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

Abstract

Anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS) are a challenge because of their various anatomic and clinical presentation. Although the prevalence is low, the absolute numbers of detected ACAOS are increasing because of the growing use of noninvasive anatomical imaging for ruling out coronary artery disease. As evidence‐based guidelines are lacking, treating physicians are left in uncertainty for the optimal management of such patients. The sole presence of ACAOS does not justify surgical correction, and therefore a thorough anatomic and hemodynamic assessment is warranted. Invasive and noninvasive multimodality imaging provides information to the clinical question whether the presence of ACAOS is an innocent coincidental finding, is responsible for the patient’s symptoms, or even might be a risk for sudden cardiac death. Based on recent clinical data, focusing on the pathophysiology of patients with ACAOS, myocardial ischemia is dependent on both the extent of fixed and dynamic components, represented by anatomic high‐risk features. These varying combinations should be considered individually in the decision making for the different therapeutic options. This state‐of‐the‐art review focuses on the advantages and limitations of the common contemporary surgical, interventional, and medical therapy with regard to the anatomy and pathophysiology of ACAOS. Further, we propose a therapeutic management algorithm based on current evidence on multimodality invasive and noninvasive imaging findings and highlight remaining gaps of knowledge.

Sport resumption and quality of life after surgical correction of anomalous origin of a coronary artery from the opposite sinus

“…When deciding to recommend surgical correction of ACAOS in athletes, especially in asymptomatic patients, the first object of therapy is to prevent sudden cardiac death during exercise by treating the intramural path of the ectopic coronary artery. Several techniques have been described but, in our experience, the most appropriate surgical technique to address ACAOS is the unroofing procedure of the intramural segment, which is simple, safe and associated with favorable outcomes ( 18 – 21 ). Alternative techniques, including ostioplasty alone, coronary reimplantation with neo-ostial enlargement, or pulmonary translocation, have also shown good results and can be proposed in some cases ( 22 , 23 ).…”

Congenital Anomalous Origin of the Coronary Artery in Children: Use of Computed Tomography Coronary Angiography for Diagnosis

“…However, discouraging exercise may lead to other issues related to long-term cardiovascular and emotional health in children. Bigler et al (30) concluded that conservative management should not be promoted as rst-line therapy and is only recommended for patients who have residual myocardial ischemia after surgical therapy. When choosing the surgical approach, he recommended unroo ng for patients with ACAOS and a long intramural anomalous vascular course with proven hemodynamic relevance.…”

Prevalence and Pattern of Congenital Coronary Artery Anomalies in Patients Undergoing Coronary Angiography at a Tertiary Care Hospital

“…23 With intravascular ultrasonography, it was shown that the coronary artery is compressed between the aorta and the pulmonary artery and that the intra-mural section of the artery is compressed laterally. 24 Myocardial ischemia may be caused by many different processes. However, other writers have speculated that aberrant pathways might produce endothelial damage and dysfunction, which could cause coronary artery spasms.…”

“…However, other writers have speculated that aberrant pathways might produce endothelial damage and dysfunction, which could cause coronary artery spasms. 24 The vast majority of CAAs are symptom-free and are only discovered accidentally during routine angiography. Some abnormalities manifest in the young person's life as abrupt cardiac death.…”