Coronary artery anomalies: Difference between revisions

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{{Coronary angiography2}}
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{{CMG}}; {{AE}} {{CZ}}; {{MM}}
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==Overview==
==Overview==
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==Classification==
==Classification==
Anomalous origins of coronary arteries can be classified as
*Benign Coronary Anomalies
*Potentially More Serious Coronary Artery Anomalies
*Coronary Arteries Anomalies without Structural Heart Disease
*Coronary Arteries Anomalies with Structural Heart Disease


==Benign Coronary Anomalies==
=== Anomalous Pulmonary Origin of the Coronary Arteries ===
*Separate ostia for the [[left anterior descending artery]] and the left circumflex from the left Valsalva sinus
Anomalous Pulmonary Origin of the Coronary Arteries (APOCA) is characterized by the origin of a coronary artery from the pulmonary artery.<ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6 | pages =  }}</ref>  [[Left coronary artery]] is the most common anomaly seen arising from pulmonary artery (ALCAPA),<ref name="Hofmeyr-2009">{{Cite journal  | last1 = Hofmeyr | first1 = L. | last2 = Moolman | first2 = J. | last3 = Brice | first3 = E. | last4 = Weich | first4 = H. | title = An unusual presentation of an anomalous left coronary artery arising from the pulmonary artery (ALCAPA) in an adult: anterior papillary muscle rupture causing severe mitral regurgitation. | journal = Echocardiography | volume = 26 | issue = 4 | pages = 474-7 | month = Apr | year = 2009 | doi = 10.1111/j.1540-8175.2008.00815.x | PMID = 19054023 }}</ref> in which angiography shows the absence of left coronary ostium normal flow from the left aortic sinus.  Other anomalies of the coronary arteries origin include:<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url = http://circ.ahajournals.org/content/115/10/1296 | publisher =  | date =  | accessdate = 4 December 2013 }}</ref>
*Absent left circumflex (with maximally dominant [[right coronary artery]])  
*Origin of left circumflex artery from [[right coronary artery]] or right sinus of Valsalva
*Ectopic origin of [[right coronary artery]] or left main trunk from posterior sinus of Valsalva
*Ectopic coronary origin from the [[ascending aorta]]
*Intercoronary communication
*Small coronary artery fistula


<div align="left">
*[[Left circumflex artery]] (Cx) arising from pulmonary artery posterior facing sinus
<gallery heights="175" widths="175">
*[[Left anterior descending artery]] (LAD) arising from pulmonary artery posterior facing sinus
Image:Variation of CO.jpg|
*[[Right coronary artery]] (RCA) arising from pulmonary artery anterior right facing sinus (ARCAPA):
Image:Variation of CO2.jpg|
</gallery>
</div>


==Potentially More Serious Coronary Artery Anomalies==
:Rare, only about 10% of left main coronary artery originated from the pulmonary artery. <ref>Coe JY, Radley-Smith R, Yacoub M. Clinical and hemodynamic significance of anomalous origin of the right coronary artery from the pulmonary artery. Thorac Cardiovasc Surg 1982;30:84-7.</ref> <ref>Fontana RS, Edwards JE. Congenital Cardiac Disease: A Review of 357 Cases Studied Pathologically. Philadelphia: WB Saunders, 1962.</ref> <ref>Ogden JA. Congenital anomalies of the coronary arteries. Am J Cardiol 1970;25:474-79.</ref> <ref>Neufeld HN, Schneeweiss A. Coronary Artery Disease in Infants and Children. Philadelphia: Lea & Febiger, 1983.</ref> <ref>Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986; 111: 941-63.</ref> <ref>Yao CT, Wang JN, Yeh CN, et al. Isolated anomalous origin of right coronary artery from the main pulmonary artery. J Card Surg 2005;20:487-89.</ref>
*Ectopic coronary origin from the [[pulmonary artery]]
:*Left main trunk from [[pulmonary artery]]: [[Bland-White-Garland syndrome]]
:It is almost always found as an incidental autopsy finding of sudden death, and if diagnosed before death it has been associated with:
:*[[Left anterior descending artery]] from [[pulmonary artery]]
#Symptoms of myocardial ischemia
:*[[Right coronary artery]] from [[pulmonary artery]]
#Syncope
:*All coronary arteries from [[pulmonary artery]]
#Cardiomyopathy
*Ectopic origin of the left coronary artery from the right sinus of Valsalva
:*Left main trunk from right sinus of Valsalva
:*[[Left anterior descending artery]] from right sinus of Valsalva
:*[[Right coronary artery]] from left sinus of Valsalva


==Coronary Arteries Anomalies without Structural Heart Disease==
*Coronary artery arising from other locations outside pulmonary facing sinuses e.g. anterior left sinus, pulmonary trunk, or pulmonary branch


===Normal Variations===
Mortality rate in the first year of life has been reported to be 95% in untreated cases with poor collateral network.<ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6 | pages =  }}</ref>
These anomalies have no any clinical consequences. Separate origin of the conus branch of the [[right coronary artery]] is common. The similar anomaly on the left side is ”separate origins of the left anterior descending and left circumflex coronary arteries” occurs in about 1% of people and is more frequent with [[bicuspid aortic valve]]s. <ref>Baroldi G, Scomazzoni G. Coronary circulation in the normal and the pathologic heart. Washington, DC: Office of the Surgeon General, 1967</ref> <ref>Datta J, White CS, Gilkeson RC, Meyer CA, Kansal S, Jani ML, Arildsen RC, Read K [http://radiology.rsnajnls.org/cgi/content/abstract/235/3/812 Anomalous Coronary Arteries in Adults: Depiction at Multi–Detector Row CT Angiography.] Radiology 2005 235: 812-818.</ref>  


Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]
{|
|-
| [[Image:Left from PA.jpg|thumb|330px|Endocardial Fibroelastosis: Gross fair example LV endocardial thickening associated with anomalous origin of left coronary artery from pulmonary artery]]
| [[Image:Left from PA3.jpg|thumb|330px|Left Coronary Artery Anomalous Origin from Pulmonary artery: Angiogram postmortem after switch of left coronary to aorta]]
|-
|}
{|
|-
| [[Image:Cx from PA.jpg|thumb|150px|Coronary Artery Anomalous Origin Left from Pulmonary artery: Gross natural color anterior view of heart. Large marginal type coronary branches over anterior aspect of right ventricle]]
| [[Image:Cx from PA2.jpg|thumb|150px|Coronary Artery Anomalous Origin Left from Pulmonary artery: Gross natural color anterior view of heart. Large marginal type coronary branches over anterior aspect of right ventricle.]]
| [[Image:Cx from PA3.jpg|thumb|150px|Coronary Artery Anomalous Origin Left from Pulmonary artery: Gross natural color anterior view of hear showing large marginal type branches over anteriorright ventricle 5 month old infant died after operation switching artery to aorta.]]
| [[Image:Cx from PA4.jpg|thumb|150px|Coronary Artery Anomalous Origin Left from Pulmonary artery: Gross fixed tissue. Horizontal sections of ventricles showing thinning in anterior left ventricle due to scar there are some peculiar spots on the ventricles in this photo that probably are artifacts.]]
|-
|}
<SMALL>''Courtesy of Professor Peter Anderson DVM PhD''</SMALL>


<div align="left">
===Anomalous Coronary Artery From the Opposite Sinus===
<gallery heights="175" widths="175">
It is an improper site of coronary origin, in some cases in involve the origin of two coronaries from the same ostium.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url = http://circ.ahajournals.org/content/115/10/1296 | publisher =  | date =  | accessdate = 4 December 2013 }}</ref> The anomalous coronary origin leads to different anomalous course for the coronary arteries, which can be detected by angiography and they are as follow:
Image:High take off.jpg|Gross natural color high origin of coronary well shown. The heart is enlarged.
Image:Intramural coronary artery.jpg|Gross fixed tissue horizontal section of ventricle with intramural [[right coronary artery]] also lateral wall scar case of [[Artificial heart valve|aortic valve prosthesis]] for [[aortic stenosis]] two years problem was arrhythmias
Image:RCA multiple ostia.jpg|Anomalous Origin Coronary Artery: Gross natural color close-up view of [[right coronary artery]] cusp with two ostia
</gallery>
</div>


==Abnormal Origin of Right or Left Coronary Artery from Inappropriate Sinus==
======LCA that arises from right anterior sinus======
LCA runs in a different courses when arise from right sinus of valsalva, and it includes a septal, anterior,
interarterial, and posterior course.  The anomalous courses can be more specified as follow:<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url =http://circ.ahajournals.org/content/115/10/1296 | publisher =  | date =  | accessdate = 4 December 2013 }}</ref><ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6| pages = }}</ref>


===Anomalous Origin of Left Coronary Arterial Branches from Right Sinus of Valsalva===
*Posterior atrioventricular groove
*Retroaortic
*Between aorta and pulmonary artery
*Intraseptal
*Anterior to pulmonary artery
*Posteroanterior interventricular groove


Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]
{|
|-
| [[File:ALCA RCS 02.jpg|800px|thumb|Possible Pathways of Anomalous LCA Arising from Right Coronary Sinus]]
|-
|}
{|
|-
| [[Image:Single coronary artery.jpg|285px|thumb|Gross shows common origin of right and left coronary arteries from right coronary cusp]]
| [[Image:Single coronary artery2.jpg|285px|thumb|Gross natural color opened right coronary sinus showing single origin of both coronaries]]
|-
|}
<SMALL>''Courtesy of Professor Peter Anderson DVM PhD''</SMALL>


<div align="left">
======LAD that arises from right anterior sinus======
<gallery heights="175" widths="175">
Image:Anomalous Origin Coronary Artery1.jpg|Gross [[aortic valve]] origin of left coronary artery from right sinus of Valsalva sudden unexpected death
Image:Anomalous Origin Coronary Artery2.jpg|Gross left coronary artery originates from right sinus of Valsalva sudden unexpected death
</gallery>
</div>


When LAD arises from the right anterior sinus, it may run in a similar course as LCA which include:<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url =http://circ.ahajournals.org/content/115/10/1296 |publisher =  | date =  | accessdate = 4 December 2013 }}</ref>


<div align="left">
*Between aorta and pulmonary artery  
<gallery heights="175" widths="175">
Image:Anomalous Origin Coronary Artery3.jpg|Anomalous Origin Coronary Artery: Gross [[left atrium]] and [[mitral valve]] normal
Image:Anomalous Origin Coronary Artery5.jpg|Gross view of [[aorta]] from above with probes in coronary artery to illustrate origin of left coronary from right sinus and to a degree at least the relation of the main left coronary with the [[aorta]] and [[pulmonary artery]]
</gallery>
</div>


<div align="left">
*Intraseptal
<gallery heights="175" widths="175">
Image:Left from RSV2.jpg|Gross natural color close-up of [[aortic valve]] opened with probe in origin of [[left coronary artery]] which is in right cusp
Image:Left from RSV3.jpg|[[Tricuspid valve]] normal: Gross natural color (a good view) 18 year old African-American male died due to anomalous origin left coronary artery from right cusp
</gallery>
</div>


===Anomalous Origin of Right Coronary Arterial Branches from the Left Sinus of Valsalva===
*Anterior to pulmonary artery


===Single Coronary Artery===
*Posteroanterior interventricular groove
* From right coronary sinus
:* Right coronary artery continues as left circumflex artery and Left anterior descending artery.
:* Right coronary artery gives off left main coronary artery
:* Right coronary artery gives off left anterior descending artery and left circumflex artery
* From left coronary sinus
:* Left main coronary artery gives off left anterior descending artery, left circumflex artery, and right coronary artery
:* Left circumflex artery continues as right coronary artery
:* Left circumflex artery gives off right coronary artery
:* Left anterior descending artery gives off right coronary artery


Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]
======LCx artery that arises from right anterior sinus======


<div align="left">
LCx artery when arise from right sinus of valsalva, it may run in the posterior atrioventricular groove, or follow a retroaortic course.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url =http://circ.ahajournals.org/content/115/10/1296 |publisher =  | date =  | accessdate = 4 December 2013 }}</ref>
<gallery heights="175" widths="175">
Image:Single coronary artery.jpg|Gross shows common origin of right and left coronary arteries from right coronary cusp
Image:Single coronary artery2.jpg|Gross natural color opened right coronary sinus showing single origin of both coronaries
</gallery>
</div>


==Rare Coronary Anomalies==
======RCA that arises from left anterior sinus======


===Coronary Atresia===
When RCA arise from the left sinus, it follows the same anomalous courses as the LAD when arise from the the right sinus of Valsalva, with the most common course is the interarterial.<ref name="circ.ahajournals.org">{{Cite web  | last = | first =  | title = Coronary Artery Anomalies | url =http://circ.ahajournals.org/content/115/10/1296 |publisher =  | date =  | accessdate = 4 December 2013 }}</ref><ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 |publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6| pages = }}</ref>


Total absence of the epicardial (extramural) coronary arteries is rare and occurs most often with [[pulmonary atresia]] and aortic atresia.
=== [[Coronary artery fistula|Coronary Artery Fistulas]] ===
Coronary artery fistulas are rare findings, defines as any abnormal communication through which coronary artery blood is shunted into:


In these congenital anomalies, pressure in the small but hypertrophied right or left ventricle is similar or higher than aortic pressure, and enlarged sinusoids carry blood from the ventricle to be distributed in the distal coronary arteries. <ref>Musiani A, Cernigliaro C, Sansa M, Maselli D, De Gasperis C. Left main coronary artery atresia: literature review and therapeutical considerations. Eur J Cardiothorac Surg. 1997 Mar; 11(3):505-14. PMID 9105816</ref> <ref>Elian D, Hegesh J, Agranat O, Guetta V, Har-Zahav Y, Rath S, Chouraqui P, Di Segni E. Left main coronary artery atresia: extremely rare coronary anomaly in an asymptomatic adult and an adolescent soccer player. Cardiol Rev. 2003 May-Jun;11(3):160-2. PMID 12705847 </ref>
*Any of the cardiac chambers
*The besian veins that empty into the cardiac chambers
*The coronary sinus
*The SVC
*The pulmonary veins
*The mediastinal vessels


===Stenosis or Atresia of a Coronary Ostium===
It is identified in 10 (0.05%) of 18,272 diagnostic cardiac catheterizations.  The number, origin, and course of the coronary arteries is otherwise normal.<ref name="pmid17965946">{{cite journal| author=Cebi N, Schulze-Waltrup N, Frömke J, Scheffold T, Heuer H| title=Congenital coronary artery fistulas in adults: concomitant pathologies and treatment. | journal=Int J Cardiovasc Imaging | year= 2008 | volume= 24 | issue= 4 | pages= 349-55 | pmid=17965946 | doi=10.1007/s10554-007-9277-x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17965946  }} </ref><ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6| pages = }}</ref>


* Stenosis or atresia of the ostium or first few millimeters of the [[left main coronary artery]] is one of the rarest of the congenital coronary artery anomalies.
=== Congenital Coronary Stenosis or Atresia ===
* The more distal branches are normal and develop multiple collaterals from the [[right coronary artery]].
* According to published literature, presentation range is 3 months to 60 years of age. Usual presentation with;
:*[[Sudden death]]
:*[[Congestive heart failure]]
:*[[Angina pectoris]]
:*[[Myocardial infarction]]


===All Coronary Arteries from Pulmonary Artery===
Congenital coronary stenosis can be associated with other congenital diseases (e.g. supravalvular aortic stenosis, calcific coronary sclerosis, or rubella syndrome), or one of the intrinsic coronary arterial anatomy anomalies, which may involve [[left coronary artery]], [[left anterior descending artery]], [[right coronary artery]], and [[left circumflex artery]].<ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6| pages =  }}</ref>
* Both right and left coronary arteries, or a single coronary artery, may come from the pulmonary trunk.
* These children do not survive infancy without surgical intervention unless there is a cardiac lesion causing pulmonary hypertension. <ref>Ochoa-Ramirez E, Valdez-Garza HE, Reyes-Gonzalez R, et al. Double anomalous coronary origin from the pulmonary artery: Successful surgical correction in an infant. Tex Heart Inst J 2005;32:348-50.</ref>


===Left Anterior Descending Coronary Artery from the Pulmonary Artery===
Other intrinsic coronary arterial anatomy anomalies include:<ref name="circ.ahajournals.org">{{Cite web  | last = | first =  | title = Coronary Artery Anomalies | url =http://circ.ahajournals.org/content/115/10/1296 | publisher =  | date =  | accessdate = 4 December 2013 }}</ref>
Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]
*Coronary ostial dimple
*Coronary ectasia or aneurysm
*Absent coronary artery
*Coronary hypoplasia
*Intramural coronary artery (muscular bridge)
*Subendocardial coronary course
*Coronary crossing
*Anomalous origination of posterior descending artery from the anterior descending branch or a septal penetrating branch
*Split RCA
*Split LAD
*Ectopic origination of first septal branch


<div align="left">
=== [[Myocardial bridging|Myocardial Bridging]] ===
<gallery heights="175" widths="175">
Myocardial bridge is defined as a segment of a major [[coronary artery|coronary]] [[epicardial]] [[artery]] that "tunnels" or passes intramurally through the [[myocardium]] beneath the muscle bridge during [[systole]].<ref name="pmid15764618">{{cite journal |author=Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS |title=Myocardial bridging |journal=[[European Heart Journal]] |volume=26 |issue=12 |pages=1159–68 |year=2005 |month=June |pmid=15764618 |doi=10.1093/eurheartj/ehi203 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15764618 |accessdate=2012-07-01}}</ref><ref name="pmid12427660">{{cite journal |author=Möhlenkamp S, Hort W, Ge J, Erbel R |title=Update on myocardial bridging |journal=[[Circulation]] |volume=106 |issue=20 |pages=2616–22 |year=2002 |month=November |pmid=12427660 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12427660 |accessdate=2012-07-01}}</ref> Myocardial bridges are generally located in the distribution of the [[left anterior descending artery]] ([[LAD]]) and its [[diagonal branch]]es.  It has been associated with angina, arrhythmia, depressed left ventricular function, myocardial stunning, early death after cardiac transplantation, and sudden death.<ref name="pmid15764618">{{cite journal| author=Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS| title=Myocardial bridging. | journal=Eur Heart J | year= 2005 | volume= 26 | issue= 12 | pages= 1159-68 | pmid=15764618 | doi=10.1093/eurheartj/ehi203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15764618  }} </ref><ref name="pmid19620504">{{cite journal| author=Ishikawa Y, Akasaka Y, Suzuki K, Fujiwara M, Ogawa T, Yamazaki K et al.| title=Anatomic properties of myocardial bridge predisposing to myocardial infarction. | journal=Circulation | year= 2009 | volume= 120 | issue= 5 | pages= 376-83 | pmid=19620504 | doi=10.1161/CIRCULATIONAHA.108.820720 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19620504  }} </ref>
Image:Left from PA.jpg|Endocardial Fibroelastosis: Gross fair example LV endocardial thickening associated with anomalous origin of [[left coronary artery]] from [[pulmonary artery]]
Image:Left from PA3.jpg|Left Coronary Artery Anomalous Origin from [[Pulmonary artery]]: Angiogram postmortem after switch of left coronary to [[aorta]]
</gallery>
</div>


===Left Circumflex Coronary Artery from the Pulmonary Artery or Branches===
On angiography, the bridged segment appears of normal caliber during diastole, and abruptly narrows with systole. Shown below is an animated image depicting myocardial bridge, and two static images of the same case depicting myocardial bridge. Outlined with yellow in the image on the left is the part of the coronary artery during diastole. This same part of the coronary artery is outlined in yellow in the image on the right during systole; note that this outlined part is narrowed compared to its shape during diastole.
Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]


<div align="left">
[[Image:Myocardial-Bridging.gif|300px| Myocardial bridging]]
<gallery heights="175" widths="175">
[[Image:Myocardial bridging static 1.gif|300px| Shape of the coronary artery during diastole]]
Image:Cx from PA.jpg|Coronary Artery Anomalous Origin Left from [[Pulmonary artery]]: Gross natural color anterior view of heart. Large marginal type coronary branches over anterior aspect of [[right ventricle]].
[[Image:Myocardial-Bridging-Static-2.gif|300px| The coronary artery is narrowed during systole which is consistent myocardial bridging.]]
Image:Cx from PA2.jpg|Coronary Artery Anomalous Origin Left from [[Pulmonary artery]]: Gross natural color anterior view of heart. Large marginal type coronary branches over anterior aspect of [[right ventricle]].
</gallery>
</div>


 
=== High Anterior Origin of the Right Coronary Artery ===
<div align="left">
A superior origin of the RCA above the sinotubular ridge, although it is found commonly, it has no hemodynamic significance. This case is suspected during catheterization when it fails to engage the ostium of the RCA, and injection of contrast medium into the right sinus of Valsalva may reveal the anomalous origin.<ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6| pages =  }}</ref>
<gallery heights="175" widths="175">
Image:Cx from PA3.jpg|Coronary Artery Anomalous Origin Left from [[Pulmonary artery]]: Gross natural color anterior view of hear showing large marginal type branches over anterior[[right ventricle]] 5 month old infant died after operation switching artery to [[aorta]]
Image:Cx from PA4.jpg|Coronary Artery Anomalous Origin Left from [[Pulmonary artery]]: Gross fixed tissue. Horizontal sections of ventricles showing thinning in anterior [[left ventricle]] due to scar there are some peculiar spots on the ventricles in this photo that probably are artifacts.
</gallery>
</div>
 
===Right Coronary Artery from the Pulmonary Artery===
* Rare, only about 10% of left main coronary artery originated from the pulmonary artery. <ref>Coe JY, Radley-Smith R, Yacoub M. Clinical and hemodynamic significance of anomalous origin of the right coronary artery from the pulmonary artery. Thorac Cardiovasc Surg 1982;30:84-7.</ref> <ref>Fontana RS, Edwards JE. Congenital Cardiac Disease: A Review of 357 Cases Studied Pathologically. Philadelphia: WB Saunders, 1962.</ref> <ref>Ogden JA. Congenital anomalies of the coronary arteries. Am J Cardiol 1970;25:474-79.</ref> <ref>Neufeld HN, Schneeweiss A. Coronary Artery Disease in Infants and Children. Philadelphia: Lea & Febiger, 1983.</ref> <ref>Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986; 111: 941-63.</ref> <ref>Yao CT, Wang JN, Yeh CN, et al. Isolated anomalous origin of right coronary artery from the main pulmonary artery. J Card Surg 2005;20:487-89.</ref>
* Almost always found as an incidental autopsy finding of sudden death, and if diagnosed before death it has been associated with:
:* Symptoms of myocardial ischemia
:* Syncope
:* Cardiomyopathy


==2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 |doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }}</ref>==
==2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)<ref name="pmid19038677">{{cite journal| author=Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA et al.| title=ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 23 | pages= e1-121 | pmid=19038677 |doi=10.1016/j.jacc.2008.10.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19038677  }}</ref>==
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with an anomalous left [[coronary artery]] from the [[pulmonary artery]] (ALCAPA), reconstruction of a dual [[coronary artery]] supply should be performed. The surgery should be performed by surgeons with training and expertise in [[CHD]] at centers with expertise in the management of anomalous[[coronary artery]] origins. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with an anomalous left [[coronary artery]] from the [[pulmonary artery]] (ALCAPA), reconstruction of a dual [[coronary artery]] supply should be performed. The surgery should be performed by surgeons with training and expertise in [[CHD]] at centers with expertise in the management of anomalous [[coronary artery]] origins. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|<nowiki>”</nowiki>'''2.''' For adult survivors of ALCAPA repair, clinical evaluation with [[echocardiography]] and noninvasive stress testing is indicated every 3 to 5 years. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>”</nowiki>'''2.''' For adult survivors of ALCAPA repair, clinical evaluation with [[echocardiography]] and noninvasive stress testing is indicated every 3 to 5 years. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
Line 277: Line 244:
| bgcolor="LightGreen"|<nowiki>”</nowiki>'''3.''' Transcatheter delineation of CAVF course and access to distal drainage should be performed in all patients with audible continuous[[murmur]] and recognition of CAVF. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
| bgcolor="LightGreen"|<nowiki>”</nowiki>'''3.''' Transcatheter delineation of CAVF course and access to distal drainage should be performed in all patients with audible continuous[[murmur]] and recognition of CAVF. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
|}
==Classification==
==== Anomalous Pulmonary Origin of the Coronary Arteries ====
Anomalous Pulmonary Origin of the Coronary Arteries (APOCA) is characterized by the origin of a coronary artery from the pulmonary artery.<ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6 | pages =  }}</ref>  [[Left coronary artery]] (LCA) is the most common anomaly seen arising from pulmonary artery,<ref name="Hofmeyr-2009">{{Cite journal  | last1 = Hofmeyr | first1 = L. | last2 = Moolman | first2 = J. | last3 = Brice | first3 = E. | last4 = Weich | first4 = H. | title = An unusual presentation of an anomalous left coronary artery arising from the pulmonary artery (ALCAPA) in an adult: anterior papillary muscle rupture causing severe mitral regurgitation. | journal = Echocardiography | volume = 26 | issue = 4 | pages = 474-7 | month = Apr | year = 2009 | doi = 10.1111/j.1540-8175.2008.00815.x | PMID = 19054023 }}</ref> in which angiography shows the absence of left coronary ostium normal flow from the left aortic sinus.  Other anomalies of the coronary arteries origin include:<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url = http://circ.ahajournals.org/content/115/10/1296 | publisher =  | date =  | accessdate = 4 December 2013 }}</ref>
*[[Left circumflex artery]] (Cx) arising from pulmonary artery posterior facing sinus
*[[Left anterior descending artery]] (LAD) arising from pulmonary artery posterior facing sinus
*[[Right coronary artery]] (RCA) arising from pulmonary artery anterior right facing sinus:
:Rare, only about 10% of left main coronary artery originated from the pulmonary artery. <ref>Coe JY, Radley-Smith R, Yacoub M. Clinical and hemodynamic significance of anomalous origin of the right coronary artery from the pulmonary artery. Thorac Cardiovasc Surg 1982;30:84-7.</ref> <ref>Fontana RS, Edwards JE. Congenital Cardiac Disease: A Review of 357 Cases Studied Pathologically. Philadelphia: WB Saunders, 1962.</ref> <ref>Ogden JA. Congenital anomalies of the coronary arteries. Am J Cardiol 1970;25:474-79.</ref> <ref>Neufeld HN, Schneeweiss A. Coronary Artery Disease in Infants and Children. Philadelphia: Lea & Febiger, 1983.</ref> <ref>Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986; 111: 941-63.</ref> <ref>Yao CT, Wang JN, Yeh CN, et al. Isolated anomalous origin of right coronary artery from the main pulmonary artery. J Card Surg 2005;20:487-89.</ref>
:It is almost always found as an incidental autopsy finding of sudden death, and if diagnosed before death it has been associated with:
#Symptoms of myocardial ischemia
#Syncope
#Cardiomyopathy
*Coronary artery arising from other locations outside pulmonary facing sinuses e.g. anterior left sinus, pulmonary trunk, or pulmonary branch
Mortality rate in the first year of life has been reported to be 95% in untreated cases with poor collateral network.<ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6 | pages =  }}</ref>
Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]
<div align="left">
<gallery heights="175" widths="175">
Image:Left from PA.jpg|Endocardial Fibroelastosis: Gross fair example LV endocardial thickening associated with anomalous origin of [[left coronary artery]] from [[pulmonary artery]]
Image:Left from PA3.jpg|Left Coronary Artery Anomalous Origin from [[Pulmonary artery]]: Angiogram postmortem after switch of left coronary to [[aorta]]
</gallery>
</div>
Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]
<div align="left">
<gallery heights="175" widths="175">
Image:Cx from PA.jpg|Coronary Artery Anomalous Origin Left from [[Pulmonary artery]]: Gross natural color anterior view of heart. Large marginal type coronary branches over anterior aspect of [[right ventricle]].
Image:Cx from PA2.jpg|Coronary Artery Anomalous Origin Left from [[Pulmonary artery]]: Gross natural color anterior view of heart. Large marginal type coronary branches over anterior aspect of [[right ventricle]].
</gallery>
</div>
<div align="left">
<gallery heights="175" widths="175">
Image:Cx from PA3.jpg|Coronary Artery Anomalous Origin Left from [[Pulmonary artery]]: Gross natural color anterior view of hear showing large marginal type branches over anterior[[right ventricle]] 5 month old infant died after operation switching artery to [[aorta]]
Image:Cx from PA4.jpg|Coronary Artery Anomalous Origin Left from [[Pulmonary artery]]: Gross fixed tissue. Horizontal sections of ventricles showing thinning in anterior [[left ventricle]] due to scar there are some peculiar spots on the ventricles in this photo that probably are artifacts.
</gallery>
</div>
====Anomalous Coronary Artery From the Opposite Sinus====
It is an improper site of coronary origin, in some cases in involve the origin of two coronaries from the same ostium.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url = http://circ.ahajournals.org/content/115/10/1296 | publisher =  | date =  | accessdate = 4 December 2013 }}</ref>  The anomalous coronary origin leads to different anomalous course for the coronary arteries, which can be detected by angiography and they are as follow:
=====LCA that arises from right anterior sinus=====
LCA runs in a different courses when arise from right sinus of valsalva, and it includes a septal, anterior,
interarterial, and posterior course.  The anomalous courses can be more specified as follow:<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url =http://circ.ahajournals.org/content/115/10/1296 | publisher =  | date =  | accessdate = 4 December 2013 }}</ref><ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6| pages =  }}</ref>
[[File:LCA runs septal.jpg |280px|left]]
[[File:LCA runs anterior.jpg|270px|central]]
[[File:Interarterial.jpg|200px|central]]
[[File:Posterior.jpg|280px|central]]
*Posterior atrioventricular groove
*Retroaortic
*Between aorta and pulmonary artery
*Intraseptal
*Anterior to pulmonary artery
*Posteroanterior interventricular groove
Images shown below are courtesy of Professor Peter Anderson DVM PhD and published with permission. [http://www.peir.net © PEIR, University of Alabama at Birmingham, Department of Pathology]
<div align="left">
<gallery heights="175" widths="175">
Image:Single coronary artery.jpg|Gross shows common origin of right and left coronary arteries from right coronary cusp
Image:Single coronary artery2.jpg|Gross natural color opened right coronary sinus showing single origin of both coronaries
</gallery>
</div>
=====LAD that arises from right anterior sinus=====
When LAD arises from the right anterior sinus, it may run in a similar course as LCA which include:<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url =http://circ.ahajournals.org/content/115/10/1296 |publisher =  | date =  | accessdate = 4 December 2013 }}</ref>
*Between aorta and pulmonary artery
*Intraseptal
*Anterior to pulmonary artery
*Posteroanterior interventricular groove
=====LCx artery that arises from right anterior sinus=====
LCx artery when arise from right sinus of valsalva, it may run in the posterior atrioventricular groove, or follow a retroaortic course.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url =http://circ.ahajournals.org/content/115/10/1296 |publisher =  | date =  | accessdate = 4 December 2013 }}</ref>
=====RCA that arises from left anterior sinus=====
When RCA arise from the left sinus, it follows the same anomalous courses as the LAD when arise from the the right sinus of Valsalva, with the most common course is the interarterial.<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url =http://circ.ahajournals.org/content/115/10/1296 |publisher =  | date =  | accessdate = 4 December 2013 }}</ref><ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 |publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6| pages =  }}</ref>
==== [[Coronary artery fistula|Coronary Artery Fistulas]] ====
Coronary artery fistulas are rare findings, defines as any abnormal communication through which coronary artery blood is shunted into:
*Any of the cardiac chambers
*The besian veins that empty into the cardiac chambers
*The coronary sinus
*The SVC
*The pulmonary veins
*The mediastinal vessels
It is identified in 10 (0.05%) of 18,272 diagnostic cardiac catheterizations.  The number, origin, and course of the coronary arteries is otherwise normal.<ref name="pmid17965946">{{cite journal| author=Cebi N, Schulze-Waltrup N, Frömke J, Scheffold T, Heuer H| title=Congenital coronary artery fistulas in adults: concomitant pathologies and treatment. | journal=Int J Cardiovasc Imaging | year= 2008 | volume= 24 | issue= 4 | pages= 349-55 | pmid=17965946 | doi=10.1007/s10554-007-9277-x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17965946  }} </ref><ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6| pages =  }}</ref>
==== Congenital Coronary Stenosis or Atresia ====
Congenital coronary stenosis can be associated with other congenital diseases (e.g. supravalvular aortic stenosis, calcific coronary sclerosis, or rubella syndrome), or one of the intrinsic coronary arterial anatomy anomalies, which may involve [[left coronary artery]], [[left anterior descending artery]], [[right coronary artery]], and [[left circumflex artery]].<ref>{{Cite book  | last1 = Braunwald | first1 = Eugene | last2 = Bonow | first2 = Robert O. | title = Braunwald's heart disease : a textbook of cardiovascular medicin | date = 2012 | publisher = Saunders | location = Philadelphia | isbn = 978-1-4377-0398-6| pages =  }}</ref>
Other intrinsic coronary arterial anatomy anomalies include:<ref name="circ.ahajournals.org">{{Cite web  | last =  | first =  | title = Coronary Artery Anomalies | url =http://circ.ahajournals.org/content/115/10/1296 | publisher =  | date =  | accessdate = 4 December 2013 }}</ref>
*Coronary ostial dimple
*Coronary ectasia or aneurysm
*Absent coronary artery
*Coronary hypoplasia
*Intramural coronary artery (muscular bridge)
*Subendocardial coronary course
*Coronary crossing
*Anomalous origination of posterior descending artery from the anterior descending branch or a septal penetrating branch
*Split RCA
*Split LAD
*Ectopic origination of first septal branch
==== [[Myocardial bridging|Myocardial Bridging]] ====
Myocardial bridge is defined as a segment of a major [[coronary artery|coronary]] [[epicardial]] [[artery]] that "tunnels" or passes intramurally through the [[myocardium]] beneath the muscle bridge during [[systole]].<ref name="pmid15764618">{{cite journal |author=Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS |title=Myocardial bridging |journal=[[European Heart Journal]] |volume=26 |issue=12 |pages=1159–68 |year=2005 |month=June |pmid=15764618 |doi=10.1093/eurheartj/ehi203 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=15764618 |accessdate=2012-07-01}}</ref><ref name="pmid12427660">{{cite journal |author=Möhlenkamp S, Hort W, Ge J, Erbel R |title=Update on myocardial bridging |journal=[[Circulation]] |volume=106 |issue=20 |pages=2616–22 |year=2002 |month=November |pmid=12427660 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12427660 |accessdate=2012-07-01}}</ref> Myocardial bridges are generally located in the distribution of the [[left anterior descending artery]] ([[LAD]]) and its [[diagonal branch]]es.
On angiography, the bridged segment is of normal caliber during diastole and abruptly narrows with each systole.  Myocardial bridging has been associated with angina, arrhythmia, depressed left ventricular function, myocardial stunning, early death after cardiac transplantation, and sudden death.<ref name="pmid15764618">{{cite journal| author=Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS| title=Myocardial bridging. | journal=Eur Heart J | year= 2005 | volume= 26 | issue= 12 | pages= 1159-68 | pmid=15764618 | doi=10.1093/eurheartj/ehi203 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15764618  }} </ref><ref name="pmid19620504">{{cite journal| author=Ishikawa Y, Akasaka Y, Suzuki K, Fujiwara M, Ogawa T, Yamazaki K et al.| title=Anatomic properties of myocardial bridge predisposing to myocardial infarction. | journal=Circulation | year= 2009 | volume= 120 | issue= 5 | pages= 376-83 | pmid=19620504 | doi=10.1161/CIRCULATIONAHA.108.820720 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19620504  }} </ref>
==== High Anterior Origin of the Right Coronary Artery ====


==References==
==References==

Latest revision as of 16:10, 23 December 2013

Coronary Angiography

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Preprocedural Lesion Morphology

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Quantitative Coronary Angiography
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Mohamed Moubarak, M.D. [3]

Overview

The coronary arteries are usually perpendicular to the aortic wall and they are radially arranged relative to the center of the aorta. The ostia may be rounding, oval, or elliptical, and the position of the ostium does not appear to affect the flow through it.

Classification

Anomalous Pulmonary Origin of the Coronary Arteries

Anomalous Pulmonary Origin of the Coronary Arteries (APOCA) is characterized by the origin of a coronary artery from the pulmonary artery.[1] Left coronary artery is the most common anomaly seen arising from pulmonary artery (ALCAPA),[2] in which angiography shows the absence of left coronary ostium normal flow from the left aortic sinus. Other anomalies of the coronary arteries origin include:[3]

Rare, only about 10% of left main coronary artery originated from the pulmonary artery. [4] [5] [6] [7] [8] [9]
It is almost always found as an incidental autopsy finding of sudden death, and if diagnosed before death it has been associated with:
  1. Symptoms of myocardial ischemia
  2. Syncope
  3. Cardiomyopathy
  • Coronary artery arising from other locations outside pulmonary facing sinuses e.g. anterior left sinus, pulmonary trunk, or pulmonary branch

Mortality rate in the first year of life has been reported to be 95% in untreated cases with poor collateral network.[10]

Endocardial Fibroelastosis: Gross fair example LV endocardial thickening associated with anomalous origin of left coronary artery from pulmonary artery
Left Coronary Artery Anomalous Origin from Pulmonary artery: Angiogram postmortem after switch of left coronary to aorta
Coronary Artery Anomalous Origin Left from Pulmonary artery: Gross natural color anterior view of heart. Large marginal type coronary branches over anterior aspect of right ventricle
Coronary Artery Anomalous Origin Left from Pulmonary artery: Gross natural color anterior view of heart. Large marginal type coronary branches over anterior aspect of right ventricle.
Coronary Artery Anomalous Origin Left from Pulmonary artery: Gross natural color anterior view of hear showing large marginal type branches over anteriorright ventricle 5 month old infant died after operation switching artery to aorta.
Coronary Artery Anomalous Origin Left from Pulmonary artery: Gross fixed tissue. Horizontal sections of ventricles showing thinning in anterior left ventricle due to scar there are some peculiar spots on the ventricles in this photo that probably are artifacts.

Courtesy of Professor Peter Anderson DVM PhD

Anomalous Coronary Artery From the Opposite Sinus

It is an improper site of coronary origin, in some cases in involve the origin of two coronaries from the same ostium.[3] The anomalous coronary origin leads to different anomalous course for the coronary arteries, which can be detected by angiography and they are as follow:

LCA that arises from right anterior sinus

LCA runs in a different courses when arise from right sinus of valsalva, and it includes a septal, anterior, interarterial, and posterior course. The anomalous courses can be more specified as follow:[3][11]

  • Posterior atrioventricular groove
  • Retroaortic
  • Between aorta and pulmonary artery
  • Intraseptal
  • Anterior to pulmonary artery
  • Posteroanterior interventricular groove
Possible Pathways of Anomalous LCA Arising from Right Coronary Sinus
Gross shows common origin of right and left coronary arteries from right coronary cusp
Gross natural color opened right coronary sinus showing single origin of both coronaries

Courtesy of Professor Peter Anderson DVM PhD

LAD that arises from right anterior sinus

When LAD arises from the right anterior sinus, it may run in a similar course as LCA which include:[3]

  • Between aorta and pulmonary artery
  • Intraseptal
  • Anterior to pulmonary artery
  • Posteroanterior interventricular groove
LCx artery that arises from right anterior sinus

LCx artery when arise from right sinus of valsalva, it may run in the posterior atrioventricular groove, or follow a retroaortic course.[3]

RCA that arises from left anterior sinus

When RCA arise from the left sinus, it follows the same anomalous courses as the LAD when arise from the the right sinus of Valsalva, with the most common course is the interarterial.[3][12]

Coronary Artery Fistulas

Coronary artery fistulas are rare findings, defines as any abnormal communication through which coronary artery blood is shunted into:

  • Any of the cardiac chambers
  • The besian veins that empty into the cardiac chambers
  • The coronary sinus
  • The SVC
  • The pulmonary veins
  • The mediastinal vessels

It is identified in 10 (0.05%) of 18,272 diagnostic cardiac catheterizations. The number, origin, and course of the coronary arteries is otherwise normal.[13][14]

Congenital Coronary Stenosis or Atresia

Congenital coronary stenosis can be associated with other congenital diseases (e.g. supravalvular aortic stenosis, calcific coronary sclerosis, or rubella syndrome), or one of the intrinsic coronary arterial anatomy anomalies, which may involve left coronary artery, left anterior descending artery, right coronary artery, and left circumflex artery.[15]

Other intrinsic coronary arterial anatomy anomalies include:[3]

  • Coronary ostial dimple
  • Coronary ectasia or aneurysm
  • Absent coronary artery
  • Coronary hypoplasia
  • Intramural coronary artery (muscular bridge)
  • Subendocardial coronary course
  • Coronary crossing
  • Anomalous origination of posterior descending artery from the anterior descending branch or a septal penetrating branch
  • Split RCA
  • Split LAD
  • Ectopic origination of first septal branch

Myocardial Bridging

Myocardial bridge is defined as a segment of a major coronary epicardial artery that "tunnels" or passes intramurally through the myocardium beneath the muscle bridge during systole.[16][17] Myocardial bridges are generally located in the distribution of the left anterior descending artery (LAD) and its diagonal branches. It has been associated with angina, arrhythmia, depressed left ventricular function, myocardial stunning, early death after cardiac transplantation, and sudden death.[16][18]

On angiography, the bridged segment appears of normal caliber during diastole, and abruptly narrows with systole. Shown below is an animated image depicting myocardial bridge, and two static images of the same case depicting myocardial bridge. Outlined with yellow in the image on the left is the part of the coronary artery during diastole. This same part of the coronary artery is outlined in yellow in the image on the right during systole; note that this outlined part is narrowed compared to its shape during diastole.

Myocardial bridging Shape of the coronary artery during diastole The coronary artery is narrowed during systole which is consistent myocardial bridging.

High Anterior Origin of the Right Coronary Artery

A superior origin of the RCA above the sinotubular ridge, although it is found commonly, it has no hemodynamic significance. This case is suspected during catheterization when it fails to engage the ostium of the RCA, and injection of contrast medium into the right sinus of Valsalva may reveal the anomalous origin.[19]

2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)[20]

Evaluation and Surgical Intervention (DO NOT EDIT)[20]

Class I
"1. Any patient with CHD who has had coronary artery manipulation should be evaluated for coronary artery patency, function, and anatomic integrity at least once in adulthood. (Level of Evidence: C)"
”2. Surgeons with training and expertise in CHD should perform operations for the treatment of coronary artery anomalies.(Level of Evidence: C)"

Coronary Anomalies Associated With Supravalvular Aortic Stenosis (DO NOT EDIT)[20]

Class I
"1. Adults with a history or presence of SupraAS should be screened every 1 or 2 years for myocardial ischemia. (Level of Evidence: C)"
"2. Interventions for coronary artery obstruction in patients with SupraAS should be performed in ACHD centers with demonstrated expertise in the interventional management of these patients. (Level of Evidence: C)"

Coronary Anomalies Associated With Tetralogy of Fallot (DO NOT EDIT)[20]

Class I
"1. Coronary artery anatomy should be determined before any intervention for RV outflow. (Level of Evidence: C)"

Coronary Anomalies Associated With Dextro-Transposition of the Great Arteries After Arterial Switch Operation (DO NOT EDIT)[20]

Class I
"1. Adult survivors with dextro-TGA (d-TGA) after arterial switch operation (ASO) should have noninvasive ischemia testing every 3 to 5 years. (Level of Evidence: C)"

Congenital Coronary Anomalies of Ectopic Arterial Origin (DO NOT EDIT)[20]

Class I
"1. The evaluation of individuals who have survived unexplained aborted sudden cardiac death or with unexplained life-threateningarrhythmia, coronary ischemic symptoms, or LV dysfunction should include assessment of coronary artery origins and course. (Level of Evidence: B)"
”2. CT or magnetic resonance angiography is useful as the initial screening method in centers with expertise in such imaging.(Level of Evidence: B)"
”3. Surgical coronary revascularization should be performed in patients with any of the following:
a. Anomalous left main coronary artery coursing between the aorta and pulmonary artery. (Level of Evidence: B)
b. Documented coronary ischemia due to coronary compression (when coursing between the great arteries or in intramural fashion). (Level of Evidence: B)
c. Anomalous origin of the right coronary artery between aorta and pulmonary artery with evidence of ischemia. (Level of Evidence: B)"
Class IIa
"1. Surgical coronary revascularization can be beneficial in the setting of documented vascular wall hypoplasia, coronary compression, or documented obstruction to coronary flow, regardless of inability to document coronary ischemia. (Level of Evidence: C)"
”2. Delineation of potential mechanisms of flow restriction via intravascular ultrasound can be beneficial in patients with documented anomalous coronary artery origin from the opposite sinus. (Level of Evidence: C)"
Class IIb
"1. Surgical coronary revascularization may be reasonable in patients with anomalous left anterior descending coronary artery coursing between the aorta and pulmonary artery. (Level of Evidence: C)"

Anomalous Left Coronary Artery From the Pulmonary Artery (DO NOT EDIT)[20]

Class I
"1. In patients with an anomalous left coronary artery from the pulmonary artery (ALCAPA), reconstruction of a dual coronary artery supply should be performed. The surgery should be performed by surgeons with training and expertise in CHD at centers with expertise in the management of anomalous coronary artery origins. (Level of Evidence: C)"
”2. For adult survivors of ALCAPA repair, clinical evaluation with echocardiography and noninvasive stress testing is indicated every 3 to 5 years. (Level of Evidence: C)"

Coronary Arteriovenous Fistula (DO NOT EDIT)[20]

Class I
"1. If a continuous murmur is present, its origin should be defined either by echocardiography, MRI, CT angiography, or cardiac catheterization. (Level of Evidence: C)"
”2. A large coronary arteriovenous fistula (CAVF), regardless of symptomatology, should be closed via either a transcatheter or surgical route after delineation of its course and its potential to fully obliterate the fistula. (Level of Evidence: C)"
”3. A small to moderate CAVF in the presence of documented myocardial ischemia, arrhythmia, otherwise unexplained ventricular systolic or diastolic dysfunction or enlargement, or endarteritis should be closed via either a transcatheter or surgical approach after delineation of its course and its potential to fully obliterate the fistula. (Level of Evidence: C)"
Class III
"1. Patients with small, asymptomatic CAVF should not undergo closure of CAVF. (Level of Evidence: C)"
Class IIa
"1. Clinical follow-up with echocardiography every 3 to 5 years can be useful for patients with small, asymptomatic CAVF to exclude development of symptoms or arrhythmias or progression of size or chamber enlargement that might alter management. (Level of Evidence: C)"

Management Strategies for CAVF(DO NOT EDIT)[20]

Class I
"1. Surgeons with training and expertise in CHD should perform operations for management of patients with CAVF. (Level of Evidence: C)"
”2. Transcatheter closure of CAVF should be performed only in centers with expertise in such procedures. (Level of Evidence: C)"
”3. Transcatheter delineation of CAVF course and access to distal drainage should be performed in all patients with audible continuousmurmur and recognition of CAVF. (Level of Evidence: C)"

References

  1. ↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-0398-6.
  2. ↑ Hofmeyr, L.; Moolman, J.; Brice, E.; Weich, H. (2009). "An unusual presentation of an anomalous left coronary artery arising from the pulmonary artery (ALCAPA) in an adult: anterior papillary muscle rupture causing severe mitral regurgitation". Echocardiography. 26 (4): 474–7. doi:10.1111/j.1540-8175.2008.00815.x. PMID 19054023. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 "Coronary Artery Anomalies". Retrieved 4 December 2013.
  4. ↑ Coe JY, Radley-Smith R, Yacoub M. Clinical and hemodynamic significance of anomalous origin of the right coronary artery from the pulmonary artery. Thorac Cardiovasc Surg 1982;30:84-7.
  5. ↑ Fontana RS, Edwards JE. Congenital Cardiac Disease: A Review of 357 Cases Studied Pathologically. Philadelphia: WB Saunders, 1962.
  6. ↑ Ogden JA. Congenital anomalies of the coronary arteries. Am J Cardiol 1970;25:474-79.
  7. ↑ Neufeld HN, Schneeweiss A. Coronary Artery Disease in Infants and Children. Philadelphia: Lea & Febiger, 1983.
  8. ↑ Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986; 111: 941-63.
  9. ↑ Yao CT, Wang JN, Yeh CN, et al. Isolated anomalous origin of right coronary artery from the main pulmonary artery. J Card Surg 2005;20:487-89.
  10. ↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-0398-6.
  11. ↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-0398-6.
  12. ↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-0398-6.
  13. ↑ Cebi N, Schulze-Waltrup N, Frömke J, Scheffold T, Heuer H (2008). "Congenital coronary artery fistulas in adults: concomitant pathologies and treatment". Int J Cardiovasc Imaging. 24 (4): 349–55. doi:10.1007/s10554-007-9277-x. PMID 17965946.
  14. ↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-0398-6.
  15. ↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-0398-6.
  16. ↑ 16.0 16.1 Alegria JR, Herrmann J, Holmes DR, Lerman A, Rihal CS (2005). "Myocardial bridging". European Heart Journal. 26 (12): 1159–68. doi:10.1093/eurheartj/ehi203. PMID 15764618. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  17. ↑ Möhlenkamp S, Hort W, Ge J, Erbel R (2002). "Update on myocardial bridging". Circulation. 106 (20): 2616–22. PMID 12427660. Retrieved 2012-07-01. Unknown parameter |month= ignored (help)
  18. ↑ Ishikawa Y, Akasaka Y, Suzuki K, Fujiwara M, Ogawa T, Yamazaki K; et al. (2009). "Anatomic properties of myocardial bridge predisposing to myocardial infarction". Circulation. 120 (5): 376–83. doi:10.1161/CIRCULATIONAHA.108.820720. PMID 19620504.
  19. ↑ Braunwald, Eugene; Bonow, Robert O. (2012). Braunwald's heart disease : a textbook of cardiovascular medicin. Philadelphia: Saunders. ISBN 978-1-4377-0398-6.
  20. ↑ 20.0 20.1 20.2 20.3 20.4 20.5 20.6 20.7 20.8 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.


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