ANOMALOUS CORONARY ARTERY FROM THE OPPOSITE SINUS

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Presentation transcript:

ANOMALOUS CORONARY ARTERY FROM THE OPPOSITE SINUS S. Chamanian Cardiologist, ACHD Fellowship; Mums

Coronary anomalies are defined as those angiographic findings in which the number, origin, course, and termination of the arteries are rarely encountered in the general population. Coronary anomalies may occur in 1 to 5 percent of patients undergoing coronary arteriography, depending on the threshold for defining an anatomical variant .

Origin of the LCA from the proximal RCA or the right aortic sinus with subsequent passage between the aorta and the right ventricular outflow tract has been associated with sudden death during or shortly after exercise in young persons

The increased risk of sudden death may be due to a Slit-like ostium, A bend with acute takeoff angles of the aberrant coronary arteries, or Arterial compression between the pulmonary trunk and aorta when there is increased blood flow through these vessels with exercise and stress

Origin of the RCA from the LCA or left aortic sinus with passage between the aorta and the right ventricular outflow tract is also associated with myocardial ischemia and sudden death.

In rare cases of anomalous origin of the LCA from the right sinus, myocardial ischemia may occur even if the LCA passes anterior to the right ventricular outflow tract or posterior to the aorta (i.e., not through a tunnel between the two great vessels

Although coronary bypass surgery has been the traditional revascularization approach in patients with ACAOS, coronary stenting has also been reported with acceptable medium-term success.

The course of the anomalous coronary arteries is easily assessed by angiography in the RAO view. The four common courses for the anomalous LCA arising from the right sinus of Valsalva include a septal, anterior, interarterial, or posterior course.

LCX

RCA

The posterior course of the anomalous LCA arising from the right sinus of Valsalva is similar to the course of the anomalous LCx artery arising from the right sinus of Valsalva, whereas the common interarterial course of the anomalous RCA from the left sinus of Valsalva is similar to the interarterial course of the anomalous LCA arising from the right sinus of Valsalva

Another angiographic method to identify the course of the anomalous vessel pass a catheter into the main pulmonary artery and then perform an arteriogram of the aberrant coronary artery in the steep AP caudal projection. This places the aberrant coronary artery, the rightward and anterior pulmonary valve, and the leftward and posterior aortic valve all in one plane. artery is between the great vessels. Although angiography is useful for establishing the presence of anomalous coronary arteries, computed tomographic (CT) angiography may also be an important adjunctive diagnostic tool for establishing the course of the vessels

Multidetector computed tomography (MDCT) allows non-invasive evaluation of coronary arteries. Continuously developing technique Improvement in image quality Visualization of distal vessels and small collateral branches. Minerva Cardioangiol. 2012 Apr;60(2):133-46.

The risks of surgical management outweigh any benefits in the asymptomatic patient with anomalous right coronary artery, and expectant management should also be strongly considered even in asymptomatic patients with anomalous left coronary artery

which patients are at risk of SCD and who should be offered corrective surgical or (potentially) percutaneous intervention . Conventional, noninvasive stress testing has limited sensitivity, but emerging, invasive stress tests, which utilize intravascular ultrasonography and measurements of fractional flow reserve, show the potential to provide more-accurate hemodynamic and prognostic assessment Nat Rev Cardiol. 2011 Oct

Coronary unroofing for AAOCA is a safe method of enlarging the coronary orifice and eliminating the intramural course. Symptomatic patients had a longer intramural course than asymptomatic patients, as assessed by preoperative imaging and intraoperative measurements. These results may have important clinical implications in determining indications for operation. Ann Thorac Surg. 2011 Sep

Small right anterior thoracotomy incision to perform a right internal mammary artery (RIMA) to right coronary artery (RCA) bypass with ligation of the proximal RCA. This was performed under direct vision and without cardiopulmonary bypass.(minimally invasive)