Atherosclerosis in type IV dual left anterior descending artery and anomalous aortic origin of the left circumflex artery in association with rheumatic valve disease: a case report

Double left anterior descending coronary artery arising from the left and right coronary arteries is a very rare congenital coronary artery anomaly. In this case, there was also a circumflex artery arising from the right sinus Valsalva and in association with severe rheumatic valve disease. Subsequently, the patient underwent mechanical aortic valve replacement with a 21-mm bileaflet mechanical aortic valve and coronary artery bypass grafting. We performed coronary artery bypass grafting of 3 vessels, including the left internal mammary artery to the large diagonal branch and the saphenous vein graft to the circumflex artery and the right coronary artery, under cardiopulmonary bypass. In this report, we describe an unusual case of this combination in association with both atherosclerosis and rheumatic aortic and mitral valve disease.     

Two cases of anomalous origin of LAD from right coronary artery requiring coronary artery bypass

We experienced two cases with anomalous origin of the left anterior descending artery (LAD) from the proximal right coronary artery requiring coronary artery bypass grafting. A 66-yr old female with a long history of angina and a positive stress test had the anomalous artery coursing anterior to the right ventricular outflow tract. A 42-yr old male with worsening angina after an anteroseptal myocardial infarction had the anomalous artery running between the great vessels. Both patients underwent left internal mammary artery-to-LAD bypass on the beating heart with complete resolution of ischemic symptoms.Isolated coronary artery anomaly is an uncommon disease (0.6-1.2%) in patients undergoing cardiac catheterization. An anomalous origin of the LAD from the proximal right coronary artery (RCA) or the right sinus of Valsalva (RSV) is very rare, found in 1.2-6.1% of all coronary anomalies. This coronary anomaly has been considered potentially serious but functionally unimportant. We report two cases of anomalous LAD from the proximal RCA resulting in anterior wall ischemia which was effectively treated by coronary artery bypass surgery.     

A rare case of an extracardiac unruptured aneurysm of the sinus of valsalva in a patient with single coronary artery

A 75-year-old man with gastric cancer underwent preoperative cardiac examination by echocardiography, and an unruptured extracardiac aneurysm was detected in the right sinus of Valsalva. Coronary angiography by multidetector computed tomography demonstrated a single left coronary artery. Patch closure of the orifice of the aneurysm of the right sinus of Valsalva was successfully performed for this extremely rare combination.     

Left main coronary bypass for aberrant (aortic) intramural left coronary artery.

This report describes the first saphenous vein bypass graft from the aorta to the left main coronary artery for an aberrant left main coronary artery arising from the anterior sinus of Valsalva. A 20-year-old college student had a cardiac arrest and documented ventricular fibrillation while jogging. He was resuscitated. An anomalous left main coronary artery, arising anteriorly from the right coronary sinus, was demonstrated at operation to be within the wall of the aorta. Following aorta--left main coronary artery bypass with the saphenous vein, results of a stress test were normal, and cardiac catheterization revealed the left coronary system to be entirely supplied by the graft.     

A case of surgical repair of aortic dissection associated with tear of the right coronary artery]

A 39-year-old female with dissecting aortic aneurysm of DeBakey type I, underwent replacement of the ascending aorta. We found that the right coronary artery originated just distally from the left sinus of Valsalva, run transversally in the aortic wall. Because the entry of dissection occurred at the right coronary artery, it was torn longitudinally. Aorto (graft)-rt. coronary bypass grafting was performed. She had no ischemic heart symptoms postoperatively. It is supposed that the dissecting aortic aneurysm was caused by the anomalous origin of the right coronary artery.     

Coronary artery bypass graft for anomalous right coronary artery

A 27-year-old man with anomalous right coronary artery (RCA) presented with ventricular fibrillatory arrest. Computed tomography angiography revealed an anomalous RCA arising from the left sinus of Valsalva with an acute angulation at the coronary takeoff and compressed interarterial segment. This patient underwent a short saphenous vein coronary artery bypass graft to the proximal RCA and recovered uneventfully. A review of the literature and discussion of the surgical management is presented.     

A giant unruptured aneurysm of the sinus of Valsalva together with ectasia of the left coronary artery

A sinus of Valsalva aneurysm is defined as a dilatation of the aortic sinuses, between the aortic valve annulus and the sinotubular junction. They are rare and most frequently involve the right coronary sinus. We report a case of an unruptured giant sinus of Valsalva aneurysm in a patient associated with ectasia of the left main stem and left anterior descending coronary artery. The patient was successfully treated with aortic root replacement using a biologic conduit.     

Anomalous origin and distribution of coronary arteries. Review of 38 patients who underwent operation.

Between October 1961 and December 1973, 38 patients with an anomaly in origin (15 patients) or distribution (23 patients) of the main coronary artery or one of its branches underwent operation at the Texas Heart Institute. The left coronary artery originating from the pulmonary artery occurred most frequently-in 13 of 15 patients. An aortocoronary artery bypass was performed in 12 patients with the saphenous vein used in ten of the 12, initially in 1965; and a Dacron tube graft in the other two. Of the 15 patients, only one died during the early period after operation. A follow-up of ten years revealed 11 asymptomatic patients; to date the longest period of patency of a saphenous vein graft is seven years in an 11-year-old girl. Of 23 patients with an unusual coronary artery distribution, 22 had tetralogy of Fallot, 20 of whom underwent total correction. In 21 of the 23 patients the left anterior descending coronary artery originated from the right coronary artery and crossed the right ventricular outflow tract. In two patients this abnormally distributed artery was injured through a vertical right ventriculotomy; both patients died from myocardial failure during the early postoperative period. Subsequently a transverse right ventriculotomy, either alone or combined with a right ventricular outflow and/or pulmonary artery patch enlargement was performed in 16 patients, and a double outlet right ventricle was created through insertion of a Dacron tube graft in two patients. With this method injury to the abnormal left anterior descending coronary artery was avoided and all 18 patients survived the operation. On the basis of our experience and today's advanced techniques, it is believed that most patients, including some under two years of age, can undergo correction of a left coronary artery originating from the pulmonary artery through insertion of a saphenous vein graft between the aorta and left coronary artery. During the surgical correction of cardiac anomalies necessitating a right ventriculotomy, a transverse or double incision in the right ventricular outflow tract in most patients will prevent injury to an abnormally distributed coronary artery branch; sometimes insertion of a Dacron tube graft between the right ventricular outflow tract and pulmonary artery is necessary.     

Anomalous origin of left main cononary artery from anterior sinus of Valsalva with myocardial infarction

The origin of the left main coronary artery, or its branches, from the right or anterior sinus of Valsalva is a recognized congenital anomaly. The origin of the entire left main coronary artery from a separate ostium in the right sinus of Valsalva and its course to the right and behind the ascending aorta, in a living patient without associated congenital heart disease, has not been described. This anomaly was recognized as the cause of an anterior myocardial infarction in a 12-year-old girl, and it is the subject of this case report.     

Isolated unruptured aneurysm of the left coronary sinus of Valsalva

An isolated unruptured aneurysm of the left coronary sinus of Valsalva was detected incidentally in a patient with a bicuspid aortic valve in whom the left circumflex coronary artery arose from the right coronary artery. With the patient on cardiopulmonary bypass, the mouth of the aneurysm was closed by suturing the reflected posterior cusp of the aortic valve to the aortic root. A Starr-Edwards prosthetic aortic valve was inserted, and an aortocoronary saphenous vein bypass graft maintained good blood flow down the left anterior descending coronary artery. Previous reports of this rare condition and its treatment are discussed.     

Anomalous origin of the right coronary artery from the left coronary sinus: case report and review of surgical treatments

An anomalous right coronary artery arising from the left sinus of Valsalva is a rare but potentially lethal abnormality. We present a case report and literature review of this anomaly as well as its surgical management in the face of unobstructed distal coronary arteries. Furthermore we report the use of intraoperative transesophageal stress echocardiography to evaluate adequacy of graft flow.     

The use of intraoperative Doppler assessment to guide the surgical treatment of anomalous right coronary arteries

Abstract   Despite its rarity, anomalous origin of the right coronary artery (RCA) from the left coronary sinus can pose risk of sudden death. Because of this risk, many patients elect surgical correction of this anomaly. Surgical strategies for correction of this include ostioplasty, coronary artery reimplantation, and, more commonly, coronary artery bypass grafting. After coronary artery bypass grafting, some advocate ligation of the proximal RCA, speculating that competitive flow will cause graft failure. As no objective criteria for this have been established, we propose a method using of intraoperative Doppler flow measurements to guide the decision to preserve the proximal anomalous native vessel. We present three cases in which an RCA with an anomalous origin from the left sinus was corrected with coronary artery bypass grafting with the assistance of intraoperative Doppler flow measurements to guide the decision to preserve the proximal anomalous native vessel. In each case, the RCA was bypassed using a saphenous vein graft (SVG) that was used to bypass origin of the RCA. Flow through the graft was compared with and without ligation of the proximal RCA, before creation of the proximal anastomosis. In each case, flow through the SVG was not significantly reduced with the proximal RCA patent and ligation was not performed.     

Ruptured aneurysms of the sinus of Valsalva.

From 1969 to 1989, 15 patients with an aneurysm of the sinus of Valsalva underwent operative correction. This represents 0.23% of 6515 cardiac operations with cardiopulmonary bypass during that time. There were 8 males and 7 females ranging in age from 15 to 54 years (mean 35.8 years). Symptoms of congestive heart failure, fatigue and palpitation were common. All patients underwent cardiac catheterization including aortography. Associated lesions included aortic valve regurgitation in 6 patients and a ventricular septal defect in 3 patients. The following connections occurred: right coronary sinus to right ventricle (8 patients), right coronary sinus to both right atrium and right ventricle (1 patient), and noncoronary sinus to right atrium (6 patients). The aneurysm was repaired via aortotomy or through the chamber into which it emptied. The aortic valve was replaced in 2 patients. There were no early or late postoperative deaths. Fourteen patients were in NYHA functional class I at late follow-up (range 0.5 to 20.5 years, mean 8.7 years). There have been no recurrences. Our experience supports the concept that early surgical intervention in patients with ruptured aneurysms of the sinus of Valsalva is justified.     

Ruptured congenital sinus of valsalva aneurysms

BACKGROUND AND AIM OF THE STUDY: Rupture of the sinus of Valsalva is rare, and there is a higher incidence of such rupture in Oriental countries than elsewhere. The objective of this study is to present the pathologic features and the clinical outcome after surgery in such patients. METHODS: Between 1980 and 2001, a total of 17 patients (15 males and 2 females) with ruptured aneurysm of sinus of Valsalva underwent surgical intervention at the Tri-Service General Hospital, Taiwan. Their age ranged from 22 to 59 years with a mean of 33.5 years. These surgical operations made up 0.51% of the total cardiac operations (3305) performed during this period. The medical records were retrospectively reviewed. RESULTS: The origin of the ruptured aneurysm of the sinus of Valsalva was the right coronary sinus in 12 patients, the noncoronary sinus in 4, and the left coronary sinus in one patient. The aneurysms ruptured into the right ventricle in 12 patients, into the right atrium in 3 patients, and into the left ventricle in 2 patients. Associated cardiac anomalies were aortic regurgitation in eight patients, ventricular septal defect in seven, and coronary artery fistula in one patient. There was no early postoperative death and one patient underwent a second operation after aneurysm of the sinus of Valsalva (ASV) relapse. CONCLUSIONS: The operation for a ruptured aneurysm of sinus of Valsalva carries a low operative risk and results in excellent long-term survival after surgical treatment.     

Right coronary artery with high takeoff

Anomalous origin of the right coronary artery is an extremely rare anomaly. We describe the case of a patient whose right coronary artery was arising from the ascending aorta with high takeoff. We diagnosed the anomaly incidentally during the operation. After transverse aortotomy for aortic valve replacement, we recognized the transection of the right coronary artery. The right coronary artery ostium was located approximately 5 cm above the right sinus of Valsalva. It was showing a complete transmural course. We repaired the right coronary artery by bypassing it with a saphenous vein graft.     

Saphenous vein bypass graft to left main coronary artery.

The first reported aorto-left main coronary artery saphenous vein bypass for an aberrant left main coronary artery arising from the anterior sinus of Valsalva is presented. Late follow-up revealed a normal stress test, and cardiac catheterization revealed the left system to be entirely supplied by the graft.     

Management of Anomalous Left Circumflex Artery Encircling the Aortic Annulus in a Patient Undergoing Multivalvular Surgery

Abstract   The abnormal origin of left circumflex artery from the right sinus of Valsalva with a retroaortic course is a well-known coronary anomaly usually without consequences. In patients undergoing aortic valve replacement, this finding becomes crucial because the left circumflex is at risk of injury during the procedure. The scenario is even more complex in patients undergoing multi-valve surgery. We report the diagnosis and successful operative strategy in a patient with anomalous left circumflex arising from the proximal right sinus of Valsalva undergoing double aortic and tricuspid valve surgery for active bacterial endocarditis.     

Congenital atresia of the left main coronary artery ostium.

Three patients with the rare anomaly of congenital absence of the ostium of the left main coronary artery are presented. In two of the patients, aged 50 and 52 respectively, the diagnosis was established during selective coronary cineangiography for a severe anginal syndrome. The third patient, a 16-year-old-girl, underwent cardiac catheterization for investigation of a congenital heart malformation, when a single right coronary artery was demonstrated with absence of the main coronary artery ostium. Two patients underwent successful aortocoronary bypass grafting. In view of the occurrence of sudden death and massive myocardial infarction in adult patients shown to have severe or complete obstruction of the left main coronary artery, it is suggested that adult patients with this condition, who require open-heart surgery for any other cardiac disorder, should undergo aortocoronary bypass grafting concurrently even prior to the development of anginal symptoms. Children shown to have this anomaly should be subjected to long-term follow-up and have an aortocoronary bypass graft performed when symptoms of coronary insufficiency develop.     

Left anterior descending artery arising as a terminal extension of posterior descending artery (a rare coronary artery anomaly)

Several types of left anterior descending artery anomalies have been detected. In these anomalies, left anterior descending artery usually originates from the right coronary artery or right sinus of Valsalva. A case of left anterior descending artery arising as a terminal extension of posterior descending artery presented. This anomaly seems rather rare.     

Anomalous origin of the left coronary artery

Coronary artery anomalies are a frequent finding in the general population and often result in sudden death. Therefore, rapid diagnosis and surgical correction are essential. Although coronary arteriography ultimately is necessary to determine the exact nature of the anomaly, two-dimensional echocardiography and radionuclide tests may provide valuable information in the initial workup of patients with chest pain, as demonstrated in the case reported here. This patient, who had angina-like symptoms, was found on cardiac angiography to have an anomalous left coronary artery rising from the right coronary sinus of Valsalva. Double coronary artery bypass grafting involving the left anterior descending and circumflex marginal vessels alleviated symptoms and resulted in improved exercise tolerance. The authors discuss theories explaining the spectrum of ischemia, infarction, and sudden death and surgical alternatives that improve survival rates.