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CT angiography images of an anomalous right coronary artery
International Journal of Cardiology 132 (2009) e49 – e50 www.elsevier.com/locate/ijcard
Letter to the Editor
CT angiography images of an anomalous right coronary artery Umair R. Qamar a , Mutahir U. Khan a , Sonober Umair a , Furqan Tejani a , Balendu C. Vasavada a , Ijaz A. Khan b,⁎ b
a Division of Cardiology, Long Island College Hospital, Brooklyn, New York, USA Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
Received 18 June 2007; accepted 7 July 2007 Available online 3 December 2007
Abstract We describe a 33-year-old male with angina pectoris who was found to have abnormal origin and course of right coronary artery from left aortic cusp. The abnormal origin was identified by conventional coronary angiography but the abnormal course of the vessel between ascending aorta and the main pulmonary artery was precisely delineated by high resolution CT angiography. Patient underwent successful surgical transposition of the anomalous vessel with complete resolution of symptoms. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Congenital coronary anomalies; Myocardial ischemia; Coronary CT angiography; Noninvasive cardiac imaging
A 33-year-old male presented to emergency department with recurrent sub-sternal chest pain of moderate to severe intensity. The pain occurred at rest and was associated with feeling of numbness in 4th and 5th digit of left hand. The patient was of average built with no risk factors for coronary artery disease. Physical examination was unremarkable with stable hemodynamic parameters and cardiac enzymes were negative for myocardial injury. The electrocardiogram presentation showed normal sinus rhythm, normal axis with no changes consistent with myocardial ischemia. Transthoracic echocardiogram showed the ejection fraction 55% with normal wall motion and chamber size. An exercise myocardial perfusion imaging was performed which showed exercise induced reversible filling defect in inferior wall. Patient underwent coronary angiogram which showed anomalous origin of right coronary artery from the left coronary sinus without any intraluminal defect. The patient underwent a high resolution coronary CT angiogram which ⁎ Corresponding author. Division of Cardiology, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, Maryland 21201, USA. Tel.: +1 410 328 2251; fax: +1 410 328 8225. E-mail address: [email protected] (I.A. Khan). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.07.118
confirmed the origin of right coronary artery from left aortic cusp and further delineated its course between ascending aorta and the main pulmonary artery (Figs. 1, 2). The patient underwent surgical transposition of right coronary artery with relief of anginal symptoms and he is asymptomatic in 11 months follow up. Anomalous origin of the right coronary artery is a rare congenital anomaly that was first described in 1948 by White and Edwards [1]. The prevalence of this anomaly, as determined from autopsy studies, ranges from 0.026% to 0.25% [2–4]. When the right coronary artery originates from the left sinus of Valsalva, the anomalous artery takes 1 of 4 aberrant pathways to reach its proper distributive area. These pathways are type A (anterior to the right ventricular outflow tract), type B (between the aorta and pulmonary trunk), type C (through the Crista supraventricularis portion of the septum), and type D (dorsal to the aorta) [1,4–6]. Although mostly clinically silent, an anomalous origin and course of the right coronary artery can lead to angina pectoris, silent ischemia, heart failure, ventricular tachycardia, syncope specially induced by exercise, myocardial infarction, or sudden death [1–6]. The pathophysiologic basis for the association of anginal symptoms and anomalous origin of
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U.R. Qamar et al. / International Journal of Cardiology 132 (2009) e49–e50
coronary artery, being situated between aorta and pulmonary artery, might be more prone to spasm [7,8]. In addition, anomalous coronaries are prone to have early development of coronary artery disease by at least 10 years [9]. The CT angiogram can precisely delineate the origin as well as the course of the anomalous coronary arteries, especially if the course runs in between the great vessels. Coronary revascularization is recommended in patients presenting with anginal symptoms, ventricular tachycardia or myocardial infarction. Surgical options include translocation of the right coronary artery to the aorta, ostioplasty by excising of the common wall between the right coronary artery and the aorta, and bypass grafting of the right coronary artery with optional ligation of the native artery proximal to the graft anastmosis to prevent competitive flow. However, the long-term benefits of such therapies have not been studied. There is limited data of intracoronary stenting at the anomalous origin of coronary artery to prevent compression of the vessel [10].
Fig. 1. Origin of right coronary artery from left coronary cusp on high resolution CT angiogram.
the right coronary artery is unclear. Mechanical compression of the right coronary artery by the great vessels is the usual explanation, because the anomalous right coronary artery may course between aorta and pulmonary artery to its normal position. The oblique angle at the juncture of the anomalous right coronary artery and the left coronary sinus may produce a slit-like orifice in the aortic wall that can collapse during exercise [7,8]. Furthermore, the proximal portion of the right
Fig. 2. Axial view of high resolution CT defining the origin and course of anomalous right coronary artery.
References [1] Angelini P. Normal and anomalous coronary arteries: definitions and classification. Am Heart J 1989;117(2):418–34. [2] Cieslinski G, Rapprich B, Kober G. Coronary anomalies: incidence and importance. Clin Cardiol Oct 1993;16(10):711–5. [3] Davis JA, Cecchin F, Jones TK. Major coronary artery anomalies in a pediatric population: incidence and clinical importance. J Am Coll Cardiol Feb 2001;37(2):593–7. [4] Shirani J, Roberts WC. Solitary coronary ostium in the aorta in the absence of other major congenital cardiovascular anomalies. J Am Coll Cardiol 1993 Jan;21(1):137–43. [5] Becker AE. Congenital coronary arterial anomalies of clinical relevance. Coron Artery Dis Mar 1995;6(3):187–93. [6] Shirani J, Roberts WC. Coronary ostial dimple (in the posterior aortic sinus) in the absence of other coronary arterial abnormalities. Am J Cardiol 1993;72(1):118–9. [7] Kaku B, Shimizu M, Yoshio H, et al. Clinical features of prognosis of Japanese patients with anomalous origin of the coronary artery. Jpn Circ J 1996;60:731–41. [8] Gowda RM, Cosme-Thormann BF, Caccavo ND, Khan IA. Single coronary artery: anomalous origin of right coronary artery from left anterior descending artery. J Clin Basic Cardiol 2005;8:73. [9] Jim MH, Ho HH, Miu R, Lee SW. Anomalous origin of the right coronary artery from the left coronary sinus is associated with early development of coronary artery disease. J Invasive Cardiol Sep 2004;16(9):466–8. [10] Doorey AJ, Pasquale MJ, Lally JF, Mintz GS, Marshall E, Ramos DA. Six-month success of intracoronary stenting for anomalous coronary arteries associated with myocardial ischemia. Am J Cardiol 2000;86:580–2.
Letter to the Editor
CT angiography images of an anomalous right coronary artery Umair R. Qamar a , Mutahir U. Khan a , Sonober Umair a , Furqan Tejani a , Balendu C. Vasavada a , Ijaz A. Khan b,⁎ b
a Division of Cardiology, Long Island College Hospital, Brooklyn, New York, USA Division of Cardiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
Received 18 June 2007; accepted 7 July 2007 Available online 3 December 2007
Abstract We describe a 33-year-old male with angina pectoris who was found to have abnormal origin and course of right coronary artery from left aortic cusp. The abnormal origin was identified by conventional coronary angiography but the abnormal course of the vessel between ascending aorta and the main pulmonary artery was precisely delineated by high resolution CT angiography. Patient underwent successful surgical transposition of the anomalous vessel with complete resolution of symptoms. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Congenital coronary anomalies; Myocardial ischemia; Coronary CT angiography; Noninvasive cardiac imaging
A 33-year-old male presented to emergency department with recurrent sub-sternal chest pain of moderate to severe intensity. The pain occurred at rest and was associated with feeling of numbness in 4th and 5th digit of left hand. The patient was of average built with no risk factors for coronary artery disease. Physical examination was unremarkable with stable hemodynamic parameters and cardiac enzymes were negative for myocardial injury. The electrocardiogram presentation showed normal sinus rhythm, normal axis with no changes consistent with myocardial ischemia. Transthoracic echocardiogram showed the ejection fraction 55% with normal wall motion and chamber size. An exercise myocardial perfusion imaging was performed which showed exercise induced reversible filling defect in inferior wall. Patient underwent coronary angiogram which showed anomalous origin of right coronary artery from the left coronary sinus without any intraluminal defect. The patient underwent a high resolution coronary CT angiogram which ⁎ Corresponding author. Division of Cardiology, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, Maryland 21201, USA. Tel.: +1 410 328 2251; fax: +1 410 328 8225. E-mail address: [email protected] (I.A. Khan). 0167-5273/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2007.07.118
confirmed the origin of right coronary artery from left aortic cusp and further delineated its course between ascending aorta and the main pulmonary artery (Figs. 1, 2). The patient underwent surgical transposition of right coronary artery with relief of anginal symptoms and he is asymptomatic in 11 months follow up. Anomalous origin of the right coronary artery is a rare congenital anomaly that was first described in 1948 by White and Edwards [1]. The prevalence of this anomaly, as determined from autopsy studies, ranges from 0.026% to 0.25% [2–4]. When the right coronary artery originates from the left sinus of Valsalva, the anomalous artery takes 1 of 4 aberrant pathways to reach its proper distributive area. These pathways are type A (anterior to the right ventricular outflow tract), type B (between the aorta and pulmonary trunk), type C (through the Crista supraventricularis portion of the septum), and type D (dorsal to the aorta) [1,4–6]. Although mostly clinically silent, an anomalous origin and course of the right coronary artery can lead to angina pectoris, silent ischemia, heart failure, ventricular tachycardia, syncope specially induced by exercise, myocardial infarction, or sudden death [1–6]. The pathophysiologic basis for the association of anginal symptoms and anomalous origin of
e50
U.R. Qamar et al. / International Journal of Cardiology 132 (2009) e49–e50
coronary artery, being situated between aorta and pulmonary artery, might be more prone to spasm [7,8]. In addition, anomalous coronaries are prone to have early development of coronary artery disease by at least 10 years [9]. The CT angiogram can precisely delineate the origin as well as the course of the anomalous coronary arteries, especially if the course runs in between the great vessels. Coronary revascularization is recommended in patients presenting with anginal symptoms, ventricular tachycardia or myocardial infarction. Surgical options include translocation of the right coronary artery to the aorta, ostioplasty by excising of the common wall between the right coronary artery and the aorta, and bypass grafting of the right coronary artery with optional ligation of the native artery proximal to the graft anastmosis to prevent competitive flow. However, the long-term benefits of such therapies have not been studied. There is limited data of intracoronary stenting at the anomalous origin of coronary artery to prevent compression of the vessel [10].
Fig. 1. Origin of right coronary artery from left coronary cusp on high resolution CT angiogram.
the right coronary artery is unclear. Mechanical compression of the right coronary artery by the great vessels is the usual explanation, because the anomalous right coronary artery may course between aorta and pulmonary artery to its normal position. The oblique angle at the juncture of the anomalous right coronary artery and the left coronary sinus may produce a slit-like orifice in the aortic wall that can collapse during exercise [7,8]. Furthermore, the proximal portion of the right
Fig. 2. Axial view of high resolution CT defining the origin and course of anomalous right coronary artery.
References [1] Angelini P. Normal and anomalous coronary arteries: definitions and classification. Am Heart J 1989;117(2):418–34. [2] Cieslinski G, Rapprich B, Kober G. Coronary anomalies: incidence and importance. Clin Cardiol Oct 1993;16(10):711–5. [3] Davis JA, Cecchin F, Jones TK. Major coronary artery anomalies in a pediatric population: incidence and clinical importance. J Am Coll Cardiol Feb 2001;37(2):593–7. [4] Shirani J, Roberts WC. Solitary coronary ostium in the aorta in the absence of other major congenital cardiovascular anomalies. J Am Coll Cardiol 1993 Jan;21(1):137–43. [5] Becker AE. Congenital coronary arterial anomalies of clinical relevance. Coron Artery Dis Mar 1995;6(3):187–93. [6] Shirani J, Roberts WC. Coronary ostial dimple (in the posterior aortic sinus) in the absence of other coronary arterial abnormalities. Am J Cardiol 1993;72(1):118–9. [7] Kaku B, Shimizu M, Yoshio H, et al. Clinical features of prognosis of Japanese patients with anomalous origin of the coronary artery. Jpn Circ J 1996;60:731–41. [8] Gowda RM, Cosme-Thormann BF, Caccavo ND, Khan IA. Single coronary artery: anomalous origin of right coronary artery from left anterior descending artery. J Clin Basic Cardiol 2005;8:73. [9] Jim MH, Ho HH, Miu R, Lee SW. Anomalous origin of the right coronary artery from the left coronary sinus is associated with early development of coronary artery disease. J Invasive Cardiol Sep 2004;16(9):466–8. [10] Doorey AJ, Pasquale MJ, Lally JF, Mintz GS, Marshall E, Ramos DA. Six-month success of intracoronary stenting for anomalous coronary arteries associated with myocardial ischemia. Am J Cardiol 2000;86:580–2.