|Year : 2018 | Volume
| Issue : 3 | Page : 114-116
Anomalous left coronary artery with single ostium (Shared with Right Coronary Artery) detected by echocardiography: Two case reports
Yingjie Zhao, Yang Liu, Mengruo Zhu, Haiyan Chen, Cuizhen Pan, Xianhong Shu
Department of Echocardiography, Shanghai Institute of Medical Imaging, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China
|Date of Web Publication||24-Sep-2018|
Department of Echocardiography, Shanghai Institute of Medical Imaging, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032
Source of Support: None, Conflict of Interest: None
Anomalous aortic origin of a coronary artery (AAOCA) from the inappropriate sinus of Valsalva has received increasing attention due to its association with malignant cardiac events in otherwise healthy and asymptomatic individuals. Despite this, we still face tremendous challenges in detecting the anomalies in a timely fashion to prevent sudden cardiac death. Here, we present two cases of anomalous left coronary artery with single ostium (shared with right coronary artery); in patients with normal cardiac function. The diagnosis of AAOCA in both cases was first suspected on transthoracic echocardiography and was later established using either coronary computed tomography angiography or invasive coronary angiography. Although angiography is the gold standard for diagnosing AAOCA, echocardiography is a more frequently used imaging modality in the workup of cardiac patients.
Keywords: Computed tomography angiography, coronary artery, echocardiography, invasive coronary angiography
|How to cite this article:|
Zhao Y, Liu Y, Zhu M, Chen H, Pan C, Shu X. Anomalous left coronary artery with single ostium (Shared with Right Coronary Artery) detected by echocardiography: Two case reports. Cardiol Plus 2018;3:114-6
|How to cite this URL:|
Zhao Y, Liu Y, Zhu M, Chen H, Pan C, Shu X. Anomalous left coronary artery with single ostium (Shared with Right Coronary Artery) detected by echocardiography: Two case reports. Cardiol Plus [serial online] 2018 [cited 2019 Aug 20];3:114-6. Available from: http://www.cardiologyplus.org/text.asp?2018/3/3/114/242081
| Introduction|| |
Anomalous aortic origin of a coronary artery (AAOCA), a type of congenital coronary artery anomaly, has been under the spotlight recently because of its association with sudden cardiac death (SCD). Although our understanding of the pathogenesis of AAOCA remains incomplete, an emphasis has been placed on early detection. Most patients with AAOCA are asymptomatic and are diagnosed following SCD or sudden cardiac arrest. The lack of signs elicited through routine physical examination and electrocardiogram further adds to the difficulty in establishing the diagnosis early. Additional imaging methods including transthoracic echocardiography (TTE), invasive coronary angiography (ICA), computed tomography angiography (CTA), and/or cardiac magnetic resonance angiography (MRA) are needed for diagnosis. Here, we present two rare cases of AAOCA, found incidentally by TTE.
| Case Reports|| |
A 38 years old previously healthy man presented with chest distress without dizziness, syncope, or chest pain. He was referred to our outpatient department for further workup and treatment. Physical examinations showed no abnormalities. TTE revealed normal cardiac function with left ventricular ejection fraction of 68%. However, in the parasternal left ventricular long axis view, an r-shaped structure in front of the aortic root was detected [Figure 1]. The same structure was also identified on aortic short axis view [Figure 1]. The proximal segment of the right coronary artery (RCA) measured 4 mm and made up a part of the r-shaped structure. Moreover, there were several vascular branches arising from the root of the RCA. Only a 1–2 mm length of the left coronary artery (LCA) was seen at the left coronary sinus. Given the TTE results, we suggested the patient undergo CTA. CTA showed anomalous LCA with shared ostium with the RCA, while both coronary arteries and their branches showed no evidence of stenosis [Figure 2].
|Figure 1: Normal: In parasternal long-axis view and parasternal short-axis view, two-dimensional echocardiography showed right coronary artery originating from anterior aortic sinus as a single vessel (dotted line) Case 1 and Case 2: In parasternal long-axis and parasternal short-axis view, two-dimensional echocardiography showed the sign of artery originating from anterior aortic sinus as a single vessel (dotted line) originated from left coronary sinus was recognized as left coronary artery by mistake. AO = Ascending aortic; LA = Left atrium; LV = Left ventricular; RVOT = Right ventricular outflow track|
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|Figure 2: In computed tomography coronary angiography, three-dimensional imaging showed the coronary artery branches sharing the same ostium (arrow). RCA = Right coronary artery; LCA = Left coronary artery|
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A 64 years old man with a history of chest pain for 10 years was admitted for workup. He reported that the precordial pain persisted for several minutes, and was alleviated by taking nitroglycerin. Onset was consistently at 4–5 am and was not associated with activity or diet. The patient had no abnormalities on electrocardiogram, and blood tests were unremarkable. On TEE, an r-shaped vessel anterior to the aortic root was again demonstrated [Figure 1]. An ICA was performed and revealed no evidence of coronary vessel stenosis or plaque, but did confirm the anomalous origin of the LCA sharing an ostium with the RCA [Figure 3].
|Figure 3: In aortic root angiography, right anterior oblique projection view showed coronary artery course arising from the right aortic ostium (arrow). RCA = Right coronary artery; LCA = Left coronary artery; LAD = Left anterior descending; LCX = Left circumflex artery|
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| Discussion|| |
We present two cases of anomalous LCA with shared ostium (shared with RCA) initially suspected by TTE. In both patients, the sign of “r”-shaped vessel at the beginning of the RCA was consistent with the coronary vessel abnormality. At the same time, the proximal LCA was not clearly recognized as a bud at left coronary sinus. Although the definite diagnosis was made through CTA or ICA, TTE played an important role in the workup and suspicion of AAOCA in these cases.
CTA is the preferred imaging modality for AAOCA due to its high spatial resolution and its ability to characterize multiple AAOCA features. ICA provides high spatial and temporal resolution, along with dynamic imaging in visualizing AAOCA, but it is invasive. MRA is also widely used in diagnosing AAOCA without requiring radiation or iodinated contrast agents. However, MRA has the disadvantage of being time-consuming. The above three methods are all superior to TTE in diagnosing AAOCA.
TTE, however, is a noninvasive, easily available, and cost-effective method, and is the most common and widely used imaging technique in patients with suspected cardiac diseases. Information regarding cardiac structure, function, and hemodynamics can be obtained from TTE in a convenient way. TTE has limited accuracy in tracing the path of coronary vessels, requiring experienced physicians, and appropriate image quality. It is not difficult, however, to show the origin of RCA in the near field of parasternal longitudinal view or short axis view. In comparison, it is more difficult to show the exact origin of LCA located at the distal field of the parasternal short axis view. In the current two cases, a “bud” that originated from the left coronary sinus was mistakenly recognized as the LCA. This brings up the important point that at least a 10 mm long proximal segment should be visualized to differentiate the real LCA from the artifact. Interarterial anomalous LCA and anomalous RCA are the top two most dangerous types of AAOCA which involve an abnormality in the proximal path of coronary vessels. These cases show that it is feasible and important to carefully evaluate the origin of the LCA and RCA on echocardiography.
Several autopsy studies have indicated that most patients have no significant symptoms before SCD, thus making it difficult to identify at-risk patients antemortem. As far as therapy is concerned, there is a lack of asymptomatic patients for large-scale clinical studies, and thus controversy exists in terms of preventative therapy. Several reports suggest that surgical repair is an effective choice to relieve symptoms, leading to lower rates of SCD and moderate postoperation complications. However, other reports argue that risks of surgery outweigh benefits for asymptomatic patients.
Although the accuracy of detecting AAOCA using TTE has not been investigated, we demonstrate that TTE it is able to show the proximal coronary artery and serve as a screening option for patients with nonspecific symptoms. However, the detection of coronary artery ostia can be challenging on TTE. In addition, physicians are sometimes confused by pseudo images of distinct cardiac structures as well as the minor segment of where the vessels originate.
However, given the rarity of these cases, current guidelines do not suggest overall preparticipation cardiac screening for AAOCA in asymptomatic individuals. After all, CTA, MRA, and ICA are not routine tools in clinical practice to screen AAOCA in view of their cost, accessibility, and invasive nature.
In summary, we should spare no efforts to figure out the best way to identify at-risk individuals and which treatment is the most appropriate and effective. Here, we emphasize the importance of TTE examination during cardiovascular screening among asymptomatic individuals, and we suggest the routine use of TTE to help identify abnormalities suspicious of cardiovascular disease that can be further investigated using more accurate but invasive modalities and techniques.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jacobs ML, Mavroudis C. Anomalies of the coronary arteries: Nomenclature and classification. Cardiol Young 2010;20 Suppl 3:15-9.
Vouhé P. Anomalous aortic origin of coronary arteries: A frequent and curable cause of sudden death. Bull Acad Natl Med 2014;198:465-70.
Budoff MJ, Dowe D, Jollis JG, Gitter M, Sutherland J, Halamert E, et al.
Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: Results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 2008;52:1724-32.
Cheezum MK, Liberthson RR, Shah NR, Villines TC, O'Gara PT, Landzberg MJ, et al.
Anomalous aortic origin of a coronary artery from the inappropriate sinus of valsalva. J Am Coll Cardiol 2017;69:1592-608.
Brothers JA, Whitehead KK, Keller MS, Fogel MA, Paridon SM, Weinberg PM, et al.
Cardiac MRI and CT: Differentiation of normal ostium and intraseptal course from slitlike ostium and interarterial course in anomalous left coronary artery in children. AJR Am J Roentgenol 2015;204:W104-9.
Mirchandani S, Phoon CK. Management of anomalous coronary arteries from the contralateral sinus. Int J Cardiol 2005;102:383-9.
Mainwaring RD, Reddy VM, Reinhartz O, Petrossian E, Punn R, Hanley FL, et al.
Surgical repair of anomalous aortic origin of a coronary artery. Eur J Cardiothorac Surg 2014;46:20-6.
Liberthson RR. Management implications for anomalous aortic origin of coronary arteries. JACC Cardiovasc Imaging 2015;8:1250-1.
Maron BJ, Levine BD, Washington RL, Baggish AL, Kovacs RJ, Maron MS, et al.
Eligibility and disqualification recommendations for competitive athletes with cardiovascular abnormalities: Task force 2: Preparticipation screening for cardiovascular disease in competitive athletes: A Scientific Statement from the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015;66:2356-61.
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