Anomalous LAD and CX artery arising separately from the proximal right coronary artery--a case report of single coronary artery with coronary artery disease

Coronary artery anomaly has been reported at a rate of 0.6% to 1.3% in routine angiographic series. Moreover, single coronary artery is one of the rarest anomalies among coronary anomalies. Eventhough patients with coronary anomalies are usually asymptomatic, they may also be associated with myocardial ischemia, ventricular fibrillation, syncope, congestive heart failure, and sudden death. In this article, we report a case of single coronary artery anomaly with the left anterior descending (LAD) and left circumflex (LCx) coronary artery arising separately from the proximal right coronary artery. Since the presented case was associated with ischemic heart disease, coronary artery bypass grafting was carried out. He is currently well.     

Surgical repair of anomalous origin of the coronary artery from the pulmonary artery in children

OBJECTIVE: To evaluate surgical management of children with coronary artery anomalies, including patients with rare abnormalities (left anterior descending artery or right coronary artery originating from the pulmonary artery). METHODS: A retrospective review of eight patients (aged 2 months--10 yr; median 3.5 yr), treated for coronary artery anomalies between 1989 and 1999. Coronary vessels were reimplanted to the aorta in four children, while the remaining four were subjected to the Takeuchi procedure. RESULTS: All children survived. None required mechanical circulatory support. In six patients significant mitral valve insufficiency developed, nevertheless, no intraoperative mitral valvuloplasty was performed. Follow-up was 2 months--10 yr. All patients developed normally and are currently in NYHA class I. Echocardiography revealed normal FS and EF values within 1--17 months postoperatively. CONCLUSIONS: In children with coronary artery anomalies, the best results are achieved with an early diagnosis and aggressive management. In our opinion coronary vessel reimplantation and the Takeuchi procedure yields comparable results.     

Congenital malformations of the coronary arteries: the Texas Heart Institute experience.

Coronary artery anomalies, some of which are considered clinically insignificant, can be associated with other congenital heart defects, myocardial ischemia, and reduced life expectancy. We conducted a retrospective study to determine the efficacy of surgical treatment in 191 patients who had a total of 202 coronary artery anomalies, which were classified as anomalies of origin (88 patients), termination (93), or distribution (10). Of the 88 patients with anomalies of origin, 60 had a coronary artery arising from the pulmonary artery, 18 had a right coronary artery arising from the left anterior descending artery, and 10 had a coronary artery arising from the contralateral sinus of Valsalva. All patients with an anomaly of termination had a coronary arteriovenous fistula, and all patients with an anomaly of origin had a single coronary artery. The diagnostic and operative techniques for each of the defects are evaluated. Based on our experience, early diagnosis and surgical intervention can yield satisfactory results in patients with coronary artery anomalies, with most experiencing relief of symptoms. The operative procedures were associated with a low early and late mortality; in addition, few patients experienced complications.     

Aortopulmonary window and anomalous coronary artery: an exceptional association

Aortopulmonary window is rarely associated with other cardiac anomalies, such as anomalous origin of one coronary artery. This exceptional association has been reported in 15 patients, with different surgical solutions. We describe 2 patients with aortopulmonary window with anomalous origin of the right coronary artery, one of which presented with tetralogy of Fallot-pulmonary atresia. A neonatal modified Blalock-Taussig shunt and ligature of the distal pulmonary artery at the level of pulmonary bifurcation was performed in the first patient, and the second patient underwent aortopulmonary window division with anomalous coronary artery reimplantation. Both patients had an uneventful postoperative course.     

The saccular coronary aneurysm associated with coronary artery to pulmonary artery fistulae

Coronary artery fistulae are relatively rare congenital anomalies. Those associated with saccular coronary artery aneurysms are even rarer. Including the current case, only 65 such cases have been reported in Japan. A 62-year-old female was admitted to our hospital for evaluation of abnormal shadow on the chest X-ray. The enhanced chest computed tomography (CT) scan demonstrated a giant saccular coronary aneurysm on the left side of the pulmonary artery. Multi-detector row CT (MDCT) scan demonstrated the coronary artery aneurysm was connected to the left anterior descending artery. Coronary angiography revealed 2 aneurysms with bilateral coronary artery to pulmonary artery fistulae. The patient underwent aneurysmectomy and ligation of fistulae under cardiopulomonary bypass. The postoperative course was uneventful and postoperative coronary angiography revealed complete resection of the aneurysms and only slight blood flow through the fistulae. She was discharged on the 10th postoperative day.     

Computed tomography angiography is an excellent tool for the diagnosis of congenital coronary artery anomalies: a report of 2 cases

Congenital coronary artery anomalies are sporadically discovered in patients undergoing coronary angiography and in autopsy series. Although most anomalies are clinically insignificant, some may become causes of cardiovascular morbidities and mortality. Diagnosis is commonly made with conventional coronary artery angiography. The current development of modern cardiac computed tomography allows less invasive imaging of the coronary arteries and might provide additional anatomical and morphological information. Herein, we report our experience with computed tomography coronary angiography, describing 2 clinical cases of patients with symptomatic congenital coronary artery anomalies requiring cardiac surgery.     

Patients with Klippel-Feil syndrome should have imaging of the subclavian artery and its branches prior to coronary artery bypass grafting

Patients with Klippel-Feil syndrome have increased incidence of subclavian artery anomalies. We report a case of a patient with this syndrome undergoing coronary artery bypass grafting. Intra-operatively, the patient was found to have the left internal mammary artery arising from the second intercostal space and the decision was taken to use it as a free graft. As other anomalies of the subclavian arteries and their branches are recognised in patients with Klippel-Feil syndrome, we propose that imaging of the internal mammary arteries is carried out pre-operatively in such patients to assess the suitability for use as conduit in coronary artery bypass grafting.     

Isolated anomalous origin of right coronary artery from the main pulmonary artery

The anomalous origin of the right coronary artery (ARCA) from the main pulmonary artery (MPA) is a rare congenital cardiac malformation and usually associated with other cardiac anomalies. Most patients with isolated ARCA from MPA remain asymptomatic, but they may develop myocardial ischemia and even sudden death. We reported an asymptomatic 7-year-old boy referred for evaluation of a heart murmur. Isolation of ARCA from MPA was diagnosed by echocardiography and then confirmed by cardiac catheterization and angiography. The right coronary artery was re-implanted into the ascending aorta. A preoperative thallium-201 myocardial perfusion showed a myocardial ischemia pattern in the anterolateral septal area after a dipyridamole stress test; the ischemia was completely resolved after surgery.     

Coronary artery bypass grafting for coronary artery anomalies in infants and young children

Open in a separate window OBJECTIVESCoronary artery bypass grafting (CABG) has been reported for coronary artery diseases in patients with Kawasaki disease and coronary artery complications after arterial switch operations for transposition of the great arteries. However, only a few studies have explored this modality for congenital coronary artery anomalies. As congenital coronary artery anomalies, particularly left coronary artery atresia and stenosis, are one of the reasons for sudden death, coronary revascularization is often required in infants and young children. Therefore, we aimed to investigate the outcome of CABG for such anomalies in infants and young children.METHODSFrom 2014 to 2018, 3 infants and 2 children (median age: 10 months; range: 6–40 months) with coronary artery anomalies underwent CABG at our hospital. The indications for the procedure included left main coronary artery atresia and stenosis in 2 and 3 patients, respectively. Graft patency was evaluated postoperatively by contrast-enhanced computed tomography or coronary angiography, and postoperative outcomes (including death and cardiac events) were assessed during the follow-up period.RESULTSNo 30-day or in-hospital mortalities were noted. Postoperative examinations revealed patent grafts in all patients. They were discharged without any cardiac complications. Regarding the outcomes at the follow-up period, the graft patency rate was 80.0% (4/5 grafts), with no deaths or cardiac events.CONCLUSIONSCABG is a useful strategy for coronary revascularization in infants and young children with coronary artery anomalies. Although the mid-term outcomes and patency are satisfactory, careful follow-up is necessary because the long-term outcomes remain unknown.     

A very rare case of single coronary artery anomaly, with left anterior descending and left circumflex arteries originating separately from proximal right coronary artery

Coronary artery anomalies are rare, with the reported prevalence of 0.2% to 1% in routine angiographic studies. Among them, presence of a single coronary artery is one of the rarest anomalies, comprising less than 3% of all coronary anomalies. In this article we report a case of single coronary artery anomaly with left anterior descending and left circumflex arteries arising separately from proximal right coronary artery, and left anterior descending artery reaching atrioventricular sulcus by passing between aortic and pulmonary artery trunci. The patient underwent off-pump coronary artery bypass grafting and is currently symptom-free.     

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.     

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.     

Internal thoracic artery grafting for congenital coronary malformations.

We report 2 patients with congenital coronary anomalies (atresia of left main coronary artery and anomalous origin of the left coronary artery from the pulmonary artery) successfully treated with single or double internal thoracic artery grafting. Because the internal thoracic artery has a potential for circumferential as well as longitudinal development, and because of the uncertainty of ultimate vein graft function, we believe that the internal thoracic artery is the best graft material for the treatment of congenital coronary malformations requiring bypass operation in children, adolescents, or even in adults.     

Congenital coronary artery fistulas: clinical considerations and surgical treatment

BACKGROUND: Coronary artery fistulas are uncommon abnormalities that can cause significant cardiac morbidity. Indications for operation vary, particularly, for asymptomatic patients. Early surgical correction is indicated because of the high incidence of late symptoms and complications. METHODS: From January 1981 to December 2001, all 15 patients who underwent surgical management of congenital coronary artery fistulas at the Tri-Service General Hospital, Taipei, Taiwan, China were included in the present retrospective study. RESULTS: Twelve patients were symptomatic at the time of the diagnosis. Coronary artery fistulas involved the right coronary artery in five patients, left coronary artery in nine, and both the right and the left coronary arteries in one. Coronary artery fistula drained into the right ventricle in seven patients, right atrium in three, pulmonary artery in two, left ventricle in one, left atrium in two, and coronary venous sinus in one. The value of pulmonary blood flow/systemic blood flow ranged from 0.98 to 2.1. Six patients had associated cardiac anomalies. All patients received surgical correction. Nine patients received cardiopulmonary bypass during operation. There was zero operative mortality and operative morbidity was low. All patients had a stable condition and were asymptomatic during a mean postoperative follow-up of 13.3 years. CONCLUSIONS: Early surgical treatment for coronary artery fistulas is safe and effective. The risk of operative correction appears to be considerably less than the potential for development of serious and potentially fatal complications, even in asymptomatic patients.     

Sudden death related to an anomalous origin of the right coronary artery

Nonatherosclerotic anomalies of the coronary arteries are not rare. They account for a third of sudden cardiac deaths in young patients. We report a case of resuscitated cardiac arrest due to an abnormal origin of the right coronary artery. Subsequently, coronary bypass grafting was carried out successfully. After resuscitated sudden death, there is no consensus on the diagnosis or therapeutic management of patients with abnormal coronary arteries.     

Surgical treatment of giant coronary artery aneurysm

OBJECTIVE: Giant coronary artery aneurysm is an extremely uncommon disease. Most previous reports have involved only single cases. This report describes 6 patients with giant coronary artery aneurysm, examines its causes, and aims to establish the optimal surgical strategies for this exceptional and rare pathology. METHODS: From July 1996 to October 2004, a total of 30,268 patients underwent heart surgery at Fuwai Hospital in Beijing. Among these, 6 patients had giant coronary artery aneurysm diagnosed and underwent operation. Various surgical strategies were used for the operations of these 6 patients, such as coronary artery aneurysm resection, coronary artery reconstruction, and concomitant coronary bypass. Additional procedures, such as fistula closure, aortic valve replacement, aortoplasty, and embolectomy, were done at same time for the patients with complications of coronary fistula, aortic valve insufficiency, or thrombus. Patients were followed up from 8 to 87 months, with a mean of 48 months. Doppler echocardiography, ultrafast computed tomography, and 3-dimensional aerial image studies were performed during follow-up. RESULTS: Five of these six cases were found combined with coronary artery fistula, and the cause for these giant coronary artery aneurysms was congenital. The remaining case was caused by atherosclerosis. After surgery, all patients recovered uneventfully, without in-hospital mortality. None died during the follow-up, nor did any have recurrence of the symptoms or giant coronary artery aneurysm. CONCLUSION: Giant coronary artery aneurysm is a rare entity that is commonly caused by congenital malformation and combined with other cardiac anomalies. An optimal surgical operation should be based on the specific cardiac anomaly of the individual patient.     

Surgical therapy in the management of coronary anomalies: emphasis on utility of internal mammary artery grafts

Three patients with an anomalous main coronary artery coursing between the great vessels are presented with a review of the literature. Their surgical treatment by coronary artery bypass grafting with use of the ipsilateral internal mammary artery is described with angiographic follow-up. Young patients with these anomalies, whether they are asymptomatic or have syncope, are at high risk for sudden death. Older patients with angina appear to be adequately risk stratified by thallium stress tests. For patients requiring surgical intervention, aortoplasty and coronary artery bypass grafting have both resulted in relief of symptoms, but the follow-up is limited. We suggest that coronary artery bypass grafting with an ipsilateral internal mammary artery graft to the anomalous vessel is the procedure most likely to relieve ischemia and achieve good long-term results for both symptomatic relief and survival.     

冠状动脉瘤的外科治疗

目的 介绍冠状动脉瘤的临床表现及治疗经验。方法 1996年10月－2000年5月,对6例患者行冠状动脉瘤手术,3例为川崎病,3例为冠状动脉瘘;均行冠状动脉旁路移植术,3例冠状动脉瘘患者同时切除冠状动脉瘤,修补冠状动脉瘘口,1例行主动脉瓣置换术。结果 6例患者无住院死亡和严重并发症。随访无异常。结论 冠状动脉瘤是一较为罕见的心脏病,预后差,应尽早手术治疗。手术原则是切除冠状动脉瘤,行冠状动脉旁路移植术并处理好合并病变。     

Coronary artery spasm following coronary artery revascularization

Coronary artery spasm is a well-documented phenomenon in patients undergoing medial treatment. We describe coronary artery spasm occurring in the immediate postoperative period following coronary artery bypass operation. The spasm occurred in a vessel that was not operated on and that had no apparent lesion. The diagnosis of spasm was made by coronary angiography immediately after operation. Complications associated with this spasm are discussed. Emphasis is placed on early postoperative angiography for patients whose condition is inexplicably unstable after operation.     

Coronary artery bypass grafting in two patients with single coronary artery

We experienced two patients with single coronary artery who underwent CABG using arterial grafts successfully. In two patients coronary angiography demonstrated a single coronary artery which was originated in left coronary sinus and was bifurcated to LAD and LCx, and then RCA branched off proximal LAD, passing in front of the right ventricular out flow tract (Sharbaugh Type L-IIa). To the first patient, a 52-year-old man who had angina on exertion due to long stenosis of RCA, CABG to RCA using RITA was carried out. To the second patient, a 57-year-old man who had inferior myocardial infarction due to 90% stenosis of proximal LAD, CABG to RCA using RITA and LAD using LITA was carried out. Single coronary artery without additional congenital cardiac anomalies may lead to myocardial ischemia, necessitating CABG as coronary reconstructions.