- Email: [email protected]
CT Coronary Angiography to Guide Intervention for Acute Myocardial Ischaemia in a Patient with an Anomalous Single Coronary Ostium
IMAGES IN CT SURGERY AND CARDIOLOGY
408
Images in CT Surgery and Cardiology
although it occurs with higher frequency in association with certain congenital cardiovascular anomalies [3]. In 1993 Shirani and Roberts proposed a classification system [4] for solitary coronary ostiums based on the location of the ostium relative to the aortic sinuses and the characteristics of aberrant-coursing arteries. Our patient would be subtype IIC4, at that time a theoretical possibility but yet to be reported. Since then many examples of retroaortic left main coronary artery (LMCA) arising from a common ostium with the RCA in the right sinus of Valsalva have been reported [5–9], although these have been subtype IIB4 where the LMCA bifurcates to the LAD and Cx. In contrast, in our patient the Cx arises from the RCA and hence is subtype IIC4 which to the best of our knowledge has not been reported.
References [1] Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology 1979;130: 39–47. [2] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary angiography. Catheter Cardiovasc Diagn 1990;21:28–40.
Heart, Lung and Circulation 2009;18:407–409
[3] Desmet W, Van Haecke J, Vrolix M, Van de Werf F, Piessens J, Willems J, De Geest H. Isolated single coronary artery: a review of 50,000 consecutive coronary angiographies. Eur Heart J 1992;13:1637–40. [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;21(1):137–43. [5] Kejriwal NK, Tan J, Gordon SP, Newman MA. Retroaortic course of the anomalous left main coronary artery: is it a benign anomaly? A case report and review of literature. Heart Lung Circ 2004;13(March (1)):97–100. [6] Schwarz ER, Hager PK, Uebis R, Hanrath P, Klues HG. Myocardial ischaemia in a case of a solitary coronary ostium in the right aortic sinus with retroaortic course of the left coronary artery: documentation of the underlying pathophysiological mechanisms of ischaemia by intracoronary Doppler and pressure measurements. Heart 1998;80:307–12. [7] Quintal R, Nguyen T, Glancy L. Successful percutaneous coronary angioplasty via a solitary coronary ostium in the aorta (single coronary artery). J Invasive Cardiol 2003;15(8): 446–7. [8] Reig J, Jornet A, Petit M. Anomalous left coronary artery originating in the right aortic sinus with retroaortic course: a postmortem study. Angiology 1994;45(January (1)):57–60. [9] Fiorilli R, Argento G, Lisanti P, Serino W. Single coronary artery–a case report. G Ital Cardiol 1998;28(September (9)):1021–4.
CT Coronary Angiography to Guide Intervention for Acute Myocardial Ischaemia in a Patient with an Anomalous Single Coronary Ostium W.Y. Wandy Chan, MB ChB a , Dougal R. McClean, MB ChB, MD, FRACP a,∗ , John M. Elliott, MB ChB, PhD, FRACP a and Sharyn MacDonald, MB ChB, FRANZCR b a
Cardiology Department, Christchurch Public Hospital, Private Bag 4710, Christchurch, New Zealand b Radiology Department, Christchurch Public Hospital, Christchurch, New Zealand
Keywords. Myocardial ischaemia; Anomalous coronary ostium; Computed tomography; Cardiology images
Case Report
A
56-year-old man presented with 48 h of crescendo angina pectoris and labile ECG changes with transient lateral ST elevation and deep anterior/inferior ST depression. Primary PCI was unsuccessful as nonselective cusp injections could not identify the left and
Received 18 April 2008; accepted 19 April 2008; available online 27 June 2008 ∗
Corresponding author. Tel.: +64 33641416; fax: +64 33641120. E-mail address: [email protected] (D.R. McClean).
right coronary ostia. On-table echocardiography revealed a dilated aortic root suggesting an acute aortic dissection. An urgent 64-slice multi-detector row CT (MDCT) gated scan of the thoracic aorta and coronary arteries showed a single coronary ostium arising higher and more anterior above the sinotubular ridge. Originating from the ostium were two vessels: a small anomalous left anterior descending artery (LAD), and a common trunk that branched into a small septal branch, a large anomalous circumflex artery (Cx), and a right coronary artery (Figure 1A and B). An atherosclerotic non-calcified “culprit” plaque was identified in the anomalous Cx (Figure 2). Repeat coronary
Crown Copyright © 2008 Published by Elsevier Inc. on behalf of Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. All rights reserved.
1443-9506/04/$36.00 doi:10.1016/j.hlc.2008.04.006
Images in CT Surgery and Cardiology
409
Figure 1. (A) 5 layer 3D CT reconstruction of coronary anatomy and (B) coronary angiogram: white curved arrow (LAD), black line arrow (septal branch), white block arrow (Cx), white line arrow (Cx stenosis), black block arrow (RCA), PT (pulmonary trunk) and Ao (aorta).
angiography with a 6Fr Amplatz left 1 guide confirmed the anatomical findings. The patient made a good recovery after successful direct stenting. This case demonstrates a rare coronary artery anomaly with multiple vessels arising from a higher than usual single coronary ostium. It also highlights the utility of MDCT for non-invasively mapping the anatomy of anomalous coronary arteries, locating the site of the unstable plaque, and avoiding potential delays in diagnosis and treatment.
Acknowledgement We thank Denis Hely for preparing the CT reconstruction pictures. Figure 2. 2D CT reconstruction showing a non-calcified plaque (black block arrow) and site of rupture (black line arrow) in anomalous Cx artery between the aorta (Ao) and the left atrium (LA).
IMAGES IN CT SURGERY AND CARDIOLOGY
Heart, Lung and Circulation 2009;18:407–409
408
Images in CT Surgery and Cardiology
although it occurs with higher frequency in association with certain congenital cardiovascular anomalies [3]. In 1993 Shirani and Roberts proposed a classification system [4] for solitary coronary ostiums based on the location of the ostium relative to the aortic sinuses and the characteristics of aberrant-coursing arteries. Our patient would be subtype IIC4, at that time a theoretical possibility but yet to be reported. Since then many examples of retroaortic left main coronary artery (LMCA) arising from a common ostium with the RCA in the right sinus of Valsalva have been reported [5–9], although these have been subtype IIB4 where the LMCA bifurcates to the LAD and Cx. In contrast, in our patient the Cx arises from the RCA and hence is subtype IIC4 which to the best of our knowledge has not been reported.
References [1] Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology 1979;130: 39–47. [2] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary angiography. Catheter Cardiovasc Diagn 1990;21:28–40.
Heart, Lung and Circulation 2009;18:407–409
[3] Desmet W, Van Haecke J, Vrolix M, Van de Werf F, Piessens J, Willems J, De Geest H. Isolated single coronary artery: a review of 50,000 consecutive coronary angiographies. Eur Heart J 1992;13:1637–40. [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;21(1):137–43. [5] Kejriwal NK, Tan J, Gordon SP, Newman MA. Retroaortic course of the anomalous left main coronary artery: is it a benign anomaly? A case report and review of literature. Heart Lung Circ 2004;13(March (1)):97–100. [6] Schwarz ER, Hager PK, Uebis R, Hanrath P, Klues HG. Myocardial ischaemia in a case of a solitary coronary ostium in the right aortic sinus with retroaortic course of the left coronary artery: documentation of the underlying pathophysiological mechanisms of ischaemia by intracoronary Doppler and pressure measurements. Heart 1998;80:307–12. [7] Quintal R, Nguyen T, Glancy L. Successful percutaneous coronary angioplasty via a solitary coronary ostium in the aorta (single coronary artery). J Invasive Cardiol 2003;15(8): 446–7. [8] Reig J, Jornet A, Petit M. Anomalous left coronary artery originating in the right aortic sinus with retroaortic course: a postmortem study. Angiology 1994;45(January (1)):57–60. [9] Fiorilli R, Argento G, Lisanti P, Serino W. Single coronary artery–a case report. G Ital Cardiol 1998;28(September (9)):1021–4.
CT Coronary Angiography to Guide Intervention for Acute Myocardial Ischaemia in a Patient with an Anomalous Single Coronary Ostium W.Y. Wandy Chan, MB ChB a , Dougal R. McClean, MB ChB, MD, FRACP a,∗ , John M. Elliott, MB ChB, PhD, FRACP a and Sharyn MacDonald, MB ChB, FRANZCR b a
Cardiology Department, Christchurch Public Hospital, Private Bag 4710, Christchurch, New Zealand b Radiology Department, Christchurch Public Hospital, Christchurch, New Zealand
Keywords. Myocardial ischaemia; Anomalous coronary ostium; Computed tomography; Cardiology images
Case Report
A
56-year-old man presented with 48 h of crescendo angina pectoris and labile ECG changes with transient lateral ST elevation and deep anterior/inferior ST depression. Primary PCI was unsuccessful as nonselective cusp injections could not identify the left and
Received 18 April 2008; accepted 19 April 2008; available online 27 June 2008 ∗
Corresponding author. Tel.: +64 33641416; fax: +64 33641120. E-mail address: [email protected] (D.R. McClean).
right coronary ostia. On-table echocardiography revealed a dilated aortic root suggesting an acute aortic dissection. An urgent 64-slice multi-detector row CT (MDCT) gated scan of the thoracic aorta and coronary arteries showed a single coronary ostium arising higher and more anterior above the sinotubular ridge. Originating from the ostium were two vessels: a small anomalous left anterior descending artery (LAD), and a common trunk that branched into a small septal branch, a large anomalous circumflex artery (Cx), and a right coronary artery (Figure 1A and B). An atherosclerotic non-calcified “culprit” plaque was identified in the anomalous Cx (Figure 2). Repeat coronary
Crown Copyright © 2008 Published by Elsevier Inc. on behalf of Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. All rights reserved.
1443-9506/04/$36.00 doi:10.1016/j.hlc.2008.04.006
Images in CT Surgery and Cardiology
409
Figure 1. (A) 5 layer 3D CT reconstruction of coronary anatomy and (B) coronary angiogram: white curved arrow (LAD), black line arrow (septal branch), white block arrow (Cx), white line arrow (Cx stenosis), black block arrow (RCA), PT (pulmonary trunk) and Ao (aorta).
angiography with a 6Fr Amplatz left 1 guide confirmed the anatomical findings. The patient made a good recovery after successful direct stenting. This case demonstrates a rare coronary artery anomaly with multiple vessels arising from a higher than usual single coronary ostium. It also highlights the utility of MDCT for non-invasively mapping the anatomy of anomalous coronary arteries, locating the site of the unstable plaque, and avoiding potential delays in diagnosis and treatment.
Acknowledgement We thank Denis Hely for preparing the CT reconstruction pictures. Figure 2. 2D CT reconstruction showing a non-calcified plaque (black block arrow) and site of rupture (black line arrow) in anomalous Cx artery between the aorta (Ao) and the left atrium (LA).
IMAGES IN CT SURGERY AND CARDIOLOGY
Heart, Lung and Circulation 2009;18:407–409