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Catheter ablation of left-sided accessory pathway with left superior vena cava
Volume 130, Number 3, Part 1
M a et al.
American Heart Journal
normal, and the blood pressure was 130/50 m m Hg. A transthoracic echocardiogram ( T I ~ ) demonstrated severe aortic insufficiency, mild sclerosis of the aortic valve leaflets, and normal left ventricular hmction. A TEE showed normal diastolic coaptation of the aortic valve leaflets without leaflet prolapse or aortic root dilatation or dissection (Fig. 1, A). An eccentric jet of aortic regurgitation was noted to traverse the belly of the right coronary cusp (Fig. 1, B) consistent with cusp perforation. Despite medical therapy, the congestive heart failure could not be controlled. Repeat cardiac catheterization showed restenosis of the ostial lesion of the right coronary artery. During selective right coronary injection, refluxing contrast was noted to enter the left ventricle in diastole. Severe aortic regurgitation was documented on aortic root angiography. The patient underwent open heart surgery, and the right coronary and left anterior descending arteries were bypassed with the right and left internal m a m m a r y arteries. The aorta was opened with a J-shaped incision, and a 6 m m circular perforation was noted in the center of the right coronary cusp close to its attachment to the annulus. A 1 cm pericardial patch was treated with glutaraldehyde and attached to the aortic side of the right coronary cusp with a running Ticron suture. Intraoperative TEE confirmed the competence of the repair after the patient was taken off of bypass. The patient made an uneventfifl recovery without recurrence of angina or congestive heart failure. A T r E obtained 3 months a ~ r surgery demonstrated a competent aortic valve without a transvalx,ular systolic gradient. Interventional cardiology with catheter-based techniques has assumed an increasingly important role in the management of cardiac patients. Although the risk-benefit ratio of these invasive procedures is extremely favorable, complications do occur. Recognition and proper management of these complications by the operator is crucial. Aortic valve cusp perforation is a rarely reported complication of invasive cardiac procedures. Aortic cusp perforation associated with significant aortic regurgitation requiring surgical repair with a pericardial patch has been reported a ~ r diagnostic cardiac catheterization. 1 Trivial aortic regurgitation not requiring surgical intervention as a result of aortic cusp perforation has been reported al~er radiofrequency ablation. 2 Severe aortic regurgitation resulting from cusp perforation has been reported after percutaneous aortic balloon valvuloplasty. 3 ,4 TEE has been shown to be more sensitive than TTE for diagnosing mitral and aortic leaflet perforation in patients with infective endocarditis. 5, 6 Even if the actual perforation is not visualized, Doppler color flow mapping may demonstrate a regurgitant jet traversing the body of the leaflet and not originating from the point of leaflet coaptation from which perforation may be inferred. Our patient had hemodynamically significant aortic regurgitation as a result of a surgically confirmed perforation of the right coronary cusp after DCA of a right coronary ostial lesion. The catheter used to introduce the atherectomy device is
613
larger and stiffer than other catheters, and we speculate that this may have contributed to the perforation. ~ was useful in evaluating the severity of the aortic regurgitation but could not accurately diagnose the cause. The findings on TEE of an eccentric jet with color flow signals traversing the belly of the right coronary cusp strongly suggested the diagnosis of leaflet perforation preoperatively. Intraoperative TEE confirmed that valve competence had been restored by the pericardial patch graft and that poor diastolic coaptation had not developed from cusp distortion. REFERENCES
1. Denyer MH, Elliot CM, Rebicsek F. Pericardial patch repair of aortic cusp perforation caused by cardiac catheterization. J Card Surg 1988; 3:155-7. 2. Seifert MJ, Morady F, Calkins HG, Langberg JJ. Aortic leaflet perforation during radiofrequency ablation. PACE 1991;14:1582-5. 3. Bu'Lock FA, Joffe HS, Jordan SC, Martin RP. Balloon dilatation (valvuloplasty) as first line treatment for severe stenosis of the aortic valve in early infancy: medium term results and determinants of survival. Br Heart J 1993;70:546-53. 4. Kasten-Sportes CH, Piechaud JF, Sidi D, Kachaner J. Percutaneous balloon valvuloplasty in neonates with critical aortic stenosis. J Am Cell Cardiol 1989;13:1101-5. 5. Cziner DG, Rosenzweig BP, Katz ES, Keller AM, Daniel WG, Kronzon I. Transesophageal versus transthoracic echocardiography for diagnosing mitral valve perforation. Am J Cardiol 1992;69:1495-7. 6. Ballal RS, Mahan III EF, Nanda NC, Sanyal R. Aortic and mitral perforation: diagnosis by transesophageal echocardiography and Doppler color flow imaging. AM HEARTJ 1991;121:214-7.
Catheter ablation of left-sided accessory pathway with left superior vena cava C. S. Ma, MD, a Dayi Hu, MD, a Q. Fang, MD, a L. H. Shang, MD, a L. F. Wang, MD, a Michael K. Belz, MD, b and Mark A. Wood, MD b
Beijing, People's Republic of China, and Richmond, Va.
Coronary sinus mapping can be an integral part of radiofrequency catheter ablation of left-sided accessory pathways. Such mapping may be precluded by inability to cannulate the coronary sinus or by coronary sinus involvement with venous anomalies. This report describes successful catheter ablation of a left-sided accessory pathway in a patient with a persistent left superior vena cava (LSVC). From the aHeart Centre, Capital Institute of Medicine Affiliated Peking Red Cross Chao Yang Hospital; and the bDepartment of Medicine (Cardiology), Medical College of Virginia Hospital. Reprint requests: C. S. Ma, MD, Bejing Red Cross Chao Yang Hospital, 8 Bai Jianzhuang Read, Chao Yang District, Beijing, People's Republic of China 100020. AM HEARTJ 1995;130:613-5. Copyright © 1995 by Mosby-Year Book, Inc. 0002-8703/95/$3.00 + 0 4/4/65070
September 1995
614
M a ~, c~.
Fig. 1. Left anterior oblique view during contrast injection filling left superior vena cava (LSVC) and coronary sinus (CS) via left subclavian vein. Mapping catheter (MAP) passes from left subclavian vein through left superior vena cava to distal coronary sinus. Large tipped ablation catheter (AB) passes through foramen ovale to posterolateral mitral valve annulus. Third catheter is positioned in right ventricular apex CRV).Approximate diameter of coronary sinus is 2 cm referenced to I cm interelectrode spacing of mapping catheter.
A 44-year-old woman with a 3-year history of palpitations was admitted to the Red Cross Chao Yang Hospital for radiofrequency ablation of a manifest left-sided accessory pathway. During the procedure a left subclavian venous catheter placed for coronary sinus mapping was advanced by an anomalous course inferiorly in the left chest to the posterior aspect of the heart. Contrast injections into the left subclavian sheath demonstrated the presence of a persistent LSVC in continuity with the coronary sinus (Figs. 1 and 2). Excessive motion of the coronary sinus mapping catheter in this very large-diameter vessel precluded accurate accessory pathway localization by this means. A 4 m m tip, steerable ablation catheter was positioned along the posterolateral mitral valve annulus by the transseptal approach through a patent foramen ovale. Mapping of this region soon demonstrated a stable catheter position with a 60 msec ventriculoatrial conduction time during incessant orthodromic reciprocating tachycardia. The fifth radiofrequency lesion (30 W for 60 seconds) terminated tachycardia and permanently abolished antegrade and retrograde accessory pathway function. Total fluoroscopy time was 22 minutes. Persistent LSVC is the most common systemic venous anomaly, occurring in 0.5% of the general population. 1 The incidence is approximately 4% in patients with congenital heart disease. 2 Associated anomalies are most commonly atrial septal defects (40%), tetralogy of Fallot, atrioventricular canal defects, and partial anomalous pulmonary venous connection. 3 Although persistent LSVC alone is asymptomatic, this anomaly may affect left-sided ablation procedures in several ways. First, when anastomosed with
American Heart Journal
Fig. 2. Right anterior oblique view during contrast injection into left subclavian vein. Catheter positions and abbreviations as per Fig. 1.
the coronary sinus, the cavernous nature of this vessel virtually precludes catheter mapping of the coronary sinus as demonstrated in this case and the authors' previous clinical experience with a second patient with LSVC and a left-sided accessory pathway. Of note, the presence of an LSVC may be less obvious during the femoral approach to coronary sinus cannulation as recently reported. 4 Second, in its "pure" form the LSVC enters directly into the left atrium between the appendage and left pulmonary veins, providing ready transvenous access to the left heart. Rarely, the absence of a coexistent right superior vena cava complicates right heart access by all but the femoral approach. T h e partial unroofed coronary sinus variant may exhibit fenestrated communication between the coronary sinus and left atrium, also providing left atrial access but conceivably also entangling mapping/ablation catheters. Also, associated cor triatriatum may confound transatrial mapping of the mitral annulus. Third, LSVC has been associated with ectopic supraventricular rhythm with left-axis P-wave deviation and isorhythmic atrioventricular dissociation. 5 This "coronary sinus" rhythm has been reported to originate in the atrioventricular node or ectopic pacemaker tissue and should be recognized during ablation procedures. Fourth, the frequent occurrence of LSVC with congenital heart disease should prompt evaluation for additional anomalies. 3, 6 In stmmmry, LSVC is a rare but important finding to recognize during attempted catheter ablation of left-sided tachycardias. Physicians performing such procedures should be knowledgeable as to the anatomy and implications of this anomaly. REFERENCES 1. Steinberg I, Dubflier W, Lucas D. Persistence oflei~ superior vena cava. Dis Chest 1953;24:479-88. 2. Fraser RS, Dvorkin J, Rossan RE, Eidem R. Left superior vena cava: a review of associated congenital heart lesions, catheterization data, and roentgenologic findings. Am J Med 1961;31:711-6o 3. Bjerregaard P, Laursen HB. Persistent left superior vena cavm Acta Paediatr Scand 1980;69:105-8.
Volume 130, Number 3, Part 1
American Heart Journal
Manning et al.
615
4. Daoud EG, Niebauer M, Bakr O, Jentzer J, Man KC, Williamson BD, Hummel JD, Strickberger A, Morady F. Placement of electrode catheters into the coronary sinus during electrophysiology procedures using a femoral approach. Am J Cardiol 1994;74:194-5. 5. Momma K, Linde LM. Abnormal rhythms associated with left superior vena cava. Pediatr Res 1969;3:210-6. 6. Winter FS. Persistent left superior vena cava: survey of world literature and report of thirty additional cases. Angiology 1954;5:90-132.
Improved definition of anomalous left coronary artery by magnetic resonance coronary angiography Warren J. Manning, MD, a, b, d Wei Li, MD, b, d Stafford I. Cohen, MD, a, d Robert G. Johnson, MD, c, d and Robert R. Edelman, MD b, d Boston, Mass.
Congenital coronary artery anomalies are rare, occurring in only 0.6% to 1.2% of adults referred for coronary angiography13 and frequently in association with other forms of congenital cardiac abnormalities. The majority of coronary anomalies are not associated with impaired myocardial perfusion. Hemodynamically significant anomalies with abnormalities of myocardial perfusion 4 include origin of the left coronary artery from the pulmonary artery, congenital coronary artery stenosis or atresia, coronary artery fistulae, and origin of the left coronary artery from the right sinus of Valsalva with subsequent passage of the vessel between the aorta and right ventricular infundibulum. The latter condition was thought to be benign until the postmortem observations of Cheitlin et al. 5 of the sudden death of 9 of 33 patients in whom the left coronary artery rose from the right sinus of Valsalva. The cause of sudden death is not known but has been hypothesized to include coronary artery compression, an abnormal, slitlike ostium, or acute take-off angles of the anomalous vessel. 5 Although the diagnosis of anomalous coronary arteries is easily made by angiography, definition of the subsequent course of these vessels (anterior or posterior to the right ventricular outflow trac0 is often difficult. 6 Such information is important because a posteriorly directed course is associated with a poor prognosis. Magnetic resonance coronary angiography (MRCA), with the ability
From the Departments of aMedicine (Cardiovascular Division), bRadiology, and CSurgery, Charles A. Dana Research Institute, and the dHarvardThorndike Laboratory of the Beth Israel Hospital and Harvard Medical School. Supported in part by a grant from the National Institute of Health (R01 HL48538), Bethesda, Md. Dr. Manning is supported in part by the Edwar d Mallinckrodt Jr. Foundation, St. Louis, Mo. Reprint requests: Warren J. Manning, MD, Cardiovascular Division , Beth Israel Hospital, 330 Brookline Ave., Boston, MA 02215. AM HEARTJ 1995;130:615-7. Copyright © 1995 by Mosby-Year Book, Inc. 0002-8703/95/$3.00 + 0 4]4]65074
Fig. 1. Coronary angiogram after contrast injection into right coronary ostia (solid arrow) demonstrates anomalous left coronary artery (open arrows). Pulmonary artery catheter is also noted curved arrows).
to noninvasively acqmre data in double-oblique orientations, is uniquely suited for the evaluation of anomalous coronary arteries. In this report, we describe a case of an anomalous left anterior descending coronary artery in which MRCA aided in defining its course. A 67-year-old man underwent diagnostic catheterization at an outside hospital 2 years before admission for evaluation of atypical chest pain. Coronary angiography demonstrated anomalous origin of the left coronary artery from the right sinus of Valsalva and a 50% mid right coronary artery (RCA) stenosis. The specific course of the left coronary artery could not be determined, and he was treated medically. He did well for 18 months but then had typical symptoms of exertional angina. Exercise thallium testing was stopped after 9 minutes of the Bruce protocol because of 9/10 angina that required sublingual nitroglycerin for relief at a rate-pressure product of 8.3 K. He had nondiagnostic 0.5 mm horizontal ST depressions anterolaterally, but thallium scintigraphy revealed reversible inferior, apical, and posterobasal perfusion deficits. Coronary angiography demonstrated an occlusion of the mid RCA with distal filling via collaterals. The left coronary artery rose from the proximal RCA (Fig. 1) and appeared to course posteriorly to the pulmonary outflow tract (which was identified by a pulmonary artery catheter). Mild systolic narrowing of this segment was also noted. No left circumflex coronary artery was identified. The patient was referred for MRCA to confirm the course of the anomalous left coronary artery. MRCA was performed with a superconducting 1.5 T echo-planar-capable system (Siemen's Medical Systems, Iselin, N.J.) with a standard planar elliptical spine coil as radiofrequency receiver. An ECG-gated gradient-echo sequence with fat saturation and k-space segmentation was used in conjunction with breath holding. 7A repetition time (TR) of 13 msec and an echo time (TE) of 8 msec were used with a 3 mm slice thickness, i mm overlap, and 230 x 230 mm field of view. Transverse images demonstrated the origin of the RCA and anomalous left coronary artery (Fig. 2, A). The left
M a et al.
American Heart Journal
normal, and the blood pressure was 130/50 m m Hg. A transthoracic echocardiogram ( T I ~ ) demonstrated severe aortic insufficiency, mild sclerosis of the aortic valve leaflets, and normal left ventricular hmction. A TEE showed normal diastolic coaptation of the aortic valve leaflets without leaflet prolapse or aortic root dilatation or dissection (Fig. 1, A). An eccentric jet of aortic regurgitation was noted to traverse the belly of the right coronary cusp (Fig. 1, B) consistent with cusp perforation. Despite medical therapy, the congestive heart failure could not be controlled. Repeat cardiac catheterization showed restenosis of the ostial lesion of the right coronary artery. During selective right coronary injection, refluxing contrast was noted to enter the left ventricle in diastole. Severe aortic regurgitation was documented on aortic root angiography. The patient underwent open heart surgery, and the right coronary and left anterior descending arteries were bypassed with the right and left internal m a m m a r y arteries. The aorta was opened with a J-shaped incision, and a 6 m m circular perforation was noted in the center of the right coronary cusp close to its attachment to the annulus. A 1 cm pericardial patch was treated with glutaraldehyde and attached to the aortic side of the right coronary cusp with a running Ticron suture. Intraoperative TEE confirmed the competence of the repair after the patient was taken off of bypass. The patient made an uneventfifl recovery without recurrence of angina or congestive heart failure. A T r E obtained 3 months a ~ r surgery demonstrated a competent aortic valve without a transvalx,ular systolic gradient. Interventional cardiology with catheter-based techniques has assumed an increasingly important role in the management of cardiac patients. Although the risk-benefit ratio of these invasive procedures is extremely favorable, complications do occur. Recognition and proper management of these complications by the operator is crucial. Aortic valve cusp perforation is a rarely reported complication of invasive cardiac procedures. Aortic cusp perforation associated with significant aortic regurgitation requiring surgical repair with a pericardial patch has been reported a ~ r diagnostic cardiac catheterization. 1 Trivial aortic regurgitation not requiring surgical intervention as a result of aortic cusp perforation has been reported al~er radiofrequency ablation. 2 Severe aortic regurgitation resulting from cusp perforation has been reported after percutaneous aortic balloon valvuloplasty. 3 ,4 TEE has been shown to be more sensitive than TTE for diagnosing mitral and aortic leaflet perforation in patients with infective endocarditis. 5, 6 Even if the actual perforation is not visualized, Doppler color flow mapping may demonstrate a regurgitant jet traversing the body of the leaflet and not originating from the point of leaflet coaptation from which perforation may be inferred. Our patient had hemodynamically significant aortic regurgitation as a result of a surgically confirmed perforation of the right coronary cusp after DCA of a right coronary ostial lesion. The catheter used to introduce the atherectomy device is
613
larger and stiffer than other catheters, and we speculate that this may have contributed to the perforation. ~ was useful in evaluating the severity of the aortic regurgitation but could not accurately diagnose the cause. The findings on TEE of an eccentric jet with color flow signals traversing the belly of the right coronary cusp strongly suggested the diagnosis of leaflet perforation preoperatively. Intraoperative TEE confirmed that valve competence had been restored by the pericardial patch graft and that poor diastolic coaptation had not developed from cusp distortion. REFERENCES
1. Denyer MH, Elliot CM, Rebicsek F. Pericardial patch repair of aortic cusp perforation caused by cardiac catheterization. J Card Surg 1988; 3:155-7. 2. Seifert MJ, Morady F, Calkins HG, Langberg JJ. Aortic leaflet perforation during radiofrequency ablation. PACE 1991;14:1582-5. 3. Bu'Lock FA, Joffe HS, Jordan SC, Martin RP. Balloon dilatation (valvuloplasty) as first line treatment for severe stenosis of the aortic valve in early infancy: medium term results and determinants of survival. Br Heart J 1993;70:546-53. 4. Kasten-Sportes CH, Piechaud JF, Sidi D, Kachaner J. Percutaneous balloon valvuloplasty in neonates with critical aortic stenosis. J Am Cell Cardiol 1989;13:1101-5. 5. Cziner DG, Rosenzweig BP, Katz ES, Keller AM, Daniel WG, Kronzon I. Transesophageal versus transthoracic echocardiography for diagnosing mitral valve perforation. Am J Cardiol 1992;69:1495-7. 6. Ballal RS, Mahan III EF, Nanda NC, Sanyal R. Aortic and mitral perforation: diagnosis by transesophageal echocardiography and Doppler color flow imaging. AM HEARTJ 1991;121:214-7.
Catheter ablation of left-sided accessory pathway with left superior vena cava C. S. Ma, MD, a Dayi Hu, MD, a Q. Fang, MD, a L. H. Shang, MD, a L. F. Wang, MD, a Michael K. Belz, MD, b and Mark A. Wood, MD b
Beijing, People's Republic of China, and Richmond, Va.
Coronary sinus mapping can be an integral part of radiofrequency catheter ablation of left-sided accessory pathways. Such mapping may be precluded by inability to cannulate the coronary sinus or by coronary sinus involvement with venous anomalies. This report describes successful catheter ablation of a left-sided accessory pathway in a patient with a persistent left superior vena cava (LSVC). From the aHeart Centre, Capital Institute of Medicine Affiliated Peking Red Cross Chao Yang Hospital; and the bDepartment of Medicine (Cardiology), Medical College of Virginia Hospital. Reprint requests: C. S. Ma, MD, Bejing Red Cross Chao Yang Hospital, 8 Bai Jianzhuang Read, Chao Yang District, Beijing, People's Republic of China 100020. AM HEARTJ 1995;130:613-5. Copyright © 1995 by Mosby-Year Book, Inc. 0002-8703/95/$3.00 + 0 4/4/65070
September 1995
614
M a ~, c~.
Fig. 1. Left anterior oblique view during contrast injection filling left superior vena cava (LSVC) and coronary sinus (CS) via left subclavian vein. Mapping catheter (MAP) passes from left subclavian vein through left superior vena cava to distal coronary sinus. Large tipped ablation catheter (AB) passes through foramen ovale to posterolateral mitral valve annulus. Third catheter is positioned in right ventricular apex CRV).Approximate diameter of coronary sinus is 2 cm referenced to I cm interelectrode spacing of mapping catheter.
A 44-year-old woman with a 3-year history of palpitations was admitted to the Red Cross Chao Yang Hospital for radiofrequency ablation of a manifest left-sided accessory pathway. During the procedure a left subclavian venous catheter placed for coronary sinus mapping was advanced by an anomalous course inferiorly in the left chest to the posterior aspect of the heart. Contrast injections into the left subclavian sheath demonstrated the presence of a persistent LSVC in continuity with the coronary sinus (Figs. 1 and 2). Excessive motion of the coronary sinus mapping catheter in this very large-diameter vessel precluded accurate accessory pathway localization by this means. A 4 m m tip, steerable ablation catheter was positioned along the posterolateral mitral valve annulus by the transseptal approach through a patent foramen ovale. Mapping of this region soon demonstrated a stable catheter position with a 60 msec ventriculoatrial conduction time during incessant orthodromic reciprocating tachycardia. The fifth radiofrequency lesion (30 W for 60 seconds) terminated tachycardia and permanently abolished antegrade and retrograde accessory pathway function. Total fluoroscopy time was 22 minutes. Persistent LSVC is the most common systemic venous anomaly, occurring in 0.5% of the general population. 1 The incidence is approximately 4% in patients with congenital heart disease. 2 Associated anomalies are most commonly atrial septal defects (40%), tetralogy of Fallot, atrioventricular canal defects, and partial anomalous pulmonary venous connection. 3 Although persistent LSVC alone is asymptomatic, this anomaly may affect left-sided ablation procedures in several ways. First, when anastomosed with
American Heart Journal
Fig. 2. Right anterior oblique view during contrast injection into left subclavian vein. Catheter positions and abbreviations as per Fig. 1.
the coronary sinus, the cavernous nature of this vessel virtually precludes catheter mapping of the coronary sinus as demonstrated in this case and the authors' previous clinical experience with a second patient with LSVC and a left-sided accessory pathway. Of note, the presence of an LSVC may be less obvious during the femoral approach to coronary sinus cannulation as recently reported. 4 Second, in its "pure" form the LSVC enters directly into the left atrium between the appendage and left pulmonary veins, providing ready transvenous access to the left heart. Rarely, the absence of a coexistent right superior vena cava complicates right heart access by all but the femoral approach. T h e partial unroofed coronary sinus variant may exhibit fenestrated communication between the coronary sinus and left atrium, also providing left atrial access but conceivably also entangling mapping/ablation catheters. Also, associated cor triatriatum may confound transatrial mapping of the mitral annulus. Third, LSVC has been associated with ectopic supraventricular rhythm with left-axis P-wave deviation and isorhythmic atrioventricular dissociation. 5 This "coronary sinus" rhythm has been reported to originate in the atrioventricular node or ectopic pacemaker tissue and should be recognized during ablation procedures. Fourth, the frequent occurrence of LSVC with congenital heart disease should prompt evaluation for additional anomalies. 3, 6 In stmmmry, LSVC is a rare but important finding to recognize during attempted catheter ablation of left-sided tachycardias. Physicians performing such procedures should be knowledgeable as to the anatomy and implications of this anomaly. REFERENCES 1. Steinberg I, Dubflier W, Lucas D. Persistence oflei~ superior vena cava. Dis Chest 1953;24:479-88. 2. Fraser RS, Dvorkin J, Rossan RE, Eidem R. Left superior vena cava: a review of associated congenital heart lesions, catheterization data, and roentgenologic findings. Am J Med 1961;31:711-6o 3. Bjerregaard P, Laursen HB. Persistent left superior vena cavm Acta Paediatr Scand 1980;69:105-8.
Volume 130, Number 3, Part 1
American Heart Journal
Manning et al.
615
4. Daoud EG, Niebauer M, Bakr O, Jentzer J, Man KC, Williamson BD, Hummel JD, Strickberger A, Morady F. Placement of electrode catheters into the coronary sinus during electrophysiology procedures using a femoral approach. Am J Cardiol 1994;74:194-5. 5. Momma K, Linde LM. Abnormal rhythms associated with left superior vena cava. Pediatr Res 1969;3:210-6. 6. Winter FS. Persistent left superior vena cava: survey of world literature and report of thirty additional cases. Angiology 1954;5:90-132.
Improved definition of anomalous left coronary artery by magnetic resonance coronary angiography Warren J. Manning, MD, a, b, d Wei Li, MD, b, d Stafford I. Cohen, MD, a, d Robert G. Johnson, MD, c, d and Robert R. Edelman, MD b, d Boston, Mass.
Congenital coronary artery anomalies are rare, occurring in only 0.6% to 1.2% of adults referred for coronary angiography13 and frequently in association with other forms of congenital cardiac abnormalities. The majority of coronary anomalies are not associated with impaired myocardial perfusion. Hemodynamically significant anomalies with abnormalities of myocardial perfusion 4 include origin of the left coronary artery from the pulmonary artery, congenital coronary artery stenosis or atresia, coronary artery fistulae, and origin of the left coronary artery from the right sinus of Valsalva with subsequent passage of the vessel between the aorta and right ventricular infundibulum. The latter condition was thought to be benign until the postmortem observations of Cheitlin et al. 5 of the sudden death of 9 of 33 patients in whom the left coronary artery rose from the right sinus of Valsalva. The cause of sudden death is not known but has been hypothesized to include coronary artery compression, an abnormal, slitlike ostium, or acute take-off angles of the anomalous vessel. 5 Although the diagnosis of anomalous coronary arteries is easily made by angiography, definition of the subsequent course of these vessels (anterior or posterior to the right ventricular outflow trac0 is often difficult. 6 Such information is important because a posteriorly directed course is associated with a poor prognosis. Magnetic resonance coronary angiography (MRCA), with the ability
From the Departments of aMedicine (Cardiovascular Division), bRadiology, and CSurgery, Charles A. Dana Research Institute, and the dHarvardThorndike Laboratory of the Beth Israel Hospital and Harvard Medical School. Supported in part by a grant from the National Institute of Health (R01 HL48538), Bethesda, Md. Dr. Manning is supported in part by the Edwar d Mallinckrodt Jr. Foundation, St. Louis, Mo. Reprint requests: Warren J. Manning, MD, Cardiovascular Division , Beth Israel Hospital, 330 Brookline Ave., Boston, MA 02215. AM HEARTJ 1995;130:615-7. Copyright © 1995 by Mosby-Year Book, Inc. 0002-8703/95/$3.00 + 0 4]4]65074
Fig. 1. Coronary angiogram after contrast injection into right coronary ostia (solid arrow) demonstrates anomalous left coronary artery (open arrows). Pulmonary artery catheter is also noted curved arrows).
to noninvasively acqmre data in double-oblique orientations, is uniquely suited for the evaluation of anomalous coronary arteries. In this report, we describe a case of an anomalous left anterior descending coronary artery in which MRCA aided in defining its course. A 67-year-old man underwent diagnostic catheterization at an outside hospital 2 years before admission for evaluation of atypical chest pain. Coronary angiography demonstrated anomalous origin of the left coronary artery from the right sinus of Valsalva and a 50% mid right coronary artery (RCA) stenosis. The specific course of the left coronary artery could not be determined, and he was treated medically. He did well for 18 months but then had typical symptoms of exertional angina. Exercise thallium testing was stopped after 9 minutes of the Bruce protocol because of 9/10 angina that required sublingual nitroglycerin for relief at a rate-pressure product of 8.3 K. He had nondiagnostic 0.5 mm horizontal ST depressions anterolaterally, but thallium scintigraphy revealed reversible inferior, apical, and posterobasal perfusion deficits. Coronary angiography demonstrated an occlusion of the mid RCA with distal filling via collaterals. The left coronary artery rose from the proximal RCA (Fig. 1) and appeared to course posteriorly to the pulmonary outflow tract (which was identified by a pulmonary artery catheter). Mild systolic narrowing of this segment was also noted. No left circumflex coronary artery was identified. The patient was referred for MRCA to confirm the course of the anomalous left coronary artery. MRCA was performed with a superconducting 1.5 T echo-planar-capable system (Siemen's Medical Systems, Iselin, N.J.) with a standard planar elliptical spine coil as radiofrequency receiver. An ECG-gated gradient-echo sequence with fat saturation and k-space segmentation was used in conjunction with breath holding. 7A repetition time (TR) of 13 msec and an echo time (TE) of 8 msec were used with a 3 mm slice thickness, i mm overlap, and 230 x 230 mm field of view. Transverse images demonstrated the origin of the RCA and anomalous left coronary artery (Fig. 2, A). The left