Diagnosis of anomalous origin of the right coronary artery using multislice computed tomography: evaluation of possible causes of myocardial ischemia

Anomalous origin of the right coronary artery (RCA) is a rare condition, but may cause myocardial ischemia and sudden death. Multislice computed tomography, which allows three-dimensional visualization of the coronary artery with high spatial resolution, may be the most promising imaging modality for diagnosing this anomaly. We describe a patient with anomalous origin of the RCA arising from the left sinus of Valsalva. Volume rendering, and axial and curved multiplanar images showed stenosis in the proximal portion of the RCA that coursed between the aorta and the pulmonary artery, and an acute angled take-off of the RCA from the aorta. Three-dimensional virtual angioscopic images showed a hypoplastic RCA orifice and luminal narrowing in the proximal portion of the RCA. Multislice computed tomography was thought to be useful for detecting anomalous origin of the RCA and for evaluating possible causes of myocardial ischemia.     

Primary stenting of the left main coronary artery with anomalous origin from the right sinus of valsalva

The presence of an aberrant origin of left main coronary artery from the right sinus of valsalva passing between the aorta ascendens and pulmonary trunk is one of the anomalies most frequently associated with malignant clinical events, and surgical treatment is recommended. We report of a 64-year-old patient with a highly increased risk for surgery due to severe chronic obstructive pulmonary disease. This case demonstrates that the use of a drug-eluting stent offers a suitable and valuable alternative.     

Hypertrophic cardiomyopathy associated with anomalous origin of the left coronary artery from the right sinus of valsalva

A 47 year old Japanese male with exertional shortness of breath, cardiac murmur and ECG abnormalities was examined with invasive and non-invasive cardiology techniques that disclosed hypertrophic cardiomyopathy, and the anomalous origin of the left coronary artery from the right sinus of Valsalva. Although both situations have been known to cause sudden death especially under a state of strenuous physical stress, his exercise thallium scintigraphy performed with the symptom limited maximal test did not uncover any significant myocardial ischemia or exercise induced malignant arrhythmias. This is a very rare association of two distinctly identified clinical situations highly indicative of a likelihood of sudden cardiac death. Therefore, careful observation is needed.     

Primary percutaneous coronary intervention of an anomalous right coronary artery originating from the left sinus of valsalva

The presence of an anomalous origin of a coronary artery as the infarct related vessel during primary percutaneous coronary intervention for acute ST elevation myocardial infarction is rare and may present a technical challenge. We reported on a primary coronary percutaneous intervention performed in a right coronary artery originating from the left coronary sinus. The technical tips and tricks of treating congenital coronary anomalies are reviewed.     

Primary percutaneous coronary intervention of an anomalous right coronary artery originating from the left sinus of valsalva

The presence of an anomalous origin of a coronary artery as the infarct related vessel during primary percutaneous coronary intervention for acute ST elevation myocardial infarction is rare and may present a technical challenge. We reported on a primary coronary percutaneous intervention performed in a right coronary artery originating from the left coronary sinus. The technical tips and tricks of treating congenital coronary anomalies are reviewed.     

Anomalous origin of the left coronary artery from the right sinus of valsalva

We present the clinical, angiographic and surgical findings in a 63-year-old man with anomalous origin of the left main coronary artery from the right sinus of valsalva. The course of the left main artery was abnormal in that it passed between the aorta and the pulmonary artery; in addition, there was obstructive disease involving the left main coronary artery. The association of these two entities in this age group is unusual.     

Usefulness of three-dimensional visualization of coronary arteries using electron-beam computed tomography data with volume rendering

Three-dimensional images of the coronary arteries using electron-beam computed tomography (EBCT) data with shaded surface rendering makes it possible to achieve images easily with a short reconstruction time. However, a lower threshold is required to estimate vessel diameters and there is a quantitative problem compared with conventional coronary arteriography. In combination with volume rendering, EBCT may be useful to detect the normal coronary artery wall, the major components of the atherosclerotic plaque (lipid, fibrous connective tissue and calcium). EBCT scans offer a new, non-invasive alternative to conventional coronary arteriography for diagnosis of coronary artery disease.     

Anomalous origin of the right coronary artery above the left sinus of valsalva

Various anomalies of coronary arterial origin have been described. These anatomical variations are discovered either by coronary angiography or at autopsy. We are reporting a case of anomalous origin of the right coronary artery above the left sinus of Valsalva. To our knowledge, this anomaly has not been described before. A technique for selectively catheterizing such an aberrant coronary artery is described.     

Endoluminal perspective volume rendering of coronary arteries using electron-beam computed tomography.

Remarkable progress has been made in the treatment of coronary heart diseases because of a variety of new interventional devices, but as each new device or procedure has suitability for a particular type of patient or purpose, patient selection is increasingly important. Endoluminal perspective volume renderings of the coronary arteries of a 70-year-old male with old myocardial infarction and recurrent chest pain were carried out using electron-beam computed tomography. Conventional coronary angiography had revealed significant stenosis of the distal portion of the left anterior descending branch, and subsequent conventional balloon angioplasty had failed to expand the stenotic site. Perspective volume rendering images can distinguish differences in objects and evaluate the cross sectional area of the lumen and the morphology of calcification. In the present patient, a huge mass of calcified plaque occupied most of the lumen at a site corresponding to the angiographic site of stenosis. According to this finding, rotational atherectomy was indicated and had a good outcome. The qualitative information for characterizing and determining the morphology of atherosclerotic plaque provided by perspective volume rendering may be useful in selecting the appropriate intervention.     

Acute inferior myocardial infarction and coronary spasm in a patient with an anomalous origin of the right coronary artery from the left sinus of valsalva

A 56-year-old Japanese woman with an acute inferior myocardial infarction was admitted to hospital. Emergency coronary angiography revealed an anomalous origin of the right coronary artery from the left sinus of Valsalva, but there was no stenosis or thrombus in either the right or left coronary artery. Coronary spasm was provoked at the site of the proximal portion of the anomalous coronary artery, which was located between the aorta and pulmonary trunk. This was thought to be the cause of the myocardial infarction.     

Diagnosis and management of anomalous origin of the right coronary artery from the left coronary sinus

The anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva coursing between the aorta and the pulmonary artery or right ventricular outflow tract, is considered a potentially fatal abnormality which may require surgery. However, diagnosing the correct course with coronary arteriography may be difficult. Fast gradient echo magnetic resonance (MR) imaging can be helpful to identify and confirm the course of aberrant coronary arteries and their relationship to the surrounding tissue. In this study, diagnostic procedures and management are described of four patients in whom the RCA originated from the left sinus of Valsalva. Although reported as investigational by the Task Force document on MR imaging by the European Society of Cardiology we are of the opinion that MR coronary angiography may have an important future role in the assessment of anomalous coronary arteries.     

Surgical correction of anomalous left coronary artery from the anterior sinus of valsalva

Origination of the left main coronary artery from the anterior sinus of Valsalva is a rare congenital anomaly that has been associated with sudden death. Anatomical correction of this defect has only rarely been performed by unroofing the intramural segment of the proximal coronary artery or by widening the narrowed angulated origin of this anomalous vessel. This report describes the clinical course of a 33-year-old woman with this anomaly who experienced episodes of chest tightness associated with ischemic electrocardiographic changes. Surgical correction was performed by enlarging the ostium of the anomalous artery with a "sphincteroplasty" technique. Thallium scanning, which was positive prior to surgery, was normal postoperatively. The patient remains asymptomatic 6 months after surgical correction.     

An unusual congenital coronary anomaly: origin of the left circumflex coronary artery from a right coronary artery arising from the left sinus of valsalva

A 54-year-old male was admitted to our department for stable angina. Coronary angiography and 16-slice computed tomography revealed an abnormal origin of the right coronary artery from the left sinus of Valsalva, coursing between the aorta and the pulmonary trunk and then giving origin to the left circumflex coronary artery. A severe stenosis was present in the middle segment of the right coronary artery, which was successfully treated by stent implantation.     

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.     

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.     

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.