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Coronary Artery Anomalies: Angiographic Recognition of High Risk Richard E. Browne, MD John D. Symanski, MD
Case Presentation <ul><li>43-year-old male with longstanding history of palpitations </li></ul><ul><li>Undergoes cardiac C...
 
 
 
 
 
 
 
Coronary Artery Anomalies Pete Maravich (June 22, 1947 – January 5, 1988)
Sudden Cardiac Death in Athletes
Coronary Artery Anomalies Demonstrated by Echocardiography
 
RAO RAO
RAO
Myocardial Bridging Tunneled LAD
<ul><li>Autopsy: ~30%, Angiographically: <5% </li></ul><ul><li>Prevalent in HCM patients </li></ul><ul><li>Segment proxima...
M ö hlenkamp et al.  Circulation  2002;106:2616-22.
M ö hlenkamp et al.  Circulation  2002;106:2616-22.
High Takeoff Coronary Ostia Above Sinuses of Valsalva
LAD and CFX Arising from Separate Ostia Kimbiris D., et al.  Circulation  58:606-15, 1978 .
Retro-Aortic Left Circumflex Kimbiris D., et al.  Circulation  58:606-15, 1978 .
Retro-Aortic Left Circumflex
Absent Circumflex Super-dominant RCA
Absent Right Coronary Super-dominant Circumflex
Left Coronary Arising From PA Bland-White-Garland Syndrome Blood flows from the RCA via collaterals to the left coronary a...
Anomalous Coronary Arteries by Electron Beam Angiography Circulation.  May 27,   2003;107:2630
Anomalous RCA Takeoff From Left Coronary Sinus Kimbiris D., et al.  Circulation  58:606-15, 1978 . *The most common, poten...
Anterior Course of RCA Arising From Left Coronary Sinus
Anomalous Right Coronary Artery RCA Arising From Left Coronary Sinus
Coronary Artery Anomalies Magnetic Resonance Imaging
Left Main Arising from Right Coronary Sinus <ul><li>Subtypes : </li></ul><ul><ul><li>Anterior free-wall  course </li></ul>...
Left Main from Right Sinus Anterior Course The left main trunk arises ectopically from the right sinus of Valsalva and pas...
Left Main from Right Sinus Anterior Course
Anomalous Left Coronaries Retro-Aortic Circumflex, Anterior LAD The LAD and circumflex branches arise from the right sinus...
Anomalous Left Main Retro-Aortic The left main trunk originates from the right sinus of Valsalva and passes behind the aor...
Retro-Aortic Course of Left Main Kimbiris D., et al.  Circulation  58:606-15, 1978 . *Dot-sign posterior to aortic root
Anomalous Left Main Inter-Arterial The left main trunk arises ectopically from the right sinus of Valsalva and passes betw...
Inter-arterial Course of Left Main Arising From Right Coronary Sinus Kimbiris D., et al.  Circulation  58:606-15, 1978 . *...
Anomalous Coronary Artery <ul><li>15-year-old male soccer player </li></ul><ul><li>Syncope one year prevously (ECG normal)...
 
Left Main from Right Sinus Septal Course The left main trunk originates from the right sinus of Valsalva and passes intram...
Left Main from Right Sinus Septal Course
Anomalous Left Main Angiographic Features of Subtypes Kern, MJ. The Cardiac Catheterization Handbook, 1991
 
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Coronary anomalies 11-18-04

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Coronary anomalies 11-18-04

  1. 1. Coronary Artery Anomalies: Angiographic Recognition of High Risk Richard E. Browne, MD John D. Symanski, MD
  2. 2. Case Presentation <ul><li>43-year-old male with longstanding history of palpitations </li></ul><ul><li>Undergoes cardiac CT scan which reveals abnormal coronary calcium score and suspected abnormal origin of left coronary </li></ul><ul><li>Referred for diagnostic catheterization (echo also performed) </li></ul>
  3. 10. Coronary Artery Anomalies Pete Maravich (June 22, 1947 – January 5, 1988)
  4. 11. Sudden Cardiac Death in Athletes
  5. 12. Coronary Artery Anomalies Demonstrated by Echocardiography
  6. 14. RAO RAO
  7. 15. RAO
  8. 16. Myocardial Bridging Tunneled LAD
  9. 17. <ul><li>Autopsy: ~30%, Angiographically: <5% </li></ul><ul><li>Prevalent in HCM patients </li></ul><ul><li>Segment proximal to bridge frequently shows atherosclerotic plaque (tunnel spared) </li></ul><ul><li>Symptomatic patients may be treated with </li></ul><ul><li>β-blocker or CCB </li></ul><ul><li>Myotomy, CABG, and stenting in refractory cases </li></ul>Myocardial Bridging Tunneled LAD
  10. 18. M ö hlenkamp et al. Circulation 2002;106:2616-22.
  11. 19. M ö hlenkamp et al. Circulation 2002;106:2616-22.
  12. 20. High Takeoff Coronary Ostia Above Sinuses of Valsalva
  13. 21. LAD and CFX Arising from Separate Ostia Kimbiris D., et al. Circulation 58:606-15, 1978 .
  14. 22. Retro-Aortic Left Circumflex Kimbiris D., et al. Circulation 58:606-15, 1978 .
  15. 23. Retro-Aortic Left Circumflex
  16. 24. Absent Circumflex Super-dominant RCA
  17. 25. Absent Right Coronary Super-dominant Circumflex
  18. 26. Left Coronary Arising From PA Bland-White-Garland Syndrome Blood flows from the RCA via collaterals to the left coronary artery, and then into the pulmonary artery.
  19. 27. Anomalous Coronary Arteries by Electron Beam Angiography Circulation. May 27, 2003;107:2630
  20. 28. Anomalous RCA Takeoff From Left Coronary Sinus Kimbiris D., et al. Circulation 58:606-15, 1978 . *The most common, potentially serious coronary anomaly, accounting for 8.1% of serious coronary anomalies (25% incidence of sudden cardiac death).
  21. 29. Anterior Course of RCA Arising From Left Coronary Sinus
  22. 30. Anomalous Right Coronary Artery RCA Arising From Left Coronary Sinus
  23. 31. Coronary Artery Anomalies Magnetic Resonance Imaging
  24. 32. Left Main Arising from Right Coronary Sinus <ul><li>Subtypes : </li></ul><ul><ul><li>Anterior free-wall course </li></ul></ul><ul><ul><li>Retro-aortic course </li></ul></ul><ul><ul><li>Septal course </li></ul></ul><ul><ul><li>Inter-arterial - incidence 1:12,500 [Accounts for 60% of anomalous left main from right coronary sinus (2.8% overall coronary anomalies). Recognized association with ischemic symptoms and sudden death >50%] </li></ul></ul>
  25. 33. Left Main from Right Sinus Anterior Course The left main trunk arises ectopically from the right sinus of Valsalva and passes epicardially across the RV outflow tract.
  26. 34. Left Main from Right Sinus Anterior Course
  27. 35. Anomalous Left Coronaries Retro-Aortic Circumflex, Anterior LAD The LAD and circumflex branches arise from the right sinus of Valsalva. The LAD passes epicardially across the RVOT, and the CFX passes behind the aorta.
  28. 36. Anomalous Left Main Retro-Aortic The left main trunk originates from the right sinus of Valsalva and passes behind the aorta before dividing into the LAD and CFX branches.
  29. 37. Retro-Aortic Course of Left Main Kimbiris D., et al. Circulation 58:606-15, 1978 . *Dot-sign posterior to aortic root
  30. 38. Anomalous Left Main Inter-Arterial The left main trunk arises ectopically from the right sinus of Valsalva and passes between the aorta and pulmonary artery.
  31. 39. Inter-arterial Course of Left Main Arising From Right Coronary Sinus Kimbiris D., et al. Circulation 58:606-15, 1978 . *Dot sign anterior to aortic root
  32. 40. Anomalous Coronary Artery <ul><li>15-year-old male soccer player </li></ul><ul><li>Syncope one year prevously (ECG normal). </li></ul><ul><li>Died suddenly while running </li></ul><ul><li>Acute angle take-off of LMCA from right coronary sinus </li></ul>
  33. 42. Left Main from Right Sinus Septal Course The left main trunk originates from the right sinus of Valsalva and passes intramuscularly to the septum before reaching an epicardial position.
  34. 43. Left Main from Right Sinus Septal Course
  35. 44. Anomalous Left Main Angiographic Features of Subtypes Kern, MJ. The Cardiac Catheterization Handbook, 1991

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