Chest pain due to coronary artery compression in an adult with CHD.

A 47-year-old with repaired ventricular septal defect and pulmonary valve stenosis as a child presents with chronic intermittent chest pain. CT evaluation for transcatheter pulmonary valve replacement revealed right coronary artery compression between a sternal wire and dilated right ventricle. Removal of the sternal wire resulted in improved symptoms.

Surgical Management of Anomalous Right Coronary Artery in the Adult: Technique and Case Series.

BACKGROUND: The management of adult patients with anomalous aortic origin of the right coronary artery (ARCA) from the left aortic sinus poses important challenges. The presence of symptoms or documented ischaemia, the anatomical characteristics of the ostium, and the course of the coronary determine decision-making. METHODS: A retrospective review was performed of all cases of surgical management of ARCA at a single centre. The primary endpoints were mortality and myocardial infarction at 30 days. Secondary endpoints included recurrence of symptoms, freedom from re-intervention, and mortality during long-term follow-up. RESULTS: From October 2019 to August 2023, 15 adult patients underwent surgery for ARCA; 13 patients were included in this study (mean age 53.9±11.1 years; 10 female). A slit-like orifice, a long intramural segment, and an interarterial course were found in all patients. Twelve (12) patients (92.3%) were symptomatic: nine with angina, combined with dyspnoea on exertion in seven. One (1) patient had history of pre-syncope. One (1) patient presented with out-of-hospital cardiac arrest. All patients underwent formal unroofing of the orifice and intramural portion of the ARCA; five patients had a concomitant procedure. No 30-day mortality nor myocardial infarction was recorded. At a mean follow-up of 20.1±12.8 months, all patients were alive. One (1) patient (7.6%) developed recurrent dyspnoea; investigations showed no ischaemia. No repeated interventions were required. CONCLUSIONS: Surgical unroofing of anomalous coronary artery in the adult is safe and effective; correction of both the slit-like orifice and intramural portion of the anomaly provides a durable result in patients with ARCA.

Clinical presentation and angiographic findings of acute myocardial infarction in young adults in Jazan region.

BACKGROUND: There is a paucity of information about the clinical features and angiographic findings in young patients with acute myocardial infarction (MI), especially in the Arab Peninsula countries. OBJECTIVE: The aim of this study was to assess the proposed risk factors, clinical presentation, and angiographic findings of acute myocardial infarction in young adults. METHODS: This prospective study included young (range, 18 to 45 years) patients who presented with acute MI based on clinical evaluation, laboratory investigation, and electrocardiogram, and they underwent a coronary angiography procedure. KEY FINDINGS: Data of 109 patients with a diagnosis of acute MI were collected. Patients' mean age was 39.98 ± 7.52 years (range, 31 to 45 years), and 92.7% (101) were male. Smoking was the highest risk factor in 67% of patients, obesity and overweight in 66%, sedentary lifestyle in 64%, dyslipidaemia in 33%, and hypertension in 28%. Smoking was the most common risk factor for acute MI in males (p = 0.009), whereas sedentary lifestyle was the most common risk factor in females (p = 0.028). Chest pain typical of acute MI was the most common presenting symptom in 96% of patients (p < 0.001). On admission, 96% of patients were conscious, and 95% were oriented. On angiography, the left anterior descending artery (LAD) was affected in 57%, the right coronary artery (RCA) was affected in 42%, and the left circumflex artery (LCX) was affected in 32% of patients. The LAD was severely affected in 44%, the RCA was severely affected in 25.7%, and the LCX was severely affected in 19.26% of patients (p < 0.001). CONCLUSION: Smoking, obesity, sedentary lifestyle, dyslipidaemia, and hypertension were the most common risk factors for acute MI. Smoking was the most common risk factor in males and sedentary lifestyle in females. The LAD was the most commonly affected coronary artery, followed by the RCA and LCX arteries, with the same order for severity of stenosis.

Prevalence and Angiographic Characteristics of Coronary Artery Ectasia among Patients with Coronary Artery Disease: A Retrospective Analysis between 2014 and 2022.

Coronary artery ectasia (CAE) is defined as segmental dilatation with a diameter of 1.5-fold greater than that of an adjacent normal segment. Whether CAE is a unique clinical finding or results from other clinical entities remains to be determined. The purpose of the study was to investigate the prevalence, and clinical and angiographic characteristics of CAE in patients with coronary artery disease (CAD). Among the 8,845 coronary angiograms reviewed between the years 2014 and 2022, 142 patients had CAE yielding a detection rate of 4.9% among 2,870 CAD angiograms, and 28 patients had isolated CAE showing a detection rate of 0.32% (28/8,845) among total coronary angiography procedures. Overall, the incidence of CAE was 1.92% (170/8,845). The most commonly affected coronary artery by ectasia was the right coronary artery (RCA) (46.28%) among CAE coexisting with CAD cohort. The proportion of obesity, family history of CAD, and the proportion of hyperlipidemia in CAD patients who had ectasia were significantly higher than that in CAD patients who did not have ectasia (P < 0.05). In conclusion, CAE is an uncommon finding in coronary angiography, most commonly affecting the RCA. The obesity, family history of CAD, and the coexistence of hyperlipidemia were independent variables associated with CAE in CAD patients.

A rare disease detected in a school-age child aortopulmonary window with anomalous right coronary artery from the pulmonary artery.

Aortopulmonary window is a condition characterized by a communication between the pulmonary artery and the ascending aorta. The coexistence of aortopulmonary window and an anomalous right coronary artery originating from the pulmonary artery is rarely observed together, as mentioned in previous studies. In this report, we aim to describe our diagnostic and treatment experiences with a 6-year-old patient diagnosed with aortopulmonary window associated with an abnormal origin of the right coronary artery from the pulmonary artery.

The anatomy of the atrioventricular nodal artery: A meta-analysis with implications for cardiothoracic surgery and ablation procedures.

The objective of the present meta-analysis was to evaluate recent and applicable data regarding the location and variation of the atrioventricular nodal artery (AVNA) in relation to adjacent structures. In order to minimize postoperative risks and maintain physiological anastomosis for proper cardiac function, understanding such possible variations of vascularization of the AV node is of immense importance prior to cardiothoracic surgery as well as ablations. In order to perform this meta-analysis, a systematic search was conducted in which all articles regarding, or at least mentioning, the anatomy of the AVNA was searched. In general, the results were based on 3919 patients. AVNA was found to originate only from the RCA in 82.41% (95% CI: 79.46%-85.18%). The pooled prevalence of AVNA originating only from LCA was found to be 15.25% (95% CI: 12.71%-17.97%). The mean length of AVNA was found to be 22.64 mm (SE = 1.60). The mean maximal diameter of AVNA at its origin was found to be 1.40 mm (SE = 0.14). In conclusion, we believe that this is the most accurate and up-to-date study regarding the highly variable anatomy of the AVNA. The AVNA was found to originate most commonly from the RCA (82.41%). Furthermore, the AVNA was found to most commonly have no (52.46%) or only one branch (33.74%). It is hoped that the results of the present meta-analysis will be helpful for physicians performing cardiothoracic or ablation procedures.

Right-Sided Minimally Invasive Direct Coronary Artery Bypass: Clinical Experience and Perspectives.

Objective: Minimally invasive direct coronary artery bypass grafting (MIDCAB) using the left internal thoracic artery to the left descending artery is a clinical routine in the treatment of coronary artery disease. Far less is known on right-sided MIDCAB (r-MIDCAB) using the right internal thoracic artery (RITA) to the right coronary artery (RCA). We aimed to present our experience in patients with complex coronary artery disease who underwent r-MIDCAB. Materials and Methods: Between October 2019 and January 2023, 11 patients received r-MIDCAB using RITA to RCA bypass in a minimally invasive technique via right anterior minithoracotomy without using a cardiopulmonary bypass. Underlying coronary disease was complex right coronary artery stenosis (n = 7) and anomalous right coronary artery (ARCA; n = 4). All procedure-related and outcome data were evaluated prospectively. Results: Successful minimally invasive revascularization was achieved in all patients (n = 11). There were no conversions to sternotomy and no re-explorations for bleeding. Furthermore, no myocardial infarction, no strokes, and, most importantly, no deaths were observed. During the follow-up period (median 24 months), all patients were alive and 90% were completely angina free. Two patients received a repeated revascularization after surgery but independently from the RITA-RCA bypass, which was fully competent in both patients. Conclusion: Right-sided MIDCAB can be performed safely and effectively in patients with expected technically challenging percutaneous coronary intervention of the RCA and in patients with ARCA. Mid-term results showed high freedom from angina in nearly all patients. Further studies with larger patient cohorts and more evidence are needed to provide the best revascularization strategy for patients suffering from isolated complex RCA stenosis and ARCA.

Multimodality imaging of multiple giant right coronary artery aneurysms combined with anomalous aortic origin of left coronary artery.

We report a rare case of multiple giant coronary artery aneurysms combined with anomalous aortic origin of left coronary artery in a 30-years old man precisely diagnosed by multimodality imaging, including echocardiography, coronary computed tomographic angiography (CCTA), cardiac magnetic resonance imaging (CMR), and selective coronary angiography. The imaging results were finally confirmed by surgery. We present the clinical value of multimodality imaging in diagnosing coronary artery aneurysm and anomalous origin.

Incidentally detected dual right coronary artery in patient with constrictive pericarditis.

We report a case of a 29-year-old man with constrictive pericarditis where CT angiography incidentally demonstrated a dual right coronary artery (RCA). The present case highlights the diagnostic criterion for dual RCA as well as the potential clinical implications of the anomaly.

Coronary-to-pulmonary collateral artery from a superdominant morphologically right coronary artery.

We present a case of a 16-year-old cyanotic male patient with ventricular septal defect, pulmonary atresia and discordant atrioventricular connections where computed tomography angiography demonstrated a large tortuous coronary-to-pulmonary collateral artery arising from the superdominant morphologically right coronary artery and coursing cranially to supply the pulmonary parenchyma.

Surgical management and long-term follow-up of aberrant right coronary arteries in adults.

OBJECTIVES: Anomalous origins of the right coronary artery (RCA) can cause ischaemia and sudden cardiac death, particularly if the RCA runs between the aorta and pulmonary artery. Conventional coronary artery bypass grafting (CABG) can be affected by early graft failure due to collateral blood flow. We present our institutional experience in managing patients with RCA anomalies. METHODS: A single-center retrospective review of all patients who underwent surgery for aberrant right coronary arteries between 2005 and 2021 was conducted and in-hospital and long-term outcomes were analysed at our institution. RESULTS: A total of 10 patients (5 females, median age: 51 years, 36-62) were identified. They presented with symptoms of chest pain (n = 8), dyspnoea (n = 1) or following cardiac arrest (n = 1). In the majority the RCA originated from the left coronary sinus (n = 9). In one of those patients and one in whom the RCA originated directly from the left anterior descending artery CABG was performed. The other 8 patients were treated using transfer of the RCA ostium. All patients were discharged home (median hospital stay 5 days, range: 4-10). Four patients experienced post-op atrial fibrillation. No other complications were observed. At a median follow-up of 10 years and 9 months, 9 patients were alive and free from cardiac symptoms. One patient died 3 years postsurgery due to liver failure, unrelated to cardiac disease. CONCLUSIONS: In patients with an aberrant RCA, transfer of the ostium into the RCS carries a low surgical risk. It overcomes early graft failure in these patients, who present with a dynamic impairment in RCA blood flow. However, if fixed proximal RCA flow-limiting pathology exists, conventional bypass surgery is feasible.

Split right coronary artery and shepherd's crook course of direct origin of the conal artery: An unhitherto association in a case of rheumatic mitral stenosis.

In a 47-year-old lady, planned for redo percutaneous mitral commissurotomy for recurrent mitral valve stenosis, there was incidental detection of splitting of right coronary artery and direct origin and shepherd's crook course of the conal artery. Though these two anomalies have no hemodynamic significance, correct nomenclature and potential clinical implications have been described.

A rare configuration of single coronary artery: Anomalous anterior interventricular artery arising from right coronary artery with absent left circumflex artery.

We report a case of a 49-year-old woman planned mitral valve replacement surgery where computerized tomography angiography incidentally detected a rare configuration of a single coronary artery resulting from a combination of anomalous origin of anterior interventricular artery from right coronary artery and absent left circumflex artery.

Aortic root abscess and anomalous aortic origin of right coronary artery in a 5-year-old child.

BACKGROUND: Aortic root abscess is a rare complication of infective endocarditis in children. CASE REPORT: A 5-year-old boy with infective endocarditis of aortic valve and an anterior aortic root abscess was found to have anomalous aortic origin of right coronary artery from the left coronary sinus on computed tomography scan with contrast. RESULT: He was managed surgically by "patch and prosthesis" approach and required aortic root enlargement. Since anomalous aortic origin of right coronary artery is a relative contraindication for a Konno-Rastan aortic root enlargement, a Manouguian procedure was performed. CONCLUSION: Anterior aortic root abscesses are rare, the co-existence of anomalous aortic origin of right coronary artery is rarer still and such cases requiring aortic root enlargement are possibly best served by a Manouguian procedure.

A robotic-assisted hybrid coronary revascularization program: Establishment and early experience in the Middle East.

BACKGROUND: Hybrid coronary revascularization (HCR) is a technique that merges coronary artery bypass grafting surgery and percutaneous coronary intervention (PCI) approaches for the treatment of multivessel coronary artery disease. The surgical component of the procedure is minimally invasive and can be done using robotic technology that avoids the need for sternotomy. Our objective is to study all patients who underwent robotic-assisted HCR (RHCR) to evaluate the feasibility and safety of the procedure during the establishment phase. METHODS: This study is a retrospective chart review conducted at King Faisal Specialist Hospital and Research Centre in Jeddah (KFSRC-J). The study focuses on patients who underwent RHCR between July 2018 to December 2020. The study was approved by the institutional review board #2020-103. RESULTS: Robotic-assisted HCR was performed on 78 patients (mean age, 56 years (range, 43-72 years); 89.75% males) during the study phase. Left internal mammary artery grafting was used in all patients. There was no hospital mortality, and the mean hospital and intensive care unit (ICU) stay were 5.8 and 1.4 days, respectively. We found that 93.6% of the patients had no blood transfusion. There were no major adverse cardiac events (MACE) and perioperative MI recorded. There was a 3.8% rate of postoperative complications. The percentage of surgeries converted to conventional and re-exploration for bleeding were 1.2% and 2.6%, respectively. The average operation time was 164 min. CONCLUSION: This study emphasizes on the safety and effectiveness of RHCR in treating patients with multivessel coronary artery disease. Moreover, robotic-assisted hybrid coronary revascularization offers an alternative, functionally complete revascularization option to a selected group of patients with minimal surgical trauma, short hospital and ICU length of stay, quick recovery, and little to no blood transfusion requirement.

Long-term outcomes after repair for anomalous right coronary artery from the pulmonary artery.

Anomalous right coronary artery from pulmonary artery (ARCAPA) is a rare congenital heart disease that can lead to abnormal coronary perfusion and a need for surgical repair. Here, we report the outcomes of patients who underwent ARCAPA surgery within the Pediatric Cardiac Care Consortium (PCCC), a North American registry of interventions for paediatric heart diseases. We queried the PCCC for patients undergoing surgical repair for ARCAPA at <18 years of age between 1982 and 2003. Outcomes were obtained from the PCCC and after linkage with the National Death Index (NDI) and the Organ Procurement and Transplantation Network (OPTN) through 2019. Twenty-four patients (males: 15) were identified having surgery for ARCAPA at a median age of 5.8 (IQR 2.7-10.3) years. Of them, 23 cases were considered "simple" (without major intracardiac disease) and one "complex" (co-existing with tetralogy of Fallot). Five patients presented with symptoms [chest pain (1), dyspnoea on exertion (2) or history of syncope (2)]; while the remaining 19 patients were referred for evaluation of either murmur or co-existing CHD. There was no in-hospital mortality after the surgical repair. Fourteen patients had sufficient identifiers for NDI/OPTN linkage; among them, only one death occurred from unrelated non-cardiac causes within a median period of 19.4 years of follow-up (IQR: 18-24.6). Outcomes were excellent after reimplantation up to 25 years later and further longitudinal monitoring is important to understand the interaction of pre-existing coronary pathology with the effects of ageing.

Can ectopic right coronary from the left sinus have a different course than intramural? A case of ectopic right with retroaortic course.

Retrocardiac course of an ectopic right coronary artery is newly described. The alternative (usual) course of an anomalous right coronary from the left sinus of Valsalva is pre-aortic and intramural, with stenosis. In the present exceptional case, there was no stenosis.

Double right coronary artery: a plea for a standardized nomenclature.

BACKGROUND: Double coronary artery is a rare anomaly with just a few cases reported in the literature. This anomaly started being reported recently with the wide use of coronary angiography. Before the advent of advanced imaging and catheterization facilities most of the available data came from the work of anatomists. Two patients were recently operated in our department. In the first patient the preoperative coronary angiography showed two right coronary arteries. In the second patient a double ostium of the right coronary artery was encountered intraoperatively. We wanted to know the incidence of this anomaly and the available data in the literature. METHODS: A PubMed research was conducted by using the term 'double right coronary artery'. More than 50 case reports and small case series were identified. RESULTS: The review of the literature revealed a lot of controversy and debate. When using the term 'double right coronary artery' authors do not always refer to the same entity. Different definitions and classifications have proposed without, however, gaining wide acceptance. In fact, there is a lot of confusion in the literature and cases that are rather common are presented as being 'extremely rare'. CONCLUSIONS: Even though the real incidence could be over or underestimated due to variability in coronary angiography interpretation, clinicians must be aware of this entity in order to avoid troubleshooting during percutaneous coronary interventions and cardiac surgery. There is need for a close collaboration between interventional cardiologists, anatomists and cardiac surgeons in order to standardize the nomenclature.

COVID-19-induced myocarditis in patient with anomalous origin of the left circumflex artery from the right coronary artery: a case report.

The prevalence of coronary artery anomalies has been increasing due to the increasing usage of coronary angiography. There is a paucity of literature concerning management of viral-induced myocarditis in patients with anomalous coronary artery. We present a very unusual case of a 44-year-old man with anomalous origin of the left circumflex artery from the proximal ostium of the right coronary artery who was admitted for COVID-19-induced myocarditis. He presented with signs of heart failure and coronary angiography revealed the left circumflex artery with a separate ostium originating from the proximal right coronary artery. He was treated medically with Bisoprolol, Perindopril Arginine, Rivaroxaban, and Furosemide. His condition improved rapidly and he resumed regular life within 1 month. Coexistence of cardiac disease such as viral-induced myocarditis with an underlying anomalous origin of the coronary artery is challenging to spot and can lead to worse outcomes in case of misdiagnosis and inaccurate management.

A prevalência de anomalias da artéria coronária vem aumentando devido ao uso crescente da angiografia coronariana. Há uma escassez de literatura sobre o manejo da miocardite induzida por vírus no contexto de artéria coronária anômala. Apresentamos um caso incomum de um homem de 44 anos com origem anômala da artéria circunflexa esquerda do óstio proximal da artéria coronária direita admitido por miocardite induzida por COVID-19. O paciente apresentava sinais de insuficiência cardíaca, e a cineangiocoronariografia revelou artéria circunflexa esquerda de óstio separado originando-se da artéria coronária direita proximal. Ele foi tratado clinicamente com bisoprolol, perindopril arginina, rivaroxabana e furosemida. Sua condição melhorou rapidamente, e o paciente recuperou uma vida normal em 1 mês. A coexistência de doença cardíaca, como miocardite induzida por vírus com uma origem anômala subjacente da artéria coronária, é difícil de detectar e pode levar a resultados piores em caso de diagnóstico incorreto e manejo impreciso.

The right ventricular transcriptome signature in Ossabaw swine with cardiometabolic heart failure: implications for the coronary vasculature.

Heart failure (HF) patients with deteriorating right ventricular (RV) structure and function have a nearly twofold increased risk of death compared with those without. Despite the well-established clinical risk, few studies have examined the molecular signature associated with this HF condition. The purpose of this study was to integrate morphological, molecular, and functional data with the transcriptome data set in the RV of a preclinical model of cardiometabolic HF. Ossabaw swine were fed either normal diet without surgery (lean control, n = 5) or Western diet and aortic-banding (WD-AB; n = 4). Postmortem RV weight was increased and positively correlated with lung weight in the WD-AB group compared with CON. Total RNA-seq was performed and gene expression profiles were compared and analyzed using principal component analysis, weighted gene co-expression network analysis, module enrichment analysis, and ingenuity pathway analysis. Gene networks specifically associated with RV hypertrophic remodeling identified a hub gene in MAPK8 (or JNK1) that was associated with the selective induction of the extracellular matrix (ECM) component fibronectin. JNK1 and fibronectin protein were increased in the right coronary artery (RCA) of WD-AB animals and associated with a decrease in matrix metalloproteinase 14 protein, which specifically degrades fibronectin. RCA fibronectin content was correlated with increased vascular stiffness evident as a decreased elastin elastic modulus in WD-AB animals. In conclusion, this study establishes a molecular and transcriptome signature in the RV using Ossabaw swine with cardiometabolic HF. This signature was associated with altered ECM regulation and increased vascular stiffness in the RCA, with selective dysregulation of fibronectin.