Dr/AHMED ESAWY

Anomalous Coronary

Arteries

Dr/AHMED ESAWY

Dr. Ahmed Esawy

MBBS M.Sc. MD

Dr/AHMED ESAWY

Dr/AHMED ESAWY

Normal Anatomy

R and L coronary arteries arise from the R and L aortic sinuses (of Valsalva)

Usually within 1cm superior to aortic valve

Arteries originate orthogonal to aortic wall

Epicardial (extramural course) course

Dr/AHMED ESAWY

RCA LCA

Dr/AHMED ESAWY

Anomalous Coronary Arteries

Found in ~0.1%-1.3% of patients undergoing cardiac catheterization

Can be assoc w/ congenital heart dz or be isolated anomaly

Angio evaluation can be challenging; misdiagnosis in up to 50% of cases

Rare but important cause of CP, arrhythmia, MI & sudden cardiac death; TREATABLE

Dr/AHMED ESAWY

Why Is It So Dangerous?

Not fully understood; many variants benign

But some variants w/ mortality rates >50%

Depends on course of anomalous artery: retroaortic & anterior courses benign

Dangerous: “interarterial” course b/w aorta & RVOT

Pathophysiolgy unclear: compression or kinking during systole vs. abnl narrowing of ostium

Dr/AHMED ESAWY

Anomalous Coronary Anatomy

~60% cases involve the circumflex

~40% involve the LM or RCA

Dr/AHMED ESAWY

Anomalous Circumflex Artery

Anomalous circumflex:

Either off R sinus or branches off RCA

ALMOST ALWAYS RETROCARDIAC BENIGN

Dr/AHMED ESAWY

Anomalous Circumflex: Retroaortic BENIGN

Normal Anatomy

Dr/AHMED ESAWY

Retroaortic Anomalous Circumflex

Ao

Dr/AHMED ESAWY

Congenital origin of the circumflex artery from the right coronary sinus, it shows separate origin slightly infro-posterior to the origin of the right coronary artery.

Dr/AHMED ESAWY

Anomalous Right Coronary

Anomalous RCA:

Either off L sinus or branches off single left coronary

Can be retroaortic but IN VAST MAJORITY (>90%) OF CASES INTERARTERIAL MALIGNANT

Dr/AHMED ESAWY

Normal Anatomy

Anomalous RCA: InterarterialISCHEMIA!!

Dr/AHMED ESAWY

Anomalous RCA: Retroaortic BENIGN

Normal Anatomy

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Dr/AHMED ESAWY

WHICH??

Dr/AHMED ESAWY

L sinus of Valslava

R AV groove

Dr/AHMED ESAWY

L sinus of Valslava

R AV groove

INTERARTERIAL ISCHEMIA!!!

Dr/AHMED ESAWY

Malignant right coronary artery

• anomalous origin of a right coronary artery from the left coronary sinus with an inter-arterial course, between the aorta and the main pulmonary artery.

• This variant has been called malignant because of its association with sudden death, especially in young asymptomatic athletes

Dr/AHMED ESAWY

Maximum intensity projection of top of heart showing both right coronary artey (RCA) and left coronary artey (LCA) originating from left coronary sinus. RCA has a slit-like ostium and courses between pulmonary artery (PA) and aorta (A)

Volume rendered image of same showing anomalous, interarterial course of right coronary artey (RCA), between pulmonary artery (PA) and aorta (A)

Dr/AHMED ESAWY

the origin of the RCA from the left aortic sinus and its course between the RVOT and aorta. The compression of the RCA during its interarterial course is well appreciated. The normal origin of the left main coronary artery is also seen

Dr/AHMED ESAWY

Malignant right coronary artery

Dr/AHMED ESAWY

CCT image obtained for young patient with chest pain. Arrow indicates anomalous origin and course of right coronary artery between aorta and pulmonary arterial trunk.

Dr/AHMED ESAWY

Multislice computed tomographic angiogram of an anomalous right coronary artery (RCA) that originates from the left coronary sinus. The vessel's course between the aorta and pulmonary artery caused anginal symptoms in this patient.

Visualization of coronary artery anomalies

Dr/AHMED ESAWY

• 24 years old male with chest pain on exertion, CT coronary angiography was done reveal an abnormal origin of the right coronary artery from the left posterior aortic sinus with inter aorto pulmonary course that is liable for compression during systole.

Dr/AHMED ESAWY

Anomalous Left Coronary

Anomalous LCA:

Either off R sinus or branches off single right coronary

Can be retroaortic, anterior or intramural but

IN MOST CASES (75%) INTERARTERIAL MALIGNANT

Dr/AHMED ESAWY

Normal Anatomy

Anomalous LCA: InterarterialISCHEMIA!!

Dr/AHMED ESAWY

Normal Anatomy Anom LCA: Retroaortic

Anom LCA: Anterior Anom LCA: Intramural Dr/AHMED ESAWY

Normal Anatomy Anom LCA: Retroaortic

Anom LCA: Anterior Anom LCA: Intramural

BENIGN!!

Dr/AHMED ESAWY

Dr/AHMED ESAWY

WHICH??

Dr/AHMED ESAWY

R sinus of Valsalva

Behind aorta to L AV groove Dr/AHMED ESAWY

R sinus of Valsalva

RETROAORTIC BENIGN!!

Behind aorta to L AV groove

Dr/AHMED ESAWY

Dr/AHMED ESAWY

WHICH??

Dr/AHMED ESAWY

Ao

RVOT

R sinus of Valsalva

Dr/AHMED ESAWY

Ao

RVOT

R sinus of Valsalva

INTERARTERIAL ISCHEMIA!!!

Dr/AHMED ESAWY

LCX with an anomalous origin, arising at the origin of the RCA, as shown in an oblique transverse thin-slab maximumintensity projection image. The LCX follows a retro-aortic course to its normal position in the left atrioventricular groove (arrows). This is a benign variant that is not associated with ischemia

Dr/AHMED ESAWY

47 year old woman with atypical chest pain: Anomalous LCA from RT coronary sinus

Dr/AHMED ESAWY

There is an anomalous origin of the LCA from the right sinus of Valsalva and the LCA courses between the aorta and pulmonary artery. This interarterial course can lead to compression of the LCA (yellow arrows) resulting in myocardial ischemia.

The other anomalies in the figure on the left are not hemodynamically significant.

Dr/AHMED ESAWY

Interarterial LCA On the left images of a patient with an anomalous origin of the LCA from the right sinus of Valsalva and coursing between the aorta and pulmonary artery. Sudden death is frequently observed in these patients.

Dr/AHMED ESAWY

ALCAPA On the left images of a patient with an anomalous origin of the LCA from the pulmonary artery, also known as ALCAPA. ALCAPA results in the left ventricular myocardium being perfused by relatively desaturated blood under low pressure, leading to myocardial ischemia. ALCAPA is a rare, congenital cardiac anomaly accounting for approximately 0.25-0.5% of all congenital heart diseases. Approximately 85% of patients present with clinical symptoms of CHF within the first 1-2 months of life.

Dr/AHMED ESAWY

Left to right shunt: septal branch of LAD teminates in right ventricle

Fistula On the image on the left we see a large LAD giving rise to a large septal branch that terminates in the right ventricle (blue arrow). Dr/AHMED ESAWY

“Myocardial Bridging”

Segment of coronary artery dives below epicardial surface, surrounded by myocardium

In some cases the buried segment significantly narrows during systole, thought to compromise coronary blood flow

Controversial as most coronary flow is during diastole

This finding is USUALLY BENIGN but isolated reports of clot at site of bridge leading to MI

Dr/AHMED ESAWY

Myocardial bridge over LAD

Diastole Systole

Dr/AHMED ESAWY

Myocardial bridging Myocardial bridging is most commonly observed of the LAD (figure). The depth of the vessel under the myocardium is more important that the lenght of the myocardial bridging. There is debate, whether some of these myocardial bridges are hemodynamically significant.

Dr/AHMED ESAWY