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Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
Anomalous Coronary Arteries
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Anomalous Coronary Arteries

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  • 1. Anomalous Coronary Arteries Arthur Wong, M.D. UCSD Radiology Cardiac Rotation Presentation
  • 2. 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
  • 3. RCA
  • 4. RCA LCA
  • 5. 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
  • 6. 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
  • 7. Role for Noninvasive Imaging • Often challenging to diagnose in selective coronary angiogram (e.g. difficult to see relationship to MPA) • Limited eval of small vessels w/ echo • CT allows eval of not just arterial caliber and lumen but also their course and relationship to adjacent structures • Cardiac MRI/A may also be useful but cannot perform on pts c pacers/AICDs
  • 8. Anomalous Coronary Anatomy • ~60% cases involve the circumflex • ~40% involve the LM or RCA
  • 9. Anomalous Circumflex Artery • Anomalous circumflex: - Either off R sinus or branches off RCA - ALMOST ALWAYS RETROCARDIAC BENIGN
  • 10. Normal Anatomy
  • 11. Anomalous Circumflex: Retroaortic BENIGN Normal Anatomy
  • 12. Retroaortic Anomalous Circumflex Ao
  • 13. 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
  • 14. Normal Anatomy
  • 15. Normal Anatomy Anomalous RCA: InterarterialISCHEMIA!!
  • 16. Normal Anatomy
  • 17. Anomalous RCA: Retroaortic BENIGN Normal Anatomy
  • 18. Circulation. 1995;92:3163-3171.
  • 19. Circulation. 1995;92:3163-3171. WHICH??
  • 20. L sinus of Valslava Circulation. 1995;92:3163-3171. R AV groove
  • 21. L sinus of Valslava Circulation. 1995;92:3163-3171. R AV groove INTERARTERIAL ISCHEMIA!!!
  • 22. 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
  • 23. Normal Anatomy
  • 24. Normal Anatomy Anomalous LCA: InterarterialISCHEMIA!!
  • 25. Normal Anatomy
  • 26. Normal Anatomy Anom LCA: Retroaortic Anom LCA: Anterior Anom LCA: Intramural
  • 27. Normal Anatomy Anom LCA: Retroaortic Anom LCA: Anterior Anom LCA: Intramural BENIGN!!
  • 28. Circulation. 1995;92:3163-3171.
  • 29. Circulation. 1995;92:3163-3171. WHICH??
  • 30. Circulation. 1995;92:3163-3171. R sinus of Valsalva Behind aorta to L AV groove
  • 31. Circulation. 1995;92:3163-3171. R sinus of Valsalva RETROAORTIC BENIGN!! Behind aorta to L AV groove
  • 32. Radiology 2003; 227:201-208.
  • 33. Radiology 2003; 227:201-208. WHICH??
  • 34. Radiology 2003; 227:201-208. Ao RVOT R sinus of Valsalva
  • 35. Radiology 2003; 227:201-208. Ao RVOT R sinus of Valsalva INTERARTERIAL ISCHEMIA!!!
  • 36. “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
  • 37. Myocardial bridge over LAD Diastole Systole Radiology 2004;232:7-17.
  • 38. Conclusion • Anomalous coronary arteries are rare but potentially life-threatening & treatable causes for CP, MI & sudden cardiac death • Radiologists can play vital role in making diagnosis, provided that we are aware of it • Not difficult to diagnose once familiar with basic variations on anomalous anatomy and which are the dangerous variants
  • 39. References • Angelini P. Normal and anomalous coronary arteries: definitions and classification. Amer Heart J 1989; 117:418- 430. • Bunce NH, et al. Coronary artery anomalies: assessment with free-breathing 3-D coronary MRA. Radiology 2003; 227:201- 208. • Ghersin E, et al. Anomalous origin of RCA: diagnosis and dynamic evaluation with MDCT. J Comp Assist Tomog 2004; 28:293-294. • Post JC, et al.. MRA of anomalous coronary arteries: a new gold standard for delineating the proximal course. Circulation 1995; 92:3163-3171. • Rapp AH and Hillis DL. Clinical consequences of anomalous coronary anomalies. Coron Art Disease 2001; 12:617-620. • Uppot RN, et al. Evaluation of anomalous coronary artery anatomy using MDCT. Delaware Med J 2004; 76:165-168.

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