Anomalous Coronary Arteries

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Anomalous Coronary Arteries

  1. 1. Anomalous Coronary Arteries Arthur Wong, M.D. UCSD Radiology Cardiac Rotation Presentation
  2. 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. 3. RCA
  4. 4. RCA LCA
  5. 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. 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. 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. 8. Anomalous Coronary Anatomy • ~60% cases involve the circumflex • ~40% involve the LM or RCA
  9. 9. Anomalous Circumflex Artery • Anomalous circumflex: - Either off R sinus or branches off RCA - ALMOST ALWAYS RETROCARDIAC BENIGN
  10. 10. Normal Anatomy
  11. 11. Anomalous Circumflex: Retroaortic BENIGN Normal Anatomy
  12. 12. Retroaortic Anomalous Circumflex Ao
  13. 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. 14. Normal Anatomy
  15. 15. Normal Anatomy Anomalous RCA: InterarterialISCHEMIA!!
  16. 16. Normal Anatomy
  17. 17. Anomalous RCA: Retroaortic BENIGN Normal Anatomy
  18. 18. Circulation. 1995;92:3163-3171.
  19. 19. Circulation. 1995;92:3163-3171. WHICH??
  20. 20. L sinus of Valslava Circulation. 1995;92:3163-3171. R AV groove
  21. 21. L sinus of Valslava Circulation. 1995;92:3163-3171. R AV groove INTERARTERIAL ISCHEMIA!!!
  22. 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. 23. Normal Anatomy
  24. 24. Normal Anatomy Anomalous LCA: InterarterialISCHEMIA!!
  25. 25. Normal Anatomy
  26. 26. Normal Anatomy Anom LCA: Retroaortic Anom LCA: Anterior Anom LCA: Intramural
  27. 27. Normal Anatomy Anom LCA: Retroaortic Anom LCA: Anterior Anom LCA: Intramural BENIGN!!
  28. 28. Circulation. 1995;92:3163-3171.
  29. 29. Circulation. 1995;92:3163-3171. WHICH??
  30. 30. Circulation. 1995;92:3163-3171. R sinus of Valsalva Behind aorta to L AV groove
  31. 31. Circulation. 1995;92:3163-3171. R sinus of Valsalva RETROAORTIC BENIGN!! Behind aorta to L AV groove
  32. 32. Radiology 2003; 227:201-208.
  33. 33. Radiology 2003; 227:201-208. WHICH??
  34. 34. Radiology 2003; 227:201-208. Ao RVOT R sinus of Valsalva
  35. 35. Radiology 2003; 227:201-208. Ao RVOT R sinus of Valsalva INTERARTERIAL ISCHEMIA!!!
  36. 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. 37. Myocardial bridge over LAD Diastole Systole Radiology 2004;232:7-17.
  38. 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. 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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