Article Type : Case Report
Authors : Cakir M, Bakirci EM, Degirmenci H and Karayumak MR
Keywords : Coronary computed tomography angiography; Coronary artery anomalies; Cardiac ischemia
Nowadays, Coronary Computed Tomography
(CT) angiography with use which is one of the non-invasive imaging methods in
the exclusion of coronary artery disease an increase in the incidence of
coronary arteries has been observed. Coronary artery anomalies are the second
most common cause of sudden cardiac death, especially in young athletes.
Although 20% of patients have myocardial ischemia, syncope, ventricular
arrhythmia, sudden cardiac death, it is generally benign and asymptomatic. In
this case report, our aim is to reveal the contribution of coronary CT
angiography in the investigation of cardiac ischemia.
Coronary artery anomalies and variants are rare congenital cardiac disease. Although the frequency is below 1%, patients may become symptomatic under heavy exercise and severe emotional stress. The abnormal course of coronary arteries is divided into malignant and benign. While 51% of sudden deaths at a young age were responsible for cardiac abnormality, the most common of these was coronary artery abnormality (61%).
Table 1: Anomalous course of
coronary arteries.
Bening Course |
Malignant Course |
Prepulmonic
course |
Inter-arterial course of the left coronary artery |
Inter-arterial course of the right coronary artery | |
| |
|
Malignant coronary artery anomalies are usually seen between the pulmonary artery and aorta and are mostly demonstrated by autopsies after cardiac death in young athletes [1-5]. In this case, we present a right coronary artery patient with malignant left sinus Valsalva between the pulmonary artery and aorta (Table 1).
The 64-year-old non-smoker, with diabetes
mellitus, hypertension and previously Covid-19, was admitted to our clinic with
complaints of chest pain for 1 year according to physical stress and decreases
with rest cardiovascular classification (CCS 2). The patient was comfortable
and painless on cardiac examination. Blood pressure was 135/76 mmHg, pulse 82
beats / minute, and oxygen saturation at room air 98%. Other physical examination,
routine blood tests, chest radiography were found to be normal. There was no
abnormality in his electrocardiography. Transthoracic echocardiographic
examination revealed mild global left ventricular hypertrophic findings as
pathological findings in the patient without coronary artery disease and
cardiac catheterization. Ejection fraction was evaluated as normal. The patient
was referred to the radiology department for coronary CT angiography. The
coronary CT angiography device used in our hospital was shot with 128-slice
double detector, high voltage 70-110 kvp, 825 mass, coverage 64-0.6 mm and
rotation time 0.33 s (Brilliance-128, Siemens, and The Germany). In the
coronary CT angiography report, the right coronary artery (RCA) was observed,
leaving the left sinus from the Valsalva anteriorly between the pulmonary
artery and the aorta. In addition, there was
a middle segmented muscular bridge in the left anterior descending artery (LAD) and the circumflex was found to be normal. Diagnostic coronary angiography was performed and the malignant course of the right coronary artery was confirmed. There was also a muscular Bridger in the left anterior descending artery (LAD). A middle-aged patient without critical stenosis of his coronary arteries and severe exertional angina was discharged after conservative medical treatment. In the control examination, it was understood that it was asymptomatic and that it was beneficial from the medical conservative approach (Figures 1-3).
Figure 1: The patient’s electrocardiyography is in normal sinus rhythm.
Figure 2: The patient's Multislice CT Coronary Arteries, A and B: The right coronary artery is located between the aorta and the pulmonary artery , C and D: 3D view of the right coronary artery.
Figure 3: The image on the left shows the right coronary
artery(RCA), while the right figure shows the LAD (Left anterior descending
artery) and CX ( circumflex artery)
Malignant anomaly of the interatrial located right
coronary artery in the population is between 0.03-0.2, and it is more common
than left coronary artery anomaly. However, it is more common in left coronary
artery anomalies, ventricular arrhythmia and sudden cardiac death. The
pathophysiology of coronary artery anomalies and variants are not clearly known
[6-12]. In several hypotheses, it can be expressed as the compression of the
right coronary artery between the aorta and the pulmonary artery and the artery
being under pressure in the intramural cleft of the aorta. It is detected
incidentally in coronary artery angiography or non-invasive tests. The
treatment modality of coronary artery anomalies is still controversial in the
literature. The heart team should determine the treatment algorithm according
to the patient's symptom, age, participation in competitive sports, and the anatomy
of the coronary artery. If the patient is asymptomatic and middle-aged in the
abnormal course of the right coronary artery, conservative medical treatment,
exercise restriction and close follow-up can be kept. Although there is not
enough information in the guidelines, intracardiac defibrillator (ICD) therapy
may be considered in malign coronary artery anomalies to prevent ventricular
arrhythmia and sudden cardiac death. ?n the treatment options can be listed
surgical revascularization, percutaneous coronary intervention, and
conservative medical treatment. Among the surgical techniques, the most frequently
used roof opening method is recommended, where the intramural segment in the
aorta is opened and coronary osteal re-implantation is anatomically possible.
In addition, coronary artery bypass surgery can be considered as an
alternative. While percutaneous coronary intervention is recommended as an
alternative to surgery, there is no study demonstrating its superiority to each
other. Percutaneous coronary intervention mortality was found to be less than
15% at 5-year follow-up.
Although it is a rare pathology, malignant anomalies
and variations of coronary arteries should be kept in mind in patient groups
with myocardial ischemia. Coronary CT angiography, which is one of the
non-invasive methods, can contribute to the reduction of mortality and
morbidity in early diagnosis and treatment. In this case report, our aim was to
emphasize the importance of multislice coronary CT angiography in coronary
artery anomaly.