ABSTRACT
Sinus of Valsalva aneurysm (SoVA) is a rare disease with less than 1% prevalence in the population. Most cases are asymptomatic, however, significant clinical manifestations are possible due to fistula formation and sudden rupture resulting in cardiac shunt. Eventually it may develop into progressive heart failure with high morbidity. We report the case of a 33 year old female patient who presented with shortness of breath, ascites, and recurring hospitalisation. The cardiac examination revealed sinus tachycardia along with loud and continuous murmurs on the left parasternal border. Several standard diagnostic procedures could not be performed due to malignant arrhythmia in supine position. Echocardiography examination revealed SoV rupture with a gerbode defect, which was the underlying cause of severe retractable heart failure.
Subject(s)
Aortic Rupture , Heart Failure , Sinus of Valsalva , Humans , Female , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/abnormalities , Adult , Heart Failure/etiology , Aortic Rupture/complications , Aortic Rupture/diagnostic imaging , Echocardiography , Aortic Aneurysm/complications , Aortic Aneurysm/diagnostic imagingABSTRACT
BACKGROUND: Anomalous aortic origin of a coronary artery from the inappropriate sinus of Valsalva (AAOCA) is a rare congenital heart lesion. It is uncommon for patients with AAOCA to present with severe symptoms at a very young age. CASE PRESENTATION: We describe a very rare but critical presentation in a young infant with AAOCA that requires surgical repair and pacemaker placement. A three-month-old infant was referred because of syncope. Cardiac arrest occurred shortly after admission. The electrocardiogram indicated a complete atrioventricular block and a transvenous temporary pacemaker was implanted. A further coronary computed tomographic angiography (CTA) showed the anomalous origin of the right coronary artery from the left sinus of Valsalva. Coronary artery unroofing was performed due to an interarterial course with the intramural component, and a permanent epicardial pacemaker was implanted. The postoperative recovery was uneventful, and this patient was thriving and asymptomatic at the nine-month follow-up. However, the electrocardiogram still indicated a complete pacing rhythm. CONCLUSIONS: By timely diagnosis and treatment, this patient is successfully rescued. Although rare, AAOCA may be fatal even in infants.
Subject(s)
Cardiac Pacing, Artificial , Coronary Vessel Anomalies , Pacemaker, Artificial , Humans , Infant , Coronary Vessel Anomalies/complications , Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessel Anomalies/therapy , Coronary Vessel Anomalies/surgery , Treatment Outcome , Atrioventricular Block/diagnosis , Atrioventricular Block/etiology , Atrioventricular Block/therapy , Atrioventricular Block/physiopathology , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/abnormalities , Sinus of Valsalva/surgery , Sinus of Valsalva/physiopathology , Heart Arrest/etiology , Heart Arrest/therapy , Heart Arrest/diagnosis , Coronary Angiography , Male , Electrocardiography , Computed Tomography AngiographyABSTRACT
A rare case of an anomalous location of the orifice of the coronary artery was found in a 99-year-old male cadaver undergoing routine dissection. The presence of the right coronary artery (RCA), left coronary artery (LCA), and conus artery (conus branch) originating from the right Valsalva sinus are the characteristic findings of this case. Then, the LCA passed through the aorta and the pulmonary artery. The LCA and RCA branches were normal. These findings are useful for future surgical procedures, including cardiac catheterization.
Subject(s)
Cadaver , Sinus of Valsalva , Aged, 80 and over , Humans , Male , Coronary Vessel Anomalies , Coronary Vessels/anatomy & histology , East Asian People , Japan , Sinus of Valsalva/abnormalities , Sinus of Valsalva/diagnostic imagingABSTRACT
INTRODUCTION: Anomalous origin of the right coronary artery from the left sinus of Valsalva (R-ACAOS) is a relatively rare condition that can potentially lead to devastating outcomes. The current study aims to investigate the cardiac-related disorders among patients with incidental R-ACAOS diagnosis through computed tomography angiography (CTA). METHODS: The current cross-sectional study has been conducted on 50 patients diagnosed with R-ACAOS who underwent CTA. Based on CTA, the patients' were categorized as R-ACAOS with interarterial course and non-interarterial course. The demographic and medical characteristics, any history of cardiac intervention and New York Heart Association (NYHA) Functional Classification at the time of diagnosis were recruited. Patients were revisited to assess cardiac-associated variables, including symptoms, the presence of heart failure and current NYHA function class. RESULTS: The variables including the history of cardiac intervention (P-value<0.001), the presence of heart failure (P-value = 0.010) and NYHA function class at the time of diagnosis (P-value = 0.006) were remarkably higher among those with interarterial course of R-ACAOS; while, the other variables including chest pain at rest (P-value = 0.55) or on exertion (P-value = 0.12), current NYHA function class, current cardiac-associated symptoms except for dyspnea at rest (P-value = 0.012), mortality and coronary calium score did not differ (P-value>0.05). coronary interventions led to significantly improved NYHA function class (P-value<0.05). CONCLUSION: Based on the findings of the current study, R-ACAOS with interarterial course leads to significantly higher rates of atherosclerotic-related symptoms and events compared with the other types of RCA anomalies. Moreover, coronary interventions led to significantly improved NYHA functional class regardless of R-ACAOS category.
Subject(s)
Computed Tomography Angiography , Coronary Vessel Anomalies , Incidental Findings , Sinus of Valsalva , Humans , Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessel Anomalies/diagnosis , Male , Female , Sinus of Valsalva/abnormalities , Sinus of Valsalva/diagnostic imaging , Middle Aged , Cross-Sectional Studies , Computed Tomography Angiography/methods , Adult , Aged , Coronary Angiography/methodsABSTRACT
There remains significant controversy in the risk stratification and management of patients with anomalous right coronary artery originating from the opposite sinus (R-ACAOS). We present the case of a patient with an inferior ST-elevation myocardial infarction, found to have R-ACAOS and severe atherosclerotic right coronary artery disease, treated with fractional flow reserve and intravascular ultrasound-guided percutaneous coronary intervention.
Subject(s)
Coronary Artery Disease , Coronary Vessel Anomalies , Fractional Flow Reserve, Myocardial , Sinus of Valsalva , Humans , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/therapy , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/abnormalities , Treatment Outcome , Coronary Angiography , Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessel Anomalies/therapy , Retrospective Studies , Ultrasonography, InterventionalABSTRACT
An anomalous origin of the right coronary artery from the opposite sinus of Valsalva with an intramural course (R-ACAOS-IM) may cause sudden cardiac death in children and adolescents. However, the natural history and management of patients in whom this anomaly is detected later during adulthood remains uncertain. The goals of this study were to assess the impact of an R-ACAOS-IM on the clinical outcomes in an adult population and to determine if adult patients with this anomaly who do not have significant coronary artery disease (CAD) can be managed safely without surgical intervention. A database review identified patients aged >35 years with anomalous coronary arteries diagnosed by cardiac catheterization or coronary computed tomography angiography. The outcomes of patients with R-ACAOS-IM were compared with patients with anomalous left circumflex coronary arteries with retroaortic course (LCx-RA) (an anomaly not associated with ischemic events). The primary outcome was all-cause mortality. The study population consisted of 185 patients aged 59 ± 12 years. Clinical characteristics were similar in the R-ACAOS-IM (n = 88) and LCx-RA (n = 97) groups. At a follow-up of 6.6 ± 4.5 years, there was no difference in mortality (hazard ratio 0.64, 95% confidence interval 0.32 to 1.28, p = 0.20) when adjusted for gender, age, and CAD. A subgroup analysis of 88 patients with no obstructive CAD managed nonoperatively found no difference between the LCx and R-ACAOS-IM groups in mortality (hazard ratio 2.45, 95% confidence interval 0.45 to 13.40, p = 0.30). There was no significant difference between the 2 groups in the composite outcome of death, nonfatal myocardial infarction, or survived cardiac arrest. The outcome of adult patients who have anomalous R-ACAOS-IM are similar to patients who have anomalous LCx-RA with a known benign course. In conclusion, these results suggest that most patients who survive this anomaly into adulthood may be managed conservatively without intervention.
Subject(s)
Coronary Artery Disease , Coronary Vessel Anomalies , Sinus of Valsalva , Child , Adolescent , Humans , Adult , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/abnormalities , Retrospective Studies , Coronary Angiography/methods , Coronary Artery Disease/diagnostic imaging , Coronary Artery Disease/surgery , Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessel Anomalies/complicationsSubject(s)
Coronary Vessel Anomalies , Sinus of Valsalva , Adult , Humans , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/abnormalities , Coronary Vessels/diagnostic imaging , Echocardiography , Sensitivity and Specificity , Coronary Angiography , Coronary Vessel Anomalies/diagnostic imagingABSTRACT
Anomalous origin of a left coronary artery from the right sinus of Valsalva with a single coronary orifice is a rare congenital anomaly, which has been associated with myocardial ischemia and sudden death. Surgical repair is recommended upon its detection. A 14-year-old boy was diagnosed with anomalous origin of a left coronary artery from the right sinus of valsalva with a single coronary orifice after a syncope attack. The patient underwent relocation of the left coronary orifice. The postoperative course was uneventful, with no ventricular arrhythmia or syncope. The patient did not develop cardiac ischemia or infarction on exercise Tc-99â m myocardial scintigraphy 8 months after the procedure.
Subject(s)
Coronary Artery Disease , Coronary Vessel Anomalies , Myocardial Ischemia , Sinus of Valsalva , Male , Humans , Adolescent , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/surgery , Sinus of Valsalva/abnormalities , Coronary Vessel Anomalies/complications , Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessel Anomalies/surgery , Heart , Myocardial Ischemia/complications , Coronary Artery Disease/complications , Syncope/complications , Coronary Angiography/methodsABSTRACT
PURPOSE: The coronary arterial tree has a wide range of possible benign anatomical variations. It is important to differentiate them from coronary arterial anomalies, which can remain asymptomatic or in some cases lead to sudden death if undiagnosed. METHODS: A 42-year-old female patient with a transient ST depression in right precordial leads performed an ECG-gated computed tomography angiography with dual layer spectral CT (IQon Elite Spectral CT, Philips, Amsterdam, The Netherlands) at Circolo Hospital of Varese. RESULTS: A rare variant was observed and studied: a single common trunk arising from the right sinus of Valsalva which branches into a right coronary artery, a left anterior descending artery with malignant course and a left main with a retroaortic course; the left main gives origin to a dual anterior interventricular artery ("Dual LAD") and a left circumflex artery. CONCLUSIONS: This type of variation was never described in the English literature. Identifying this variant is crucial for potential ischemic complications during sports activities or with the onset of atherosclerotic disease.
Subject(s)
Coronary Artery Disease , Coronary Vessel Anomalies , Sinus of Valsalva , Humans , Adult , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/abnormalities , Sinus of Valsalva/pathology , Coronary Vessel Anomalies/diagnosis , Coronary Vessel Anomalies/diagnostic imaging , Coronary Angiography/methods , Aorta/pathologyABSTRACT
Observing anomalies in the origin of the coronary arteries is a rare but recognised scenario during coronarography. All the major coronary arteries originating from the right sinus of Valsalva is an extremely rare anomaly, its reported incidence being 0.008% in angiographic studies. Most coronary artery variations are benign and are therefore found accidentally or postmortem. However, some anomalies in the origin of the coronary arteries are associated with myocardial ischaemia and a higher risk of sudden cardiac death. Herein, we report a sporadic case of anomalous origin of the coronary arteries, in which the right coronary artery, anterior interventricular artery and left circumflex artery arise separately from the right sinus of Valsalva, each originating from a separate ostium. Regardless of their low incidence rate, coronary artery anomalies can cause serious technical challenges during coronary angiography and percutaneous interventions because of the unusual location and course of the artery. Echocardiography, computed tomography, and magnetic resonance imaging can be useful in such cases.
Subject(s)
Coronary Vessel Anomalies , Sinus of Valsalva , Humans , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/abnormalities , Coronary Vessel Anomalies/diagnostic imaging , Coronary Angiography , Heart , Tomography, X-Ray ComputedABSTRACT
As widely discussed in recent literature, coronary artery anomalies only occasionally lead to potentially serious myocardial ischemic events. The most important group of coronary anomalies has been called anomalous coronary artery origin from an abnormal sinus or a site in the ascending aorta (ACAOS). Only some cases of right- or left-sided intramural-course ACAOS (R-ACAOS-IM or L-ACAOS-IM) can potentially cause significant symptoms or sudden cardiac death, typically during exertion in athletes. After an ACAOS-IM case is qualitatively identified, it is necessary to establish the severity of associated stenosis (which is always present to some degree in ACAOS-IM). The 3 stages of a comprehensive diagnostic process are: 1. initial screening of high-risk populations (young elite athletes, optimally by use of magnetic resonance imaging [MRI]) to identify the prevalence of similar cases in large populations (the denominator of any risk calculation); 2. evaluating symptoms (chest pain, syncope, or sudden death) and performing stress testing; 3. in patients found to carry ACAOS-IM, evaluating the severity of coronary obstruction by intravascular ultrasonography, which is an objective, definitive, and quantifying imaging modality for this condition, essential in selected carriers of such anomalies. The possible treatment alternatives are discussed and updated.
Subject(s)
Coronary Artery Disease , Coronary Vessel Anomalies , Sinus of Valsalva , Humans , Prevalence , Coronary Vessel Anomalies/diagnostic imaging , Coronary Vessel Anomalies/epidemiology , Coronary Vessel Anomalies/therapy , Sinus of Valsalva/abnormalities , Sinus of Valsalva/pathology , Coronary Angiography/methods , Coronary Artery Disease/pathologyABSTRACT
Anomalous origin of the left coronary artery from the opposite sinus of Valsalva with an intramural aortic course (L-ACAOS-IM) can cause syncope, sometimes as a prodrome of lethal events, including sudden cardiac death, in young athletes. The detailed mechanism of syncope in patients with L-ACAOS-IM is still unclear. This case report describes a 17-year-old boy who presented to the hospital because of syncope following chest pain with increasing frequency during exercise, such as playing soccer and running. In a treadmill exercise test, a decrease in blood pressure was seen (from 99/56 mm Hg to 68/38 mm Hg); chest pain and faintness accompanied by ST-segment elevation in lead aVR and ST-segment depression at other leads on electrocardiography were noted. These findings and symptoms disappeared spontaneously within a few minutes while clinicians prepared for emergency medications. Coronary computed tomography angiography (CCTA) showed that the origin of the left coronary artery (LCA) was the opposite sinus of Valsalva, and the course of the LCA was through the aortic wall toward the left coronary sinus. He was diagnosed with L-ACAOS-IM. After surgical treatment by unroofing the intramural part of the LCA and reconstructing a neo-ostium, he no longer experienced syncope during exercise. This case suggests that low cardiac output caused by myocardial ischemia, not life-threatening arrythmia, is a main mechanism of syncope in patients with L-ACAOS-IM. Consideration should be given to performing CCTA before an exercise stress test for young patients with syncope and chest pain to avoid the risk of severe myocardial ischemia.
Subject(s)
Coronary Artery Disease , Coronary Vessel Anomalies , Myocardial Ischemia , Sinus of Valsalva , Male , Adolescent , Humans , Electrocardiography , Myocardial Ischemia/complications , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/surgery , Sinus of Valsalva/abnormalities , Syncope/etiology , Syncope/complications , Coronary Artery Disease/complications , Chest Pain , Coronary Vessel Anomalies/complications , Coronary Vessel Anomalies/diagnosis , Coronary Vessel Anomalies/surgery , Coronary Angiography/adverse effectsABSTRACT
In the complex spectrum of coronary anomalies, the origin of the left coronary artery from the right sinus of Valsalva with intramural course could represent a catastrophic life-threatening condition leading to extensive myocardial infarction and sudden cardiac death, especially in young athletes. We report the case of a young female athlete with anomalous left coronary artery from the opposite sinus who survived a major non-ST-elevation myocardial infarction during the eighth kilometer of a running race. It was successfully treated by creating a neo-ostium of the left coronary artery in the left sinus at the point at which the artery left the aortic wall.
Subject(s)
Anomalous Left Coronary Artery , Coronary Vessel Anomalies , Myocardial Infarction , Sinus of Valsalva , Athletes , Coronary Angiography , Coronary Vessel Anomalies/complications , Coronary Vessel Anomalies/diagnosis , Coronary Vessel Anomalies/surgery , Female , Humans , Myocardial Infarction/complications , Myocardial Infarction/diagnosis , Sinus of Valsalva/abnormalities , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/surgeryABSTRACT
Percutaneous intervention in anomalous coronary arteries originating from the opposite sinus of Valsalva is complicated by their unusual location and course, which makes selective cannulation difficult. The GuideLiner (Vascular Solutions, Inc.) is a monorail guide extension catheter designed to advance beyond the tip of a mother guide catheter to enable deep intubation of a coronary artery, provide extra support, and improve coaxial alignment. We describe the cases of 4 patients with an anomalous coronary artery originating from the opposite sinus of Valsalva-including 2 with acute myocardial infarction-who underwent successful percutaneous coronary intervention with use of a GuideLiner catheter.
Subject(s)
Coronary Vessel Anomalies , Percutaneous Coronary Intervention , Sinus of Valsalva , Cardiac Catheterization , Catheters , Coronary Angiography , Coronary Vessel Anomalies/complications , Coronary Vessel Anomalies/diagnosis , Coronary Vessel Anomalies/surgery , Humans , Sinus of Valsalva/abnormalities , Sinus of Valsalva/diagnostic imaging , Sinus of Valsalva/surgery , StentsABSTRACT
Management of congenital coronary artery anomalies (CAA) is not standardized due to the variety of conditions included and their rare prevalence. Detection of CAA during myocardial infarction with non-obstructive coronary arteries (MINOCA) may induce clinicians to address the patient for surgery as CAA is not included in any algorithm1,2 for the management of MINOCA and American Association for Thoracic Surgery evidence-based guidelines suggest surgical repair for patients with anomalous aortic origin of a coronary artery and symptoms compatible with myocardial ischaemia.3 We present the case of a 35-year-old man with an anomalous origin of left coronary artery from right Valsalva sinus with pre-pulmonic course detected during urgent coronary angiography for suspected myocardial infarction. Stress cardiac magnetic resonance did not show signs of ischaemia at high-dose dobutamine but did reveal a recent myocarditis. This clinical case highlights the need for accurate risk stratification in CAA especially when confounding clinical scenarios co-exist.
Subject(s)
Coronary Artery Disease , Coronary Vessel Anomalies , Myocardial Infarction , Sinus of Valsalva , Male , Humans , Adult , Coronary Vessel Anomalies/complications , Coronary Vessel Anomalies/diagnosis , Coronary Vessel Anomalies/surgery , Myocardial Infarction/complications , Coronary Angiography , Sinus of Valsalva/abnormalities , Coronary Artery Disease/complicationsABSTRACT
It is uncommon for the left anterior descending coronary artery to arise from the contralateral Valsalva sinus, and more of a rarity to see coexistent left main coronary artery anomaly. Our patient reported normal daily physical activity and denied further evaluation (stress test, scintigraphy) or cardiothoracic consultation. She continues to be symptom free at 1-month follow-up.