- Email: [email protected]
Anomalous right coronary artery arising next to the left coronary ostium
International Journal of Cardiology 145 (2010) e50 – e53 www.elsevier.com/locate/ijcard
Letter to the Editor
Anomalous right coronary artery arising next to the left coronary ostium Unambiguous detection of the anatomy by computed tomography and evaluation of functional significance by cardiovascular magnetic resonance Grigorios Korosoglou a,⁎, Tobias Heye b , Evangelos Giannitsis a , Waldemar Hosch b , Hans U. Kauczor b , Hugo A. Katus a a
b
Department of Cardiology, University of Heidelberg, Heidelberg, Germany Department of Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany Received 30 September 2008; accepted 14 December 2008 Available online 25 January 2009
Abstract Herein we report on the diagnostic potential of multi-detector row computed tomography (MDCT) combined with cardiovascular magnetic resonance (CMR) for the diagnostic workup in an adult patient with a rare coronary anomaly. MDCT unambiguously detected the anomalous right coronary artery (RCA), which originated next to the left coronary ostium and coursed inter-arterially between the ascending aorta and the pulmonary trunk. The intramural proximal intussusception of the ectopic RCA could be clearly appreciated on MDCT images, while multiple mixed plaques were detected in the left anterior descending (LAD), resulting in moderate stenosis of this vessel. CMR during adenosine infusion ruled-out inducible ischemia, yielding normal perfusion patterns both in the RCA and in the LAD coronary territory. Since ischemia was not demonstrated by stress CMR, revascularization was not performed. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Coronary anomaly; Multi-slice computed tomography; Magnetic resonance imaging; Conventional angiography
1. Introduction This report describes an anomalous right coronary artery (RCA) originating from the opposite sinus in an older patient with no other form of congenital heart disease. Coronary anomalies are a heterogeneous group of clinical entities with variable pathophysiological mechanisms and clinical manifestations. The occurrence of coronary anomalies is 1.3–5.6% [1,2] in patients without structural heart disease and higher (3– 36%) in patients with structural heart defects [3,4]. While some
coronary anomalies are clearly anatomic variants without much clinical relevance, others can cause severe cardiac symptoms and death [1]. In particular origination of anomalous coronary arteries from the opposite sinus with intussusception of the ectopic proximal vessel segment has the most potential for clinical repercussions. Such patients may develop syncope and sudden death depending on the proximal course of the anomalous arteries and on the additional presence of atherosclerotic coronary disease [1,5]. 2. Case report
⁎ Corresponding author. Department of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany. Tel.: +49 6621 5637764; fax: +49 6621 565513. E-mail address: [email protected] (G. Korosoglou). 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.12.139
An 81-year-old male patient was referred to our institution from a peripheral hospital after experiencing intermittent chest tightness over the last 6 months. Baseline ECG had shown no specific signs of ischemia, while treadmill exercise testing had
G. Korosoglou et al. / International Journal of Cardiology 145 (2010) e50–e53
been inconclusive, because of inability of the patient to reach the target heart rate in the presence of poor effort tolerance. Because of his relatively high risk profile (advanced age, male gender, arterial hypertension, type 2 diabetes mellitus and hyperlipidemia) he was considered as a high risk patient for coronary artery disease and invasive coronary angiography had been performed in the referring hospital 2 days ago. X-ray coronary angiography had demonstrated multiple lesions of moderate severity in the mid and distal LAD and mild stenosis in the left circumflex coronary artery (LCX), (Fig. 1a–c). However, the selective intubation of the RCA had not been possible so that this vessel could not be visualized. Therefore a multi-detector row computed tomography (MDCT) was performed in our institu-
e51
tion (64-section CT scanner, Brilliance; Philips Medical Systems, Cleveland, Ohio), and using the following imaging parameters: tube voltage of 120 kVp with an effective tube current-time product of 800 mAs per section, slice collimation 64 ×0.625-mm acquisition and 0.4 s gantry rotation time. In agreement with invasive angiography, MDCT indeed showed mixed plaques causing moderate stenotic lesions in the LAD (Fig. 1d–e) and mild stenosis in the proximal LCX (Fig. 1f). In addition, an anomalous RCA could be unambiguously detected with MDCT images, showing an ectopic origin next to the left coronary ostium (Fig. 1g) and coursing inter-arterially between the ascending aorta and the pulmonary trunk (Fig. 1h–i, see Appendix A Data Supplement Movie I). As it can be appreciated
Fig. 1. X-ray coronary angiography demonstrated lesions of moderate and mild severity in the LAD and in the LCX, respectively (a–c). With MDCT the stenotic lesions were confirmed, (d–f), while an anomalous RCA could be unambiguously detected, showing an ectopic origin next to the left coronary ostium (g) and coursing inter-arterially between the ascending aorta and the pulmonary trunk (h–i, Data Supplement Movie I). On multiplanar reconstructions, the ectopic RCA exhibits a ‘flattening’ with eccentric stenosis within the proximal intramural segment (j–k), and is then getting round with its onwards extramural course (l). Ao indicates Aorta; PA, pulmonary artery; RAO, right anterior oblique; and CRA, cranial.
e52
G. Korosoglou et al. / International Journal of Cardiology 145 (2010) e50–e53
on multiplanar reconstructions perpendicular to the vessel lumen, the ectopic RCA exhibits a steep angulation at its origin (Fig. 1j), which causes an eccentric ‘flattening’ of the proximal intramural segment (Fig. 1j–k). The ectopic vessel then regains its round form with its onwards extramural course (Fig. 1l). To test the functional significance of these complex anatomical findings a cardiovascular magnetic resonance (CMR) was performed at baseline and during adenosine stress in a clinical 1.5T scanner (Achieva, Philips Medical Systems, Best, The Netherlands). Adenosine stress was chosen in order to induce
increased cardiac output in the presence of relative bradycardia, a hemodynamic state, which may occur early after extreme physical exercise and has been therefore implicated in the pathogenesis of sudden cardiac death in such individuals [1,6,7]. Functional steady state free precession (SSFP) cine-images (field-of-view (FOV)= 360× 360 mm2, flip angle (FA)= 60°, time repetition/time echo (TR/TE)= 2.5/1.3 ms and acquired voxel size =2.6 × 2.6× 8 mm3) demonstrated a normal function of the left ventricle (ejection fraction of 65%) (Fig. 2a–d). Furthermore, during adenosine stress no inducible ischemia
Fig. 2. With CMR, cine-images demonstrated a normal function of the left ventricle (a–d), while inducible ischemia was ruled out both in the LAD (hatched arrows in e–g) and in the RCA perfusion territory (solid arrows in e–g) during adenosine stress testing.
G. Korosoglou et al. / International Journal of Cardiology 145 (2010) e50–e53
was observed on balanced TFE images (FOV = 360×360 mm2, FA = 50°, TR/TE = 2.8/1.3 ms and acquired voxel size= 3.0 × 3.0 × 8 mm3) neither in the LAD (hatched arrows) nor in the RCA (solid arrows) perfusion territory (Fig. 2e–f). Due to the absence of inducible ischemia the patient was continued on medical treatment, and a clinical follow-up with treadmill testing was recommended in 6 months.
e53
severity of proximal stenosis may not always be easy to identify, due to the two dimensional nature of this technique. Three dimensional MDCT acquisitions on the other hand, generally allow the unambiguous interpretation of the locations of coronary origins, of the proximal intramural flattening and of additional atherosclerotic lesions, while CMR can provide valuable information on regional myocardial function, inducible ischemia and if necessary myocardial viability.
3. Discussion Acknowledgement In summary, these findings highlight the role of MDCT and CMR for the evaluation of patients with coronary anomalies. Because of its high spatial resolution and blood-to-tissue contrast, MDCT provides excellent delineation of anomalous vessels in relation to great arteries and other cardiac structures and can simultaneously detect additional atherosclerotic coronary lesions with high accuracy. The spatial resolution of CMR is generally satisfactory in defining the course of anomalous coronary vessels, but may be limited in precisely defining the degree of compression of the intramural ectopic vessel. However, this technique adds another important milestone in the diagnostic workup of such patients by its ability to evaluate the functional significance of such anatomical findings during stress testing. Coronary artery anomalies are a heterogeneous group of congenital disorders [1,2]. Most of these anomalies are commonly asymptomatic, but potentially serious ones also exist, especially those with ectopic coronary origin from the opposite aortic sinus with intussusception of the proximal intramural segment. Such patients may develop myocardial ischemia, infarction, syncope or sudden death depending on the extent of the lumen ‘flattening’, due to lateral compression within the intramural segment [1,5,8]. Traditionally intravascular ultrasound (IVUS) examinations were necessary, in order to evaluate this phenomenon; with recent advances in cardiovascular image acquisition and post-processing software with cardiac MDCT, however, this technique may also be able to provide valuable diagnostic information on the narrowing of the proximal ectopic vessel segment. Although conventional X-Ray angiography has traditionally been used to diagnose coronary anomalies, in some cases the ectopic coronaries may not be detectable with this conventional technique. Specific experience and modified techniques are required to selectively catheterize the ectopic ostia, and even if selective intubation is possible, the exact course of the artery in relation to the great vessels as well as the
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [9].
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ijcard.2008.12.139. References [1] Angelini P. Coronary artery anomalies: an entity in search of an identity. Circulation 2007;115:1296–305. [2] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Catheter Cardiovasc Diagn 1990;21: 28–40. [3] Dabizzi RP, Teodori G, Barletta GA, Caprioli G, Baldrighi G, Baldrighi V. Associated coronary and cardiac anomalies in the tetralogy of Fallot. An angiographic study. Eur Heart J 1990;11:692–704. [4] Carvalho JS, Silva CM, Rigby ML, Shinebourne EA. Angiographic diagnosis of anomalous coronary artery in tetralogy of Fallot. Br Heart J 1993;70:75–8. [5] Chaitman BR, Lesperance J, Saltiel J, Bourassa MG. Clinical, angiographic, and hemodynamic findings in patients with anomalous origin of the coronary arteries. Circulation 1976;53:122–31. [6] Eckart RE, Scoville SL, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med 2004;141:829–34. [7] Drory Y, Turetz Y, Hiss Y, et al. Sudden unexpected death in persons less than 40 years of age. Am J Cardiol 1991;68:1388–92. [8] Korosoglou G, Dengler TJ, Osman NF, Giannitsis E, Katus HA. Single coronary artery arising from the right sinus of valsalva: 'one-stop-shop' of coronary anatomy and functional significance by cardiovascular magnetic resonance. Clin Res Cardiol in press [2008 Oct 30, Electronic publication ahead of print]. [9] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.
Letter to the Editor
Anomalous right coronary artery arising next to the left coronary ostium Unambiguous detection of the anatomy by computed tomography and evaluation of functional significance by cardiovascular magnetic resonance Grigorios Korosoglou a,⁎, Tobias Heye b , Evangelos Giannitsis a , Waldemar Hosch b , Hans U. Kauczor b , Hugo A. Katus a a
b
Department of Cardiology, University of Heidelberg, Heidelberg, Germany Department of Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany Received 30 September 2008; accepted 14 December 2008 Available online 25 January 2009
Abstract Herein we report on the diagnostic potential of multi-detector row computed tomography (MDCT) combined with cardiovascular magnetic resonance (CMR) for the diagnostic workup in an adult patient with a rare coronary anomaly. MDCT unambiguously detected the anomalous right coronary artery (RCA), which originated next to the left coronary ostium and coursed inter-arterially between the ascending aorta and the pulmonary trunk. The intramural proximal intussusception of the ectopic RCA could be clearly appreciated on MDCT images, while multiple mixed plaques were detected in the left anterior descending (LAD), resulting in moderate stenosis of this vessel. CMR during adenosine infusion ruled-out inducible ischemia, yielding normal perfusion patterns both in the RCA and in the LAD coronary territory. Since ischemia was not demonstrated by stress CMR, revascularization was not performed. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Coronary anomaly; Multi-slice computed tomography; Magnetic resonance imaging; Conventional angiography
1. Introduction This report describes an anomalous right coronary artery (RCA) originating from the opposite sinus in an older patient with no other form of congenital heart disease. Coronary anomalies are a heterogeneous group of clinical entities with variable pathophysiological mechanisms and clinical manifestations. The occurrence of coronary anomalies is 1.3–5.6% [1,2] in patients without structural heart disease and higher (3– 36%) in patients with structural heart defects [3,4]. While some
coronary anomalies are clearly anatomic variants without much clinical relevance, others can cause severe cardiac symptoms and death [1]. In particular origination of anomalous coronary arteries from the opposite sinus with intussusception of the ectopic proximal vessel segment has the most potential for clinical repercussions. Such patients may develop syncope and sudden death depending on the proximal course of the anomalous arteries and on the additional presence of atherosclerotic coronary disease [1,5]. 2. Case report
⁎ Corresponding author. Department of Cardiology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany. Tel.: +49 6621 5637764; fax: +49 6621 565513. E-mail address: [email protected] (G. Korosoglou). 0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.12.139
An 81-year-old male patient was referred to our institution from a peripheral hospital after experiencing intermittent chest tightness over the last 6 months. Baseline ECG had shown no specific signs of ischemia, while treadmill exercise testing had
G. Korosoglou et al. / International Journal of Cardiology 145 (2010) e50–e53
been inconclusive, because of inability of the patient to reach the target heart rate in the presence of poor effort tolerance. Because of his relatively high risk profile (advanced age, male gender, arterial hypertension, type 2 diabetes mellitus and hyperlipidemia) he was considered as a high risk patient for coronary artery disease and invasive coronary angiography had been performed in the referring hospital 2 days ago. X-ray coronary angiography had demonstrated multiple lesions of moderate severity in the mid and distal LAD and mild stenosis in the left circumflex coronary artery (LCX), (Fig. 1a–c). However, the selective intubation of the RCA had not been possible so that this vessel could not be visualized. Therefore a multi-detector row computed tomography (MDCT) was performed in our institu-
e51
tion (64-section CT scanner, Brilliance; Philips Medical Systems, Cleveland, Ohio), and using the following imaging parameters: tube voltage of 120 kVp with an effective tube current-time product of 800 mAs per section, slice collimation 64 ×0.625-mm acquisition and 0.4 s gantry rotation time. In agreement with invasive angiography, MDCT indeed showed mixed plaques causing moderate stenotic lesions in the LAD (Fig. 1d–e) and mild stenosis in the proximal LCX (Fig. 1f). In addition, an anomalous RCA could be unambiguously detected with MDCT images, showing an ectopic origin next to the left coronary ostium (Fig. 1g) and coursing inter-arterially between the ascending aorta and the pulmonary trunk (Fig. 1h–i, see Appendix A Data Supplement Movie I). As it can be appreciated
Fig. 1. X-ray coronary angiography demonstrated lesions of moderate and mild severity in the LAD and in the LCX, respectively (a–c). With MDCT the stenotic lesions were confirmed, (d–f), while an anomalous RCA could be unambiguously detected, showing an ectopic origin next to the left coronary ostium (g) and coursing inter-arterially between the ascending aorta and the pulmonary trunk (h–i, Data Supplement Movie I). On multiplanar reconstructions, the ectopic RCA exhibits a ‘flattening’ with eccentric stenosis within the proximal intramural segment (j–k), and is then getting round with its onwards extramural course (l). Ao indicates Aorta; PA, pulmonary artery; RAO, right anterior oblique; and CRA, cranial.
e52
G. Korosoglou et al. / International Journal of Cardiology 145 (2010) e50–e53
on multiplanar reconstructions perpendicular to the vessel lumen, the ectopic RCA exhibits a steep angulation at its origin (Fig. 1j), which causes an eccentric ‘flattening’ of the proximal intramural segment (Fig. 1j–k). The ectopic vessel then regains its round form with its onwards extramural course (Fig. 1l). To test the functional significance of these complex anatomical findings a cardiovascular magnetic resonance (CMR) was performed at baseline and during adenosine stress in a clinical 1.5T scanner (Achieva, Philips Medical Systems, Best, The Netherlands). Adenosine stress was chosen in order to induce
increased cardiac output in the presence of relative bradycardia, a hemodynamic state, which may occur early after extreme physical exercise and has been therefore implicated in the pathogenesis of sudden cardiac death in such individuals [1,6,7]. Functional steady state free precession (SSFP) cine-images (field-of-view (FOV)= 360× 360 mm2, flip angle (FA)= 60°, time repetition/time echo (TR/TE)= 2.5/1.3 ms and acquired voxel size =2.6 × 2.6× 8 mm3) demonstrated a normal function of the left ventricle (ejection fraction of 65%) (Fig. 2a–d). Furthermore, during adenosine stress no inducible ischemia
Fig. 2. With CMR, cine-images demonstrated a normal function of the left ventricle (a–d), while inducible ischemia was ruled out both in the LAD (hatched arrows in e–g) and in the RCA perfusion territory (solid arrows in e–g) during adenosine stress testing.
G. Korosoglou et al. / International Journal of Cardiology 145 (2010) e50–e53
was observed on balanced TFE images (FOV = 360×360 mm2, FA = 50°, TR/TE = 2.8/1.3 ms and acquired voxel size= 3.0 × 3.0 × 8 mm3) neither in the LAD (hatched arrows) nor in the RCA (solid arrows) perfusion territory (Fig. 2e–f). Due to the absence of inducible ischemia the patient was continued on medical treatment, and a clinical follow-up with treadmill testing was recommended in 6 months.
e53
severity of proximal stenosis may not always be easy to identify, due to the two dimensional nature of this technique. Three dimensional MDCT acquisitions on the other hand, generally allow the unambiguous interpretation of the locations of coronary origins, of the proximal intramural flattening and of additional atherosclerotic lesions, while CMR can provide valuable information on regional myocardial function, inducible ischemia and if necessary myocardial viability.
3. Discussion Acknowledgement In summary, these findings highlight the role of MDCT and CMR for the evaluation of patients with coronary anomalies. Because of its high spatial resolution and blood-to-tissue contrast, MDCT provides excellent delineation of anomalous vessels in relation to great arteries and other cardiac structures and can simultaneously detect additional atherosclerotic coronary lesions with high accuracy. The spatial resolution of CMR is generally satisfactory in defining the course of anomalous coronary vessels, but may be limited in precisely defining the degree of compression of the intramural ectopic vessel. However, this technique adds another important milestone in the diagnostic workup of such patients by its ability to evaluate the functional significance of such anatomical findings during stress testing. Coronary artery anomalies are a heterogeneous group of congenital disorders [1,2]. Most of these anomalies are commonly asymptomatic, but potentially serious ones also exist, especially those with ectopic coronary origin from the opposite aortic sinus with intussusception of the proximal intramural segment. Such patients may develop myocardial ischemia, infarction, syncope or sudden death depending on the extent of the lumen ‘flattening’, due to lateral compression within the intramural segment [1,5,8]. Traditionally intravascular ultrasound (IVUS) examinations were necessary, in order to evaluate this phenomenon; with recent advances in cardiovascular image acquisition and post-processing software with cardiac MDCT, however, this technique may also be able to provide valuable diagnostic information on the narrowing of the proximal ectopic vessel segment. Although conventional X-Ray angiography has traditionally been used to diagnose coronary anomalies, in some cases the ectopic coronaries may not be detectable with this conventional technique. Specific experience and modified techniques are required to selectively catheterize the ectopic ostia, and even if selective intubation is possible, the exact course of the artery in relation to the great vessels as well as the
The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [9].
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ijcard.2008.12.139. References [1] Angelini P. Coronary artery anomalies: an entity in search of an identity. Circulation 2007;115:1296–305. [2] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Catheter Cardiovasc Diagn 1990;21: 28–40. [3] Dabizzi RP, Teodori G, Barletta GA, Caprioli G, Baldrighi G, Baldrighi V. Associated coronary and cardiac anomalies in the tetralogy of Fallot. An angiographic study. Eur Heart J 1990;11:692–704. [4] Carvalho JS, Silva CM, Rigby ML, Shinebourne EA. Angiographic diagnosis of anomalous coronary artery in tetralogy of Fallot. Br Heart J 1993;70:75–8. [5] Chaitman BR, Lesperance J, Saltiel J, Bourassa MG. Clinical, angiographic, and hemodynamic findings in patients with anomalous origin of the coronary arteries. Circulation 1976;53:122–31. [6] Eckart RE, Scoville SL, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med 2004;141:829–34. [7] Drory Y, Turetz Y, Hiss Y, et al. Sudden unexpected death in persons less than 40 years of age. Am J Cardiol 1991;68:1388–92. [8] Korosoglou G, Dengler TJ, Osman NF, Giannitsis E, Katus HA. Single coronary artery arising from the right sinus of valsalva: 'one-stop-shop' of coronary anatomy and functional significance by cardiovascular magnetic resonance. Clin Res Cardiol in press [2008 Oct 30, Electronic publication ahead of print]. [9] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.