Coronary anomalies in tetralogy of Fallot – A meta-analysis

Abstract

Background: An anomalous coronary artery is reported in 2% to 23% of patients with tetralogy of Fallot (TOF). Knowledge of coronary anatomy prior to corrective surgery is vital to avoid damage to vessels crossing the right ventricular outflow tract (RVOT). A meta-analysis on the prevalence of anomalous coronary arteries in TOF is lacking to date. Here, an overview of coronary anomalies in TOF is provided and implications for patient management are discussed. Methods: PubMed, Embase and Web of Science were searched. Analysis was done using Revman 5.3 (Cochrane Community, London). The primary analysis focused on the origin and proximal course of the right and left coronary arteries. In addition, the prevalence of large conus arteries and coronary arteriovenous fistulas (CAVF) was calculated. Results: Twenty-eight studies, encompassing 6956 patients, were included; 6% of TOF patients have an anomalous coronary artery. Hereof, 72% cross the RVOT; the majority of the remaining 28% courses behind the aorta. Six percent of patients have a large conus artery and 4% a CAVF. Other coronary anomalies include a left or right coronary artery from the pulmonary trunk or left or right pulmonary artery, coronary tree hypoplasia and anastomoses between coronary and bronchial arteries. Conclusions: The prevalence of coronary anomalies in TOF is 4-6%. In patients with an anomalous coronary artery, 72% cross the RVOT. The combined risk of encountering an anomalous coronary artery or a large conus artery crossing the RVOT is 10.3%. Coronary anatomy should be defined before surgery and the surgical approach adapted accordingly.

Anomalies of coronary arteries in tetralogy of Fallot: Evaluation on multidetector CT angiography using dual‐source scanner

“…This again corresponds to the incidence (72%) observed in the meta-analysis. 7 In another study by Kervancioglu et al 2 using a combination of angiographic and surgical methods, anomalous coronary arteries crossing the RVOT was observed in 62.3% of patients. This course undertaken by the anomalous coronary arteries assumes great significance in surgical planning as coronary arteries crossing the RVOT would interfere with right ventriculotomy or outflow resection and their preoperative identification is imperative in avoiding coronary artery damage and preserving the viability of the myocardium.…”

“…A hypertrophied conal artery has been reported in 1.6-24% in CT angiography-based studies and in 0-40% in catheter angiography-based studies with the pooled incidence being 6%. 7 In 80% (20/25) patients, the hypertrophied conal artery arising from RCA was coursing anterior to the RVOT.…”

“…However, the incidence varies widely (from 2% to 14%) across literature, often depending upon the modality used for detection such as echocardiography, catheter angiography, CT angiography, or using autopsy or intraoperative findings. 7 The low incidence (2-5%) in studies reporting intraoperative findings can be attributed to the fact that such anomalies are not always recognized intraoperatively due to the overlying myocardium, epicardial fat, and epicardialpericardial adhesions. [8][9][10] On the contrary, autopsy studies demonstrate higher incidence because of careful examination of the coronary arteries.…”

“…This is in concordance with the recently published meta-analysis that estimated the prevalence of anomalous coronary arteries to be 6% based on 6956 patients from combined studies. 7 Only a few studies utilized CT angiography for the detection of anomalous coronary arteries in TOF and these studies reported a prevalence of 8.5% and 3.6% respectively. 3,10 In the present study, the incidence of anomalous coronary arteries crossing anterior to RVOT in TOF patients was 63.29%…”

High origin of the right coronary artery with partial anomalous pulmonary venous connection to the left superior caval vein in tetralogy of Fallot

“…The prevalence of anomalous origin of coronary artery in tetralogy of Fallot (TOF) has been reported to be around 4% to 6% 1 . The left anterior descending coronary artery crossing the right ventricular outflow tract is the most common variant.…”