Origin of the right coronary artery from the opposite sinus of Valsalva in adults: Characterization by intravascular ultrasonography at baseline and after stent angioplasty

Abstract

ObjectivesWe attempted to characterize the anatomy, function, clinical consequences, and treatment of right-sided anomalous coronary artery origin from the opposite side (R-ACAOS).BackgroundAnomalous aortic origin of a coronary artery is a source of great uncertainty in cardiology. A recent study by our group found that ACAOS had a high prevalence (0.48%) in a general population of adolescents.MethodsSixty-seven consecutive patients were diagnosed with R-ACAOS according to a new definition: ectopic right coronary artery (RCA) with an intramural proximal course. We used intravascular ultrasonograms of the RCA to quantify congenital stenosis (in patients with potentially serious clinical presentations), and we correlated these measurements with clinical manifestations.ResultsAll patients had some proximal intramural stenosis (mean 50%, range 16–83% of the cross-sectional area). Forty-two patients (62%) underwent stent-percutaneous coronary intervention (PCI) of R-ACAOS because of significant symptoms, positive stress tests, and/or significant stenosis. Stent-PCI was successful in all cases and correlated with improved symptoms at >1-year follow-up in 30 patients (71%) who were available for clinical follow-up. No ACAOS-related deaths occurred. The instent restenosis rate was 4/30 (13%) at a mean follow-up time of 5.0 years.ConclusionsThis preliminary, but large and unprecedented observational study shows that cases angiographically identified as R-ACAOS universally feature an intramural aortic course but only occasionally severe stenosis on resting IVUS imaging. Our data suggest that stent-PCI with IVUS monitoring ameliorates patients’ presenting symptoms. © 2015 Wiley Periodicals, Inc.

Physiological and clinical relevance of anomalous right coronary artery originating from left sinus of Valsalva in adults

“…A recent article by Angelini et al 28 described that all of the 67 patients who received IVUS study had intramural proximal coronary course. Sixty-seven patients had significant symptoms, such as typical chest pain, dyspnoea and syncope, and 73% had a positive stress test.…”

Symptomatic right coronary anomaly with dynamic systolic intramural obliteration and isolated right ventricular ischemia

“…A 52‐year‐old man was referred to our institution for evaluation of reproducible progressive angina (described as “arm heaviness”) and dyspnea that consistently developed on walking 50 m. A previous coronary computed tomography angiogram revealed an ectopic origin of the right coronary artery (RCA) from the left sinus of Valsalva, with an anomalous course “between the aorta and the pulmonary artery” (a likely case of R‐ACAOS‐IM, Figure ) . The results of a previous nuclear scintigraphy stress test were negative, but the test was stopped prematurely because of the development of typical angina.…”

“…This exceptional case is an example of an RCA serving only the right ventricular free wall, accompanied by fixed (hypoplasia and lateral compression) and dynamic stenosis (worsening with exercise and systole). Both angina and dyspnea on moderate exertion were disabling and disappeared after effective stent angioplasty …”

Successful stent implantation for acute take‐off left coronary artery stenosis

“…Open heart surgery with cardiopulmonary bypass would cause a systemic inflammatory response that can lead to lethal pulmonary hypertension. In contrast, as noted, stent implantation has been found to be useful for CAA: the symptoms can be relieved by with stent implantation by returning the lumen from a squamous shape to a more rounded shape . Thus, stent implantation might have a positive impact on the control of stenosis of acute angular coronary artery from proper sinus.…”

“…Surgical correction and bypass grafting were previously conducted in the patients with CAA. Currently, stent implantation is also a favorable treatment option for coronary artery with unusual origin in adult patients . There has been no report, however, on percutaneous coronary intervention for the ostial stenosis of acute take‐off coronary artery in children.…”