Exercise induced QRS broadening as a potential marker for significant coronary artery disease

We describe a 33-year-old male with angina pectoris who was found to have abnormal origin and course of right coronary artery from left aortic cusp. The abnormal origin was identified by conventional coronary angiography but the abnormal course of the vessel between ascending aorta and the main pulmonary artery was precisely delineated by high resolution CT angiography. Patient underwent successful surgical transposition of the anomalous vessel with complete resolution of symptoms.     

Hypoplastic left coronary artery. In association with occlusive intimal thickening of a coronary artery with ectopic ostium and with atresia of the left coronary ostium

Two cases of hypoplastic coronary artery (HCA) are presented. Case 1, a 13 year old girl, died suddenly during a long distance race. She had HLCA with marked intimal thickening and an ectopic left coronary ostium above the commisure between the non-coronary and left coronary cusp at post mortem examination. The right coronary artery (RCA) was enlarged and also supplied parts of the area normally supplied by the left coronary artery (LCA). Pathological findings revealed a normal RCA and an extremely hypoplastic LCA with occlusive proliferation of the intima and a myocardial infarction of the left ventricle. Case 2, a 6 year old girl, had a history of effort angina. Selective coronary angiography was performed which failed to demonstrate the orifice of the LCA by aortography. However, the hypoplastic LCA was visualized by RCA angiography as a consequence of anomalous collaterals from the atrioventricular branch of the RCA. We postulate that HCA results from various conditions, including stenosis of the coronary artery orifice, an aberrant course between the pulmonary artery and aorta and ectopic positioning of the coronary artery ostium. In addition, HCA may also be associated with occlusive coronary artery abnormalities.     

Anomalous origin of right coronary artery from left coronary sinus

Anomalous aortic origin of the coronary arteries is uncommon but clinically significant. Manifestations vary from asymptomatic patients to those who present with angina pectoris, myocardial infarction, heart failure, syncope, arrhythmias, and sudden death. We describe 4 patients, aged 34 to 59 years, who were diagnosed with right coronary artery arising from the left sinus of Valsalva, confirmed by coronary angiography, which was surgically repaired. Three patients presented dyspnea and angina, and one with acute myocardial infarction. At operation, the right coronary artery was dissected at the take-off from the intramural course, and reimplanted into the right sinus of Valsalva. There was no mortality. One patient had associated coronary artery disease that required stent placement postoperatively. This reimplantation technique provides a good physiological and anatomical repair, eliminates a slit-like ostium, avoids compression of the coronary artery between the aorta and the pulmonary artery, and gives superior results to coronary artery bypass grafting or the unroofing technique.     

Repair of a right coronary artery arising from the pulmonary artery

We present here the fourth patient in the literature, over the age of 50 years old, with an abnormal right coronary artery arising from the pulmonary artery, who was successfully treated with surgery. Pre-operative computerised tomography (CT) angiography revealed an abnormal right coronary artery arising from the pulmonary artery. The right coronary artery was surgically transposed from the pulmonary artery to the ascending aorta with the aid of cardiopulmonary bypass. The patient had an uneventful postoperative course and the corrected anatomy was documented by postoperative CT angiography.     

Compression of anomalous right coronary artery between the great vessels

Coronary angiography (Figure-1) and computerized tomographic angiography (CTA) (Figure-2) of a 61-year-old man with exertional angina demonstrated proximal compression by the great vessels of an anomalous right coronary arising from the left main trunk. A significant left anterior descending lesion was also present. The patient underwent uneventful bypass surgery. CTA is very useful for confirmation of the inter-arterial course of an aberrant coronary artery. Proposed mechanisms of sudden death include exertional coronary compression between the great vessels, with associated ostial narrowing, as well as acute angulation of the coronary course. Coronary bypass is the treatment of choice for these patients.     

A rare case of anomalous left coronary artery from the pulmonary artery (ALCAPA) presenting congestive heart failure in an adult

A 41-year-old woman with no modifiable coronary risk factors presented with a progressive exertional dyspnea. Chest radiography showed an enlarged cardiac silhouette with reinforced pulmonary vasculature in bilateral lower lung fields and both pleural effusion. Echocardiography revealed a dilated, globally hypokinetic left ventricle with an ejection fraction of 40%. Multislice cardiac computed tomography revealed abnormal origin of LCA from the main pulmonary artery receiving collaterals from a normally originating dilated tortuous right coronary artery. Coronary angiography revealed a single, large, and tortuous RCA arising from the right sinus of Valsalva and giving off extensive collateral vessels coursing over the right ventricular wall, the interventricular septum, and the apex to the left coronary artery that was drained into the proximal main pulmonary. The diagnosis of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) was confirmed. The patient underwent successful reimplantation of LCA to aorta after closure of the ostium (in the main pulmonary artery) of the anomalously originating LCA. After surgical and medical treatment, the patient's symptoms were relieved and both pleural effusions were improved on chest radiography. After then, the patient was discharged on medication.     

Spasm in a single coronary artery

A 52 year old man presented with effort and resting angina with positive exercise stress testing and myocardial scintigraphy. The initial coronary angiogram showed a single coronary vessel arising from the right coronary ostium dividing into a right coronary artery with a normal trajectory lined with a few non stenotic atheromatous plaques and a left coronary artery which passed between the aorta and pulmonary artery to reach the left atrioventricular groove. At first, it was suggested that the angina was due to compression of the left coronary vessel by the great arteries during effort, but this mechanism could not explain attacks of resting angina and the failure of betablocker therapy. An ergometrine test performed during repeat coronary angiography induced almost complete occlusion of the right coronary vessel and Prinzmetal diaphragmatic ischaemia. The anginal attacks were completely suppressed by Calcium antagonist drugs. The association of coronary spasm and a single coronary artery is rare; only one case has been previously reported. We do not believe that there was a relationship between the two phenomena in our case: the spasm occurred at a distance from the aberrant course of the vessel. The authors emphasise the diagnostic problems and the potential danger of this association.     

Anomalous origin of the right coronary artery from the pulmonary artery

Two patients with an anomalous right coronary artery arising from the pulmonary artery are presented. The first patient was asymptomatic and had a continuous murmur. The correct diagnosis was established by cardiac catheterization and selective angiography. There was a moderate sized shunt from the dilated left anterior descending coronary artery to the right coronary artery, which arose from the main pulmonary artery. The second patient was also asymptomatic but died several days after a sudden cardiorespiratory arrest. On postmortem examination she was demonstrated to have anomalous origin of the right coronary artery from the pulmonary artery. The left coronary artery was completely occluded at the orifice by a thrombus, and microscopic examination demonstrated evidence of both acute and chronic left ventricular ischemia and infarction. The pathophysiologic alterations and potential danger to patients with this anomaly are discussed.     

Primary percutaneous coronary intervention of an anomalous right coronary artery arising from the left coronary cusp using an undersized Judkins catheter: A case report

Occlusion of an anomalous right coronary artery arising from the left coronary cusp is a rare cause of acute inferior wall myocardial infarction. The case of a 66-year-old man who presented with an acute inferior wall myocardial infarction from occlusion of an anomalous right coronary artery arising from the left coronary cusp is described. An undersized Judkins left guide catheter was successfully used to perform primary percutaneous coronary intervention for this anomaly. Computed tomographic angiography was subsequently used to characterize the origin and anatomical course of the anomalous right coronary artery and assess coronary stent patency.     

Right coronary artery arising from the pulmonary trunk.

The right coronary artery (RCA) abnormally originating from the pulmonary trunk (PT) is a rare congenital anomaly. Our patient is a 62-year-old woman with longstanding systemic arterial hypertension and angina pectoris. Angiographic images documented the RCA arising from the PT, and coronary angiography showed severe stenosis (70%) on the distal tract of the left anterior descending artery. The primary treatment of the anomalous origin of RCA from the pulmonary artery is surgical technique. Our surgeons opted for coronary reimplantation; 6-month follow-up has shown very good results, with complete disappearance of symptoms.     

Right coronary artery originating from distal left circumflex artery in a patient with an unusual type of isolated single coronary artery

Single coronary artery is a rare congenital anomaly and is commonly associated with other congenital cardiac malformations. This report describes a 42-year-old man with an isolated single coronary artery, in whom the right coronary artery did not originate from the aorta but rather from the distal left circumflex artery. This patient did not have any other cardiovascular anomaly. However, he experienced angina pectoris and evidence of myocardial ischemia. Coronary angiography revealed insignificant coronary artery stenosis. He received medical treatment and responded well. An isolated single coronary artery is extremely rare, and this case may be only the 12th case reported in the literature.     

Right coronary artery-pulmonary artery arteriovenous fistula secondary to open heart surgery

A patient is described who underwent atrial septal defect repair at age 12 and presented 16 years later with angina. Coronary angiography revealed a right coronary artery to pulmonary artery fistula that had developed at the site of the previous thoracotomy. This is the first report of an acquired fistula of this type developing secondary to trauma associated with open heart surgery. Diagnosis, shunt quantification and treatment are discussed.     

Acute myocardial infarction and ischemia in the left anterior descending artery territory in a patient with single coronary artery

This report describes a 77-year-old woman with a single coronary artery who suffered an acute anterior wall myocardial infarction. The single coronary artery arose from the right coronary artery through the transverse trunk, and there were no other cardiovascular anomalies. Coronary angiography did not reveal significant coronary artery stenosis in the left anterior descending artery. The patient was treated medically in the acute phase. She developed typical angina and evidence of myocardial ischemia, and underwent successful coronary artery bypass grafting in the chronic phase with anterior chest pain.     

Adult‐type ALCAPA syndrome: A rare coronary artery anomaly

Anomalous origin of the left coronary artery arising from the pulmonary artery (ALCAPA or Bland–White–Garland syndrome) is a rare but serious congenital coronary artery anomaly, with a poor prognosis without surgical repair. There are two types of ALCAPA syndrome: infant type and adult type. We present a rare case of a 63‐year‐old female patient, with isolated left anterior descending artery origin from the pulmonary artery. Coronary computed tomography angiography revealed giant and tortuous coronary arteries with many collaterals between the left and right coronary system. The patient refused any surgical treatment.     

Sudden cardiac arrest: associated with anomalous origin of the right coronary artery from the left main coronary artery

Anomalous origin of the coronary artery from the opposite sinus of Valsalva and a course of that artery between the ascending aorta and the pulmonary artery is a rare congenital anomaly. It can cause myocardial ischemia, syncope, and sudden cardiac death in young people. Herein, we report the case of a 24-year-old man who was brought to our hospital after cardiac arrest due to ventricular fibrillation. Emergent coronary angiography revealed that the left coronary artery was normal; however, the right coronary artery originated at the left sinus of Valsalva. After admission, the patient was treated with mild therapeutic hypothermia for 48 hours and had a favorable neurologic recovery. Subsequent 16-slice multidetector computed tomography revealed that the right coronary artery arose from the left main coronary artery, took an intramural course, and was severely compressed between the ascending aorta and the pulmonary artery. The patient underwent direct implantation of the anomalous artery into the correct aortic sinus. Histologic specimens from the proximal end of the right coronary artery showed an intramural segment with intimal fibrous thickening, fragmentation and random arrangement of the elastic fiber, degeneration of the medial smooth-muscle cells, and an increase in the medial stromal substance. Postoperatively, repeat coronary angiography with provocation testing for coronary spasm revealed no myocardial ischemic change. The patient recovered uneventfully. We found that cardiac multidetector computed tomography was useful in evaluating the cause of the sudden cardiac arrest, identifying the anomalous coronary artery, and helping to guide the surgical decisions.     

Multiple coronary artery fistulas with a huge right coronary artery showing exacerbation during 16 years of follow-up.

A 38-year-old Japanese woman underwent cardiac evaluation to assess an arrhythmia detected after the delivery of her fourth baby. At the age of 22 years, she had undergone cardiac evaluation, including catheter examination, because of a heart murmur. Coronary angiography showed a huge right coronary artery (RCA) draining to the right atrium and a normal left coronary artery. Because the left to right shunt ratio was trivial and the patient was asymptomatic, conservative observation was undertaken. On the current admission to hospital, there was a grade III continuous murmur at the second left sternal border. The patient underwent right and left cardiac catheter examination in March 2000. Selective coronary angiography demonstrated an enlarged lumen of the RCA, an enlarged aneurysmal cavity in the terminal portion of the RCA, and the postero-descending artery being filled by collateral circulation from the left coronary artery. Moreover, 2 new fistulas had appeared from the left coronary system. An oxygen saturation study showed that the pulmonary to somatic flow ratio (Qp/Qs) was 2.2. The patient underwent surgical treatment in July 2000 and on coronary angiography 1 month later, there was no abnormal shunt flow from either coronary artery into the aneurysmal cavity, although the RCA was still enlarged.     

Bilateral coronary fistulae to pulmonic valve in presence of severe three-vessel coronary artery disease

A 62-year-old man was admitted to the coronary care unit due to anginal pain and palpitations--coronary angiography revealed three-vessel coronary artery disease. The unexpected finding was the presence of coronary to pulmonary artery fistulae bilaterally, from both the proximal RCA and the proximal LAD. Right heart catheterization revealed normal right ventricular and pulmonary artery pressure and absence of hemodynamically significant left to right shunt. The patient underwent a triple coronary bypass including the closure of bilateral fistulae, which were draining into the left sinus of the pulmonary valve. One month after the operation he was in good health and had no complaints. Bilateral coronary artery fistulae is a rare anomaly diagnosed in 0.002-0.0013% of adult coronary angiograms. (Int J Cardiovasc Intervent 1999; 2: 249-251).     

Single coronary ostium - a right coronary artery arising from the left main coronary artery

Single coronary ostium is a very rare congenital anomaly with an incidence of 0.024% in angiographic series. This is the third case of Shirani-Roberts subtype IB4: solitary ostium in the left coronary sinus associated with a retroaortic-coursing right coronary artery that arises from the left main coronary artery. The patient is a 45-year-old male with no past medical history, and who was seen in the clinic for evaluation of a murmur. Echocardiography showed rheumatic heart disease with mild mitral regurgitation and moderate aortic regurgitation; no shunts were present. Coronary and aortic root angiography did not show a vessel originating from the right coronary cusp. The right coronary artery originated from the left main coronary artery and had an aberrant course which was dorsal to the ascending aorta. No associated congenital heart disease was present.     

Tetralogy of Fallot with abnormal coronary arteries

Between 1980 and 1989 nine patients with Tetralogy of Fallot with abnormal coronary artery underwent surgical treatment. In all but one, the abnormal coronary artery was identified at surgery. Seven (group I) had the anterior descending coronary artery arising from the right coronary artery; one (group II) with had the right coronary artery arising from the left coronary artery and finally, the only case of the group III had left coronary artery arising from the main pulmonary artery. Systemic-pulmonary anastomosis was done in two cases of the Group I, in one due to severe hypoplasia of the pulmonary ring and main pulmonary artery and in the other due to the anomaly of the coronary artery. In the case of the Group II the right coronary artery was accidentally cut and the patient developed right ventricular infarction and died. All surviving are in NYHA functional class I. Nowadays, the preoperative evaluation of Tetralogy of Fallot, can be done by echocardiography despite the possibility of its association with abnormal coronary artery. In special cases aortography or arterial coronarography should be considered.     

Left coronary artery originating from right sinus of Valsalva with diagnosis confirmed by CT--a case report

A 57-year-old woman presented with classic exertional angina and was then discovered to have a rare coronary anomaly in which the left coronary artery originated from the right sinus of Valsalva. The diagnosis was made by coronary angiography and confirmed with computed tomography (CT). The patient then underwent surgical revascularization with complete resolution of symptoms. The course of the aberrant artery between the aorta and pulmonary artery/right ventricular outflow tract was confirmed by gated thin-slice CT angiography with bolus contrast injection. To the authors' knowledge, this is the first case report where CT was used to confirm this diagnosis.