Clinical Articles: Coronary Artery Anomalies—Current Clinical Issues: Definitions, Classification, Incidence, Clinical Relevance, and Treatment Guidelines

Department of Adult Cardiology, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas 77030, USA.
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital (Impact Factor: 0.65). 02/2002; 29(4):271-8.
Source: PubMed


The study of coronary artery anomalies would benefit from the clarification of various fundamental issues, including the definitions, classification, incidence, pathophysiologic mechanisms, and clinical relevance of each anomaly. The greatest challenge is to identify the abnormality and determine its clinical relevance so that appropriate treatment can be instituted. Currently, the coronary anatomy is essentially defined by the features of the (conductive) epicardial coronary tree and its dependent territory. Therefore, one must consider all the possible and observed variations in anatomic features that are used to describe the coronary arteries. We propose that the left anterior descending, circumflex, and right coronary arteries be considered the essential elementary units of coronary anatomy. We also suggest that the coronary arteries be defined not by their origin or proximal course, but by their intermediate and distal segments or dependent microvascular bed. A strict classification system is necessary before meaningful data can be gathered about the incidence of coronary anomalies. With respect to clinical relevance, the greatest challenge is presented by anomalies that only occasionally cause critically severe clinical events and are otherwise compatible with a normal life. In such cases, it is not known whether the specific features of a given anomaly cause adverse clinical consequences, or whether additional episodic factors are required. To correlate subclassifiable anatomic and functional features with clinical events and prognoses, a large, multicenter database, relying on prospective, coordinated protocols, is urgently needed. In the absence of established official guidelines, we present practical protocols for diagnosing and treating coronary anomalies.

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    • "As described, coronary anomalies have been associated with a wide range of cardiac symptoms; however, the mechanisms behind the symptoms are poorly understood. Pinching of the anomalous RCA between the aorta and the pulmonary artery caused by the increased cardiac output during exercise has been proposed [5]. Also, an intussusception of the initial part of the RCA in the aortic wall, resulting in an intramural part, may make it vulnerable for compression by the expanding aorta on increased cardiac output [3]. "
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    ABSTRACT: An anomalous origin and course of the right coronary artery (RCA)(1) is a very rare congenital anomaly that can be fatal if it remains undiscovered. In this case report, we present a patient with a one-year history of exercise-induced angina and dyspnea caused by anomalous origin of the RCA from the left sinus, and anomalous course between the aorta and the pulmonary artery. Possible mechanisms of this disease's symptomatology are compression of the RCA between the aorta and the pulmonary artery in its anomalous inter-arterial course, and squeezing of the RCA in the proximal intramural part. In this report, we present some unique images of the RCAs course, which contribute to the understanding of this disease's symptomatology. The patient successfully underwent surgery with Right Internal Mammary Artery to RCA (RIMA-RCA)(2) bypass with complete remission of all symptoms. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.
    International Journal of Surgery Case Reports 07/2015; 14:92-94. DOI:10.1016/j.ijscr.2015.07.018
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    • "Documented coronary ischemia in the setting of an anomalous coronary artery coursing between aorta and pulmonary arteries is a class IB indication for surgery according to the American College of Cardiology and American Heart Association (ACC/AHA) guidelines for congenital heart diseases [12]. Exercise stress testing, though commonly employed for diagnosing coronary ischemia, is inadequate in predicting future risk of SCA in patients with anomalous coronaries [13] [14]. Guidelines also recommend surgical correction of anomalous coronary artery coursing between major vessels even in the absence of ischemia [12]. "
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    ABSTRACT: Sudden cardiac arrest has been reported to occur in patients with congenital anomalous coronary artery disease. About 80% of the anomalies are benign and incidental findings at the time of catheterization. We present a case of sudden cardiac arrest caused by anomalous left anterior descending artery. 61-year-old African American female was brought to the emergency department after sudden cardiac arrest. Initial EKG showed sinus rhythm with RBBB and LAFB with nonspecific ST-T wave changes. Coronary angiogram revealed no atherosclerotic disease. The left coronary artery was found to originate from the right coronary cusp. Cardiac CAT scan revealed similar findings with interarterial and intramural course. Patient received one-vessel arterial bypass graft to her anomalous coronary vessel along with a defibrillator for secondary prevention. Sudden cardiac arrest secondary to congenital anomalous coronary artery disease is characterized by insufficient coronary flow by the anomalous left coronary artery to meet elevated left ventricular (LV) myocardial demand. High risk defects include those involved with the proximal coronary artery or coursing of the anomalous artery between the aorta and pulmonary trunk. Per guidelines, our patient received one vessel bypass graft to her anomalous vessel. It is important for clinicians to recognize such presentations of anomalous coronary artery.
    07/2015; 2014(2):1-4. DOI:10.1155/2015/806291
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    • "Anomalous origin of the right coronary artery from the left sinus of Valsalva (ARCA) is a rare congenital anomaly but a common cause of sudden death in the young [1]. It is commonly identified incidentally by angiography, during cardiac operation, or at autopsy [2]. "
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    ABSTRACT: Anomalous origin of the right coronary artery from the left coronary sinus is rare but potentially dangerous if any ischemic signs are present. Multiple therapeutic options were advocated so far. We experienced three different situations and surgical approaches to these anomalies, and reviewed retrospectively. For the first case, we made a neo-ostium on the right sinus of Valsalva and anastomosed with the right coronary artery after arteriotomy. For the second and third cases, we applied coronary artery bypasses emergently: patient 2 the gastroepiploic artery during off-pump coronary artery bypass and patient 3 the left internal thoracic artery during surgery for acute aortic dissection. For the better outcomes, it is important to understand anatomic and hemodynamic characteristics of each patient and select the surgical options considering each characteristic.
    Journal of Cardiothoracic Surgery 01/2014; 9(1):21. DOI:10.1186/1749-8090-9-21 · 1.03 Impact Factor
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