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Sumario Vol. 42 - Nº 1 Enero - Marzo 2013

Anomalous origin of coronary arteries from a common trunk in right sinus of Valsalva.

Federico E. Rocca.

Hospital Interzonal General de Agudos "Dr José Penna".
Lainez 2401. CP 8000 - Bahía Blanca. Buenos Aires. Argentina.
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Recibido 03-OCT-2012 – ACEPTADO después de revisión el 07-DICIEMBRE-2013.

The author declares not having conflicts of interest

Rev Fed Arg Cardiol. 2013; 42(1): 61-62


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The anomalous origin of coronary arteries is an infrequent alteration, the significance of which lies in that it may be the cause of myocardial ischemia and sometimes its form of presentation is sudden cardiac death. There are different varieties of presentation, and from them the anomalous origin of the left coronary artery in the right sinus of Valsalva is very infrequent.

The clinical case is presented of a 50-year-old woman, without known factors of cardiovascular risk, who is admitted in our institution due to typical precordial pain. In admission, an electrocardiogram is obtained that shows 1 mm depression of the ST segment in the inferior and lateral side. It is decided to admit her into the Coronary Unit with diagnosis of acute coronary syndrome without ST elevation. An antiaggregation, anticoagulation and antiischemic treatment is established. After 8 h from the symptoms having started, troponin I is measured, with a value of 1.85 (cutoff value 0.04). She evolves stable, without recurrence of symptoms. During the hospitalization a coronary angiography is made (Figure 1) that reports absence of significant coronary obstructions and origin of right coronary artery (RCA), anterior descending artery (ADA) and circumflex artery (Cx) in a common trunk that starts in the right coronary sinus (RCS). The patient evolves favorably, so she is discharged and an outpatient follow-up is scheduled. A coronary 64-slice angiotomography is made subsequently (Figures 2 and 3), which confirms the diagnosis, highlighting also the retropulmonary trajectory of the anterior descending artery, with an intramyocardial segment at the level of the interventricular septum, absence of significant endoluminal coronary obstructions and a score of calcium of 18 Agatston units.

Figure 1

 

Figure 2

 

Figure 3

 

The control perfusionstudies carried out ambulatorily did not show myocardial ischemia. At a year of the event that motivated her admittance, the patient is asymptomatic, in treatment with atenolol 100 mg/day.

The anomalous origin of the coronary arteries comprises a group of malformations with a prevalence of around 1% in angiographic studies, a figure even lower in registries based on necropsies [1]. Although first they were considered simple anatomical findings, over the last decades its diagnosis became relevant, from studies that showed the significance of detecting it, especially the determination of the initial trajectory and its relation to the aorta and the pulmonary artery (PA), by the probable compression that these large vessels could produce on the coronary arteries [2]. The range of presentation is quite wide; from being completely silent and benign, to evolving with clinical manifestations such as syncope, angina, infarction and arrhythmias. The presence of severe symptoms has been reported in around 20%  of the cases. Sudden cardiac death (SCD) as a modality of presentation is especially significant. It has been described mainly associated to physical stress situations, with particular relevance in sportsmen by the cases documented of SCD in sportsmen. The mechanism responsible for the symptoms described has not been determined accurately, although different hypothesis have been posed. The arterial compression during physical stress in those anomalies that involve an interatrial trajectory between the aorta and the PA, the intramural trajectory in the aortic wall essentially in the origin of the artery, and the origin of the coronary arteries with excessive angles, may originate compressive phenomena triggering ischemic symptoms [3]. Different variants have been described, between them the detection of the coronary ostium in the contralateral sinus or in the non-coronary sinus and the anomalous original from the pulmonary artery.

Congenital anomalies of the coronary arteries are classically grouped into 2 large sets: anomalies of origin and distribution, and coronary fistulae, with the former being the most frequent, in a ratio of 4.1. The anomalous origin of the left coronary artery in the right sinus of Valsalva presents with a very scant prevalence, close to 0.15% of the cases [4].

The indication of surgery has been a reason for controversy, and it has not been properly established in those asymptomatic patients in whom ischemia has not been proven. The evaluation with SPECT in rest and strain have shown their usefulness to identify patients in risk and to select those candidates to surgical correction [5].

 

 

REFERENCES.

  1. Angelini P, Velasco JA, Flamm S. Coronary anomalies: incidence, pathophysiology, and clinical relevance. Circulation 2002; 105: 2449-2454.
  2. Taylor AJ, Byers JP, Cheitlin MD, et al. Anomalous right or left coronary artery from the contralateral coronary sinus: «high risk» abnormalities in the initial coronary artery course and heterogeneus clinical outcomes. Am Heart J 1997; 133: 428-435.
  3. Ugalde H, Ramírez A, Ugalde D, et al. Nacimiento anómalo de las arterias coronarias en 10000 pacientes sometidos a coronariografía. Rev Med Chile 2010; 138: 7-14.
  4. Angelini P, Villason S, Chan AV. Normal and anomalous coronary arteries in humans. En: Angelini P, editor. Coronary artery anomalies: a comprehensive approach. Philadelphia: Lipincott Williams and Wilkins; 1999. pag 27-150.
  5. De Luca L, Bovenzi F, Rubini D, et al. Stress-rest myocardial perfusion SPECT for functional assessment of coronary arteries with anomalous origin or course. J Nucl Med 2004; 45: 532-536.

 

Publication: March 2013

 
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