Anomalous coronary artery from the opposite sinus

Abstract

The authors are to be congratulated on a controversial topic. 1 As mentioned in their paper, anomalous coronary artery from the opposite sinus is rare with an incidence of around 0.26% of the population. A randomized controlled trial is not feasible for a small patient population. Most data is based on anecdotal case reports and short series. Unfortunately, asymptomatic patients' first presentation may be sudden cardiac death especially in young athletes or upon excursion. Symptoms otherwise may vary from chest pain, arrhythmias, syncope, and sudden cardiac death.Outcomes may vary, with sudden cardiac death almost universally present in an untreated left anomalous coronary artery, whereas only in 40% patients with right anomalous coronary artery. 2 Surgery remains the mainstay for symptomatic patients with anomalous coronary artery from the opposite sinus. As noted in the paper, the surgical options include unroofing of the right coronary artery (RCA), reimplantation of the ostium and coronary artery bypass surgery. The option proposed by the authors included RCA bypass grafting with proximal RCA occlusion for anomalous RCA arising from the left sinus of Valsalva. Proximal RCA occlusion may be an important maneuver, with testing for ischemia by proximal RCA snaring before complete occlusion. Competitive flow does shorten coronary artery bypass graft survival, as demonstrated by Sabik et al 3 however as noted in this paper, the option of RCA bypass for anomalous RCA from the opposite sinus had a 6% mortality and graft failure. In addition to surgical options, there have been reports with percutaneous intervention and stent implantation in the anomalous RCA. 4 A recent paper demonstrated successful percutaneous intervention and stenting with a drug-eluting stent of left coronary artery ostial stenosis, 9 months post unroofing of the intramural segment of the anomalous left coronary artery. The vessel was patent on computed tomography angiogram performed 3 months post procedure. 5 The important question with this pathology remains that which patients to be referred for intervention vs medically managed. Based on the Congenital Heart Surgery Society Registry, management decisions will be based on patient symptomatology and coronary morphology. Follow-up of patients managed surgically or medically in this registry may further help with evidence-based protocols. 6 In addition, the Japanese Coronary Anomaly Registry suggested patients with age ≤40 years, male sex, sporting activity, and an acute take-off angle appear to be risk factors for sudden cardiac death and thus surgical intervention may be appropriate therapy. 7 Driesen et al 8 performed a retrosospective review of 30 patients with anomalous coronary origin with interarterial course. Each patient was evaluated clinically, received Intravascular Ultrasound (IVUS) and Fractional Flow Reserve (FFR) to determine intervention vs conservative management. A decision for intervention was made if at least two out of three entities were abnormal.No adverse events occurred...