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

Abstract

A 52‐year‐old man was referred for an anomalous right coronary artery (RCA) originating from the left sinus of Valsalva with an intramural course (R‐ACAOS‐IM), accompanied by progressive angina and dyspnea. He had been initially advised to have surgical treatment. Computerized axial tomographic angiography showed he had an ectopic origin from the left sinus of a small RCA, with a course between the aorta and pulmonary artery. His negative treadmill nuclear stress test was prematurely terminated because of angina and dyspnea. At our institution, intravascular ultrasound imaging indicated an intramural course and critically severe phasically changing proximal stenosis (80%–100%). The stenosis was resolved with stent‐angioplasty of the intramural segment. He had no complications and returned quickly to an asymptomatic state with unrestricted physical activity.

Application of Patient-Specific Computational Fluid Dynamics in Anomalous Aortic Origin of Coronary Artery: A Systematic Review

“…The lateral compression of the IMC manifests mainly during systole and worsens with exercise, where also diastole is affected depending on the blood pressure. This has been verified in several studies, where the effect was quantified using intravascular ultrasound (IVUS) and measured fractional flow reserve (FFR) [ 10 , 11 , 12 , 13 ]. In fact, IVUS imaging showed a phasic reduction in the mean ostial area in systole in resting conditions, which aggravated under stress.…”

Non-atherosclerotic coronary artery disease: an overview of a heterogeneous disease

“…In TTE, CAs are visualized as linear, hypoechogenic, intramyocardial structures of approximately 0.5-2.5 cm in length and 2 to 4 mm in diameter [14]. Changes in the CA's wall thickness and lumen diameter can help evaluate CA vasculitis [15]. Physical (bicycle or treadmill) and pharmacological stress echocardiography (dipyridamole, adenosine and dobutamine) can be performed for regional contractility and valvular and ventricular function assessment [16].…”

“…For example, small anomalous CA vessel (hypoplastic RCA) with a small inter-arterial course (IAC) of the anomalous vessel between the pulmonary artery and the aorta with left coronary dominance. In these cases, IVUS and CFR measurement can help to evaluate the degree of stenosis and the consequent ischemia [15].…”

Therapeutic Management of Anomalous Coronary Arteries Originating From the Opposite Sinus of Valsalva: Current Evidence, Proposed Approach, and the Unknowing

“…Of note, pharmacologic vasodilatation cannot assess the dynamic components, as it requires an increased cardiac output with subsequent augmented vessel wall stress of the aorta. 24 , 39 , 40 , 41 , 42 , 43 , 44 These exercise‐induced adaptations can provoke a lateral compression sufficient to cause myocardial ischemia (even during diastole). Therefore, physical stress or positive inotrope/positive chronotrope protocols including volume infusion to mimic strenuous exercise are needed to depict ischemia by dynamic compressions.…”