Successful percutaneous coronary intervention of anomalous origin right coronary arteries with 3-D RCA guide catheters: a report of three cases

Right coronary arteries with anomalous origin (ARCA) may be associated with myocardial ischemia and sudden death. Selective catheterization and percutaneous coronary intervention (PCI) of ARCA can be technically challenging due to their slit-like orifice and aortic intramural course with abrupt angulation. The 3DRCA guide catheter is a unique catheter with a helical configuration that provides optimal guide support during PCI. We describe three cases of successful PCI to right coronary arteries with anomalous origin (two from the left sinus of Valsalva, one with ectopic origin from the right sinus of Valsalva) using 3DRCA guide catheters after a variety of other catheters were tried unsuccessfully.     

Localized dissection of the sinus of valsalva without coronary artery involvement during percutaneous coronary intervention

Dissection of the sinus of Valsalva is an extremely rare accident during percutaneous coronary intervention (PCI), but it can lead to serious complications such as dissection of the ascending aorta. We experienced a localized dissection of the right coronary cusp without coronary artery involvement that was induced by a guiding catheter during PCI in a patient with acute myocardial infarction. The localized dissection showed pooling of the contrast medium in the acute phase, but it subsided spontaneously after 12 days without any sequelae. Manipulation of the guiding catheter should be performed with great caution not only in the coronary artery but also in the sinus of Valsalva.     

Acquired pseudoaneurysm of the sinus of Valsalva

Localized aneurysms of the sinus of Valsalva are uncommon. Repair is tailored to the defective anatomy of the sinus, the aortic valve, and the coronary artery. Herein, we report the successful surgical treatment of 2 patients who had unruptured pseudoaneurysms of the sinus of Valsalva. An evident fissure in the intima of the sinus of Valsalva was seen in both patients. Patient 1 was a 57-year-old man with annuloaortic ectasia who was diagnosed with pseudoaneurysm of the right sinus of Valsalva. A thrombus that had formed in the pseudoaneurysm subsequently migrated into the right coronary artery. Aortic root remodeling was performed. Patient 2 was a 23-year-old man with a history of blunt chest trauma. He developed a pseudoaneurysm in the right sinus of Valsalva and tears on the aortic cusps. He underwent aortic valve replacement and repair of the Valsalva wall.     

Perforation of the sinus of Valsalva by guiding catheter during the percutaneous coronary intervention via the right transradial approach: A very unusual complication

Iatrogenic dissection of the sinus of Valsalva or of the ascending aorta is a rare but potentially fatal event, during the percuteneous coronary intervention (PCI). We reported a case of perforation of the sinus of Valsalva by guiding catheter during PCI via the right transradial approach (TRA) successfully managed and sealed without any sequelae. The choice of guiding catheter into the right TRA should be done carefully and its manipulation should be performed with caution in the coronary artery and in the sinus of Valsalva. © 2011 Wiley Periodicals, Inc.     

Incremental benefit of three‐dimensional transesophageal echocardiography in the assessment of left main coronary artery stent protrusion

Ostial lesions represent a challenging clinical scenario and percutaneous intervention (PCI) of left main coronary artery ostial lesions has been associated with postintervention complications, including protrusion of deployed stents into a sinus of Valsalva or aortic root. We report a case of stent protrusion into the aortic root following aorto‐ostial left main coronary artery PCI, in which three‐dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two‐dimensional images. Specifically, 3DTEE confirmed the presence of stent protrusion by allowing clear visualization of the stent scaffold, in addition to characterizing the relationship between the stent and surrounding structures.     

Anomalies of the coronary arteries originating from the right sinus of Valsalva. (1) Single coronary artery originating from the right sinus associated with fusion of the left and the non coronary cusp and atrophy of the left coronary ostium (2)Three separate coronary arteries originating from the right sinus of Valsalva

We report three patients with the entire coronary origin arising from the right sinus of Valsalva. The first patient had a single right coronary ostium associated with a bi-leaflet aortic valve. The second patient was admitted with ST-elevation myocardial infarction (STEMI) for primary PCI. The third patient had 3 isolated ostia, all originating from the right sinus of Valsalva. Coronary anomalies are associated with increased mortality, depending on the myocardium at risk. A left main originating from the right coronary sinus is supplying a greater extent of the myocardium and is associated both with an increased incidence of symptoms and of sudden cardiac death. The possibility of such an artery anomaly should always be considered in young individuals with a history of chest pain or syncope.     

Successful percutaneous coronary intervention for severe stenosis of an anomalous left coronary artery originating from the proximal right coronary artery

An isolated, single coronary artery is a rare congenital anomaly with an incidence of 0.03% to 0.4% and an uncommon finding (0.6% to 1.3%) in patients undergoing coronary angiography. In this report we describe a rare case of a patient who had an anomaly of the left and right coronary arteries with a single coronary ostium in the right sinus of Valsalva, in which percutaneous coronary intervention (PCI) was successfully performed in both arteries.     

Aortocoronary dissection resolved by coronary stenting guided by intracoronary ultrasound.

Percutaneous coronary intervention (PCI) was performed for chronic total occlusion of the proximal right coronary artery in a 70-year-old male with unstable angina. The forceful manipulation of the guide catheter led to an aortocoronary dissection involving the right Valsalva sinus and the ascending aorta. Intracoronary ultrasound (ICUS) showed the important characteristics of the dissection, enabling successful coronary stenting under ICUS guidance.     

Post-Traumatic Pseudoaneurysm of the Left Sinus of Valsalva Revealed by an Acute Coronary Compression

A 69-year-old woman presented with chest pain and electrocardiographic evidence ofsubacute anterior ischaemia. Transthoracic and transesophageal echocardiography allowed correct diagnosis of a post-traumatic pseudoaneurysm of the left sinus of Valsalva. The large pseudoaneurysm caused compression of the left main coronary artery and was successfully treated by aortic root replacement, left main coronary artery ligation, and arterial bypass.     

Post-Traumatic Pseudoaneurysm of the Left Sinus of Valsalva Revealed by an Acute Coronary Compression: An Echocardiographic Case Report

A 69-year-old woman presented with chest pain and electrocardiographic evidence of subacute anterior ischaemia. Transthoracic and transesophageal echocardiography allowed correct diagnosis of a posttraumatic pseudoaneurysm of the left sinus of Valsalva. The large pseudoaneurysm caused compression of the left main coronary artery and was successfully treated by aortic root replacement, left main coronary artery ligation, and arterial bypass.     

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.     

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.     

A case of sinus of Valsalva-right ventricle fistula without a typical aneurysm, and a single origin of the coronary arteries

Few previous reports have described a sinus of Valsalva fistula without an aneurysm in Japanese patients. A single origin of the coronary arteries is a rare coronary anomaly. We describe a 75-year-old woman with a single origin of the coronary arteries and a sinus of Valsalva fistula without a typical aneurysm. Echocardiography showed turbulent flow from the right coronary sinus of Valsalva to the right ventricle throughout the cardiac cycle. Aortography confirmed the presence of a right coronary sinus of Valsalva-right ventricle shunt jet. Echocardiography and aortography demonstrated that there was no deformity of the sinus of Valsalva. Cardiac catheterization revealed that the left-to-right shunt rate was 29% and the Qp/Qs was 1.41. Aortography and coronary angiography did not identify a right coronary artery originating from the right sinus of Valsalva. Coronary angiography revealed that the right coronary artery arose from the proximal part of the left anterior descending artery and did not detect significant organic stenosis of the coronary artery. She was diagnosed as having a sinus of Valsalva to right ventricle fistula without an aneurysm, and a single origin of the coronary arteries.     

Valsalva sinus pseudoaneurysm causes acute myocardial infarction and stroke simultaneously

Spontaneous Valsalva sinus pseudoaneurysm is a rare and highly lethal condition. Below we present a clinical case of a young woman with spontaneous Valsalva sinus pseudoaneurysm diagnosed presenting with acute myocardial infarction (AMI) and ischemic stroke.     

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.     

Ruptured aneurysm of the right sinus of valsalva associated with a ventricular septal defect and an anomalous coronary artery

Aneurysms of the sinus of Valsalva are extremely rare. Ruptured aneurysms of the sinus of Valsalva are frequently associated with other congenital defects, particularly with ventricular septal defect, aortic valve regurgitation, and bicuspid aortic valve. We describe the case of a 26-year-old man who had a ruptured aneurysm of the right coronary sinus, a ventricular septal defect, and an anomalous origin of the right coronary artery. Successful surgical correction of the aneurysm and ventricular septal defect was performed with patch repair and aortic valve replacement. A review of the English-language medical literature revealed only 1 other case of a sinus of Valsalva aneurysm associated with a ventricular septal defect and an anomalous coronary artery. Previously published reports of the coexistence of a single coronary artery with a sinus of Valsalva aneurysm or with a ventricular septal defect, and their management, are discussed herein.     

Percutaneous transluminal coronary angioplasty of anomalous left circumflex coronary artery

We present our experience of percutaneous transluminal coronary angioplasty in two patients with an anomalous left circumflex coronary artery with severe stenosis. In the first case, the anomalous vessel originated from the first portion of the right coronary artery, and in the second case it originated from the right sinus of Valsalva. Cannulating the anomalous vessel with the guiding catheter can be difficult. The right Judkins-type catheter, with a posteriorly directed tip, is the most appropriate catheter for cannulating the anomalous circumflex artery when the vessel originates from the first portion of the right coronary artery, and the left Amplatz-type 1 is most appropriate when the vessel originates from the right sinus of Valsalva.     

Anomalous aortic origin of a coronary artery: a universally applicable surgical strategy

The most commonly reported coronary arterial malformation, in accounts of sudden deaths, is anomalous aortic origin of a coronary artery. Anomalous coronary arteries may arise from the left, right, or non-coronary sinuses of Valsalva. Importantly, although the left coronary artery from the right sinus has the worst prognosis, sudden death has been reported in all variants of origin from the various sinuses of Valsalva. This paper describes a technique that addresses all of the problems relating to anomalous aortic origin of a coronary artery from the wrong sinus of Valsalva. This technique includes the transection of the ascending aorta and pulmonary trunk, coronary arterial enlargement with a pericardial patch, and lateral translocation of the pulmonary trunk to the left pulmonary artery. Anomalous aortic origin of a coronary artery from the wrong sinus of Valsalva is a potentially lethal cardiac anomaly that can be corrected in all cases using this simplified surgical technique that addresses the major anatomic and physiological problems.