Arif SUNER, Hakan KAYA, Talantbek BATYRALİEV, Cemal TUNCER, Remzi YILMAZ, Ahmet AKCAY, Sedat KOROGLU, Alper NACAR, Mustafa GOKCE, Beyhan ERYONUCU

Anomalous origin of the right coronary artery from contralateral side: a series of 17 cases

Amaç: Sağ koroner arterin sol sinüs Valsalva'dan anormal çıkışı, aort ve pulmoner arter arasında seyretmesi,ateroskleroz olmaksızın göğüs ağrısına, akut miyokard enfarktüsüne ve hatta ani ölüme sebep olabilir.Özellikle genç hastalar ciddi klinik olaylar açsından risk altında olsa da, orta-ileri yaştaki hastalarda da farklıklinik seyirler gözlenebilir. Bu çalışmada, orta-ileri yaştaki hastalarda sol sinüsten Valsalva'dan çıkan sağkoroner arterin anjiyografik varyasyonları, klinik bulguları ve uzun dönem bulguları incelenmiştir.Gereç ve Yöntemler: 1999-2005 yılları arasında farklı merkezlerde koroner anjiyografi yapılan 70.850hastanın kayıtları en az iki girişimsel kardiyolog tarafından incelendi. Sağ koroner arterin ayrıntılıdeğerlendirilmesi gerektiğinde, çok kesitli bilgisayarlı tomografi de kullanıldı. Tüm hastalar ortalama 50 aytakip edildi.Bulgular: Toplam 17 hastada (%0.024) karşı taraftan çıkan sağ koroner arter tespit edildi. Bu hastaların 12(%71) sinde sağ koroner arter sol sinüs Valsalva'dan, 5 (%29) inde çıkan aortada sol sinüs Valsalva üzerindençıkmaktaydı. Sağ koroner arterin başlangıç kısmının retro-aortik seyri 2 (%12) hastada gözlenirken, 15(%88) inde inter-arteryel seyretmekteydi. Hastaların 9 (%53) unda aterosklerotik tutulum gözlenmedi. 3(%18) hastaya, bunlardan birisinin aterosklerotik tutulumu yoktu, anormal sağ koronere bağlı koroner by-pass yapıldı. Hastalardan birisine de anormal sağ koroner arter nedeniyle stent takıldı. Takip süresince 3hasta kalp dışı nedenlere bağlı olarak kaybedildi. Diğer 14 hasta olaysız olarak takip edildi.Sonuç: Sol sinüs Valsalva kaynaklı sağ koroner arter saptanan orta-ileri yaştaki hastalarda, akut koronersendrom ya da istirahat EKG'sinde iskemi olmaksızın, tıbbi tedavi uygun bir seçenektir.

Sağ koroner arterin karşı taraftan anormal çıkışı: 17 vakalık seri

Objective: Anomalous origin of the right coronary artery (RCA) from left sinus of Valsalva (LSV), coursingbetween the aorta and pulmonary artery can lead to angina pectoris, acute myocardial infarction or evensudden death in the absence of atherosclerosis. Especially young patients have the risk of serious clinicalevents, but middle-aged-to elderly patients have variable clinical courses. In this study, we presentedangiographic variations, clinical findings and long term follow-up data of RCA originating from left side inmiddle-aged-to elderly patientsMaterial and Methods: We reviewed the records of 70,850 patients undergoing coronary angiographybetween 1999-2005 years. At least two invasive cardiologists examined the angiogram of each patient. Ifnecessary, multislice computerized tomography was used for detailed investigation of the RCA. All patientswere followed up for approximately 50 months. Results: Seventeen patients (0,024%) were found to have anomalous origin of RCA from contralateral side.The anomalous RCA originated within the LSV in 12 (71%) patient, from ascending aorta above the LSV in 5(29%) patients. The retroaortic course of the initial RCA was seen in 2 (12%) patients while 15 (88%) patientsshowed interarterial course . No atherosclerotic involvement was seen in 9 (53%) patients. Three patients(18%), one of them had no atherosclerotic lesion, underwent CABG due to anomalous RCA. One patient wasalso treated by stent implantation to the anomalous RCA. Three patients died during the follow up period dueto noncardiac causes. Other 14 patients have been followed up uneventfully. Conclusion: Medical treatmentis a plausible choice of treatment in anomalous RCA originating from LSV in middle aged-to elderlypatients in the absence of ischemia on 12-lead resting ECG and/or acute coronary syndrome.

PDF

___

1) White NK, Edwards JE. Anomalies of the coronary arteries; report of four cases. Arch Pathol 1948;45(6):766-71.
2) Cheitlin MD, De Castro CM, McAllister HA. Sudden death as a complication of anomalous left coronary origin from the anterior sinus of Valsalva, A not-so- minor congenital anomaly. Circulation 1974;50(4):780- 7.
3) Roberts WC, Siegel RJ, Zipes DP. Origin of the right coronary artery from the left sinus of Valsalva and its functional consequences: analyses of 10 necropsy patients. Am J Cardiol 1982;49(4):863-8.
4) Tuncer C, Batyraliev T, Yilmaz R, et al. Origin and distribution anomalies of the left anterior descending artery in 70,850 adult patients: multicenter data collection. Catheter Cardiovasc Interv 2006;68(4):574- 85.
5) Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardovasc Diagn 1990;21(1):28-40.
6) Gol MK, Ozatik MA, Kunt A, et al. Coronary artery anomalies in adult patients. Med Sci Monit 2002;8(9):636-41.
7) Alexander RW, Griffith GC. Anomalies of the coronary arteries and their significance. Circulation 1956;14(5):800-5.
8) Wilkins CE, Betancourt B, Mathur VS, et al. Coronary artery anomalies: a review of more than 10,000 patients from the Clayton Cardiovascular Laboratories. Tex Heart Inst J 1988;15(3):166-73.
9) Vlodaver Z, Neufeld HN, Edwards JE. Coronary arterial variations in the normal heart and in congenital heart disease. New York: Academic Press; 1975.p.171.
10) Jim MH, Siu CW, Ho HH, et al. Anomalous origin of right coronary artery from the left coronary sinus: incidence, characteristics, and a systematic approach for rapid diagnosis. J interv Cardiol 2005;18(2):101-6.
11) Ceyhan C, Tekten T, Onbasili AO. Primary percutanous coronary intervention of anomalous origin of right coronary artery above the left sinus of Valsalva in a case with acute myocardial infarction. Coronary anomalies and myocardial infarction. Int J Cardiovasc Imaging 2004;20(4):293-7.
12) Maki F, Ohtsuka T, Suzuki M, et al. Myocardial ischemia induced by anomalous aortic origin of the right coronary artery in a patient with atrial septal defect. Jpn Heart J 2001;42(3):371-6.
13) Taylor AJ, Byers JP, Cheitlin MD, et al. Anomalous right or left coronary artery from the contralateral coronary sinus: high risk abnormalities in the initial coronary artery course and heterogenous clinical outcomes. Am Heart J 1997;133(4):428-35.
14) Thomas D, Salloum J, Montalescot G, et al. Anomalous coronary arteries coursing between the aorta and pulmonary trunk: clinical indications for coronary artery bypass. Eur Heart J 1991;12(7):832-4.
15)Angelini P. Coronary artery anomalies. an entity in search of an identity. Circulation 2007;115(10):1296- 305.
16) Taylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with isolated congenital coronary anomalies. J Am Coll Cardiol 1992;20(3):640-7.
17) Kaku B, Kanaya H, Ikeda M, et al. Acute inferior myocardial infarction and coronary spasm in a patient with an anomalous origin of the right coronary artery from the left sinus of Valsalva. Jpn Circ J 2000;64(8):641-3.
18) Basso C, Maron BJ, Corrado D, et al. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. J Am Coll Cardiol 2000;35(6):1493- 501.
19) Mirchandani S, Phoon CK. Management of anomalous coronary arteries from the contralateral sinus. Int J Cardiol 2005;102(3):383-9.
20) Pelliccia A. Congenital coronary artery anomalies in young patients. new perspectives for timely identification. J Am Coll Cardiol 2001;37(2):598-600.
21) Kaku B, Shimizu M, Yoshio H, et al. Clinical features on prognosis of Japanese patients with anomalous origin of the coronary artery. Jpn Circ J 1996;60(10):731-41.
22) Ghosh PK, Agarwal SK, Kumar R, et al. Anomalous origin of right coronary from left aortic sinus. J Cardivasc Surg 1994;35(1):65-70.
23) Barriales Villa R, Moris C, Lopez Muniz A, et al. Adult congenital anomalies of the coronary arteries described over 31 years of angiographic studies in the Asturias Principality: main angiographic and clinical characteristics. Rev Esp Cardiol 2001;54(3):269-81.