from left sinus of the pulmonary trunk and the right coronary artery from the right coronary cusp of the aorta. We speculate that this patient's long life may be due to the dominant right coronary artery and rich collateral from the right coronary artery to the left coronary artery.     

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery in an Asymptomatic Adult

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital anomaly with a mortality of 90% in the first year of life, if not surgically corrected. Adult presentation of the anomalous origin of the left coronary artery from the pulmonary artery syndrome is extremely rare but may occur if a well‐developed collateral circulation from right coronary artery is present. We present the case of a 22‐year‐old asymptomatic female with anomalous origin of the left coronary artery from the pulmonary artery.     

先天性心脏病冠状动脉瘘的介入治疗

收集近年来国内外先天性冠状动脉瘘100例介入文献与85例手术文献,分析冠状动脉瘘的类型,治疗方法及预后。冠状动脉瘘起源于左冠状动脉多见,出口多在右心。单一冠状动脉瘘可以考虑以经导管介入封堵治疗,这是创伤小,相对安全有效的治疗手段且预后良好,适宜推广。合并其他先天性畸形者或冠状动脉病变者以及介入治疗失败者考虑手术治疗。     

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.     

Imaging the elusive anomalous origin of left coronary artery from pulmonary artery

A 7‐year‐old girl with severe mitral regurgitation and pulmonary artery hypertension with good ventricular function was planned for mitral valve repair, but was subsequently diagnosed to have anomalous left coronary artery from pulmonary artery. We describe the pitfalls in the diagnosis of this rare anomaly, particularly in the presence of severe pulmonary artery hypertension and absence of circumstantial evidence of coronary steal and ventricular dysfunction.     

An adult case of Bland-White-Garland syndrome with collaterals from the bronchial artery

Summary We report herein an adult case of anomalous origin of the left coronary artery from the pulmonary artery (Bland-White-Garland syndrome; BWG syndrome). The patient had chest discomfort during exercise and signs of mitral regurgitation. We diagnosed him as having BWG syndrome by angiography, and performed surgical treatment. At the operation, retrograde coronary blood flow was found through the left coronary artery during aortic crossclamping. This suggested extracardiac anastomosis from peripheral arteries to the left coronary artery. Since the collateral blood flow was considerable during aortic cross-clamping, only the left coronary artery was closed. A collateral from the left bronchial artery to the left circumflex artery was demonstrated by postoperative angiography. Cases of adults with BWG syndrome are rare, and this may be the first report of a collateral from the bronchial artery.     

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.     

Congenital atresia of the ostium of the left coronary artery. Diagnostic difficulty and successful surgical revascularization in two patients

We report two cases of congenital atresia of the ostium of the left coronary artery. Case 1: a six-month-old infant presenting with serious cardiac insufficiency. A noninvasive diagnosis of dilated myocardiopathy was established and the clinical picture was pharmacologically compensated. When the patient was nine months of age, a hemodynamic study was performed that revealed congenital atresia of the ostium of the left coronary artery; the infant immediately underwent a successful anastomosis of the internal mammary artery with the left coronary artery. Case 2: an eleven-year-old asymptomatic boy with a history of heart murmur from the age of six months on, was referred for surgery with a diagnosis of anomalous origin of the left coronary artery from pulmonary trunk. A definitive diagnosis of atresia of the left coronary ostium was only established during surgery. Successful surgical revascularization with the left internal mammary artery, and left ventricular aneurysmectomy were performed.     

Origin of both coronary arteries from the same sinus of valsalva: Report of two cases

Origin of both coronary arteries from the same sinus of Valsalva was found in two patients. In one patient the right coronary artery opened from the left sinus of Valsalva, coursed between the pulmonary artery and aorta, disclosed a 95% obstruction in its proximal third with good runoff. The portion of the artery between the aorta and pulmonary artery showed cyclic narrowing during systole. In the second patient the left coronary opened from the right sinus of Valsalva, the left main trunk crossed anteriorily the pulmonary artery conus, and both the circumflex and the left anterior descending branches showed significant narrowing. In both patients the arteries shared a common sinus with two separate orifices, both had a bicuspid aortic valve, and in both, nonaberrant coronary vessels also had stigmata of atherosclerosis.     

Anomalous origin of the main stem of the left coronary artery from the pulmonary trunk presenting with left ventricular hypertrophy

Patients with anomalous origin of the left coronary artery from the pulmonary trunk may present with paroxysmal angina on exertion, congestive heart failure, dyspnoea, syncope or sudden death. The association of such anomalous origin of the left coronary artery from the pulmonary trunk with a hypertrophic left ventricle is extremely rare. In our cohort of patients with anomalous origin of the left coronary artery from the pulmonary trunk, two presented with a hypertrophic left ventricle. We discuss these cases, accompanied by a review of the English literature describing different morphological anomalies of the coronary arteries associated with left ventricular hypertrophy. Whether the hypertrophy is a result of the evolvement of the collateral coronary system, or due to an additional pathological gene for hypertrophic obstructive cardiomyopathy, remains an enigma. The hypertrophy may have served as a compensatory mechanism accounting for the atypical clinical presentation. We further discuss the possible factors associating the occurrence of anomalous origin of the left coronary artery from the pulmonary trunk and myohypertrophy, supported by the documentation of the regression of hypertrophy following surgical correction of the anomalous arterial origin as seen in our patients.     

Echocardiographic diagnosis of anomalous origin of the left coronary artery from the pulmonary artery.

We found increased systolic coronary flow in transthoracic pulsed wave (PW) Doppler in a 42-year-old patient with anomalous origin of left main coronary artery from the pulmonary artery. This is a characteristic echocardiographic finding in this anomaly in the presence of collateral circulation and coronary L-R shunt. In comparison with so far used echocardiographic criteria this parameter when present allows quick recognition of anomalous origin of left coronary artery from the pulmonary artery, and its differentiation from other potentially lethal coronary anomalies.     

An alternative technique for transfer of anomalous left coronary artery from the pulmonary trunk in children and adults using autogenous aortic and pulmonary arterial flaps

BACKGROUND: Direct re-implantation of an anomalous left coronary artery into the aorta is the preferred surgical option for creating a dual coronary arterial system in patients in whom the anomalous artery originated from the pulmonary trunk. This technique, however, is applicable only when the anomalous artery arises from the right posterior pulmonary sinus. We report a new technique for re-implantation using combined autogenous aortic and pulmonary arterial flaps in situations when a direct connection was not possible. PATIENTS AND METHODS: We have treated 4 patients, aged 3 months, 6 months, 18 months, and 27 years respectively, who presented with anomalous origin of the left coronary artery from the left posterior pulmonary sinus. We used our proposed technique for transfer because lack of coronary arterial length, diminished vessel elasticity, and extensive collaterals around the pulmonary sinuses prevented direct attachment. RESULTS: There was no early or late death. Postoperatively, all patients are in functional class I, with good biventricular function at a median follow-up of 74 months, with a range from 9 to 96 months. Postoperative coronary angiography in our 4th patient showed good arterial flow, without any distortion. CONCLUSIONS: The potential benefits of this modification of the trapdoor technique are excellent operative exposure, use of autogenous and viable tissue capable of further growth, avoidance of injury to the aortic and pulmonary valvar apparatus and production of obstruction within the right ventricular outflow tract, complete elimination of use of pericardium for augmentation of the neo-aortic tube, achievement of the anastomosis with correct angling and length, and the possibility of implantation in all patients, including adults, regardless of the distance from the aorta or the coronary arterial configuration.     

A single coronary artery from the right sinus of valsalva associated with atherosclerosis

Anomalous origin of the main coronary arteries from the aorta is rare. We report a case with a single coronary artery from the right sinus of Valsalva associated with atherosclerosis.The patient was treated with a coronary artery bypass procedure: left internal mammary artery (LIMA) to the left anterior descending artery (LAD), right internal mammary artery (RIMA) to the right coronary artery (RCA).The postoperative course was uneventful.     

A rare case of anomalous origin of the left anterior descending artery from the pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart disease, with an incidence of <1 in 300 000 live births. We describe a rare case of a 23‐month‐old infant admitted for cough and fever. Echocardiography showed a branch of the left coronary artery originating from the pulmonary artery. The coronary computed tomographic angiography revealed anomalous origin of the left anterior descending (LAD) artery from the pulmonary artery with the left circumflex artery and right coronary artery arising normally from the aorta. The infant successfully underwent surgical reimplantation of the LAD to the ascending aorta. Our case emphasizes that echocardiography and computed tomographic angiography are valuable imaging modalities for making an accurate diagnosis and determining the precise surgical plan.     

Successful coronary intervention of chronic total occlusion of the right coronary artery by ipsilateral injection via an isolated conus artery

A conus artery is sometimes a good collateral source for the left anterior descending coronary artery and the right coronary artery (RCA). In some cases, the conus artery arises independently of the RCA from a separate orifice, which is called an isolated conus artery. The conus artery is often missed by angiography for RCA if a catheter is deeply engaged. This case report describes a percutaneous coronary intervention of chronic total occlusion of the proximal RCA with good collateral circulation from an isolated conus artery by super-selective ipsilateral injection via the artery.     

Exertional pulmonary edema revealing anomalous origin of the left coronary artery from the right coronary aortic sinus

We report a 12-year-old child with anomalous origin of the left coronary artery from the right coronary aortic sinus, the artery taking a proximal intramural course. The anomalous artery was reimplanted into the left coronary aortic sinus. Postoperative stenosis was successfully treated with percutaneous transluminal angioplasty and implantation of a stent.