Anomalous origin of coronary arteries with an interarterial course: pictorial essay

Abstract

Coronary arteries originating from the contralateral (noncoronary) sinus and having an interarterial course, in which they run from the ascending aorta to the pulmonary trunk, is a potentially fatal anomaly. Computed tomography (CT) angiography facilitates the recognition and therapeutic planning of such anomalies because of its ability to acquire high-resolution images of the entire course of the coronary artery, as well as of the accompanying atherosclerotic involvement. The right coronary artery originating from the left coronary sinus is the most prevalent anomaly of this type and usually implies a better prognosis, the interarterial course being classified as "high" or "low", depending on whether it is above or below the level of the pulmonary valve, with consequent stratification of the risk and the treatment. However, it is known that there is a high risk of sudden death among patients with a left coronary artery of anomalous origin from the right sinus. In such cases, surgical treatment is recommended, regardless of whether there are symptoms or evidence of ischemia. Given the importance of those aspects, which can be identified on CT of the chest or CT angiography of the aorta, this pictorial essay aims to illustrate such anomalies to facilitate their recognition and description by radiologists who are not specialists in cardiac imaging.

Anomalous Interarterial Right Coronary Artery: Approach to a High-Risk Course

“…The interarterial course of the anomalous coronary is commonly associated with exercise-induced myocardial ischemia with a risk of ventricular arrhythmia and sudden cardiac death, especially during exercise [1,3]. In an interarterial course of an anomalous coronary artery, the origin is usually sharply angled and oblique leading to a slit-like ostium of the vessel which has the potential to get stretched during exercise with aortic distention, which allows further narrowing of the ostium leading to exercise-induced ischemia [2,4,6].…”

“…In an interarterial course of an anomalous coronary artery, the origin is usually sharply angled and oblique leading to a slit-like ostium of the vessel which has the potential to get stretched during exercise with aortic distention, which allows further narrowing of the ostium leading to exercise-induced ischemia [2,4,6]. The interarterial course of an anomalous coronary artery also has a risk for torsion, and this course is considered the most common course of an anomalous RCA [3][4][5][6].…”

“…The clinical presentation of an anomalous origin of RCA is variable. Anomalous coronary arteries can arise without any evidence of structural heart disease [2,3].…”

Transient numerical simulation of the right coronary artery originating from the left sinus and the effect of its acute take-off angle on hemodynamics

“…AORL is more likely to cause sudden cardiac death when the acute take-off angle is <30°, but no relationship has been found between the interarterial course length and sudden cardiac arrest (10). Many studies have analyzed data from clinical cases and autopsy reports in order to understand the risk of AORL and propose treatment options (7,(11)(12)(13)(14)(15). Some studies have simulated the hemodynamics of AORL through computational fluid dynamics.…”

Inferior Myocardial Infarction and Total AV Block in a Patient with Single Ostium in the Right Sinus of Valsava (A Rare Congenital Coronary Anomaly)

“…With exercise or physical activity, the blood flow through major vessels such as aorta and pulmonary artery as well as myocardial contractility increases, predisposing these anomalously coursing arteries for compression. [8][9][10] In nearly 15% of patients with SCA, myocardial ischemia can develop in the absence of acute (non-orthogonal) angle of take-off and kinking of the coronary artery as it exits from the aorta; c.) hypoplasia and/or stenosis of the intramural segment, particularly at the level of the valvar commissure. [6,11,12] Angiography can definitely distinguish between the intramural and the intraseptal course and the coexistence of atherosclerotic [13,14] .…”