Hemodynamic Relevance of Anomalous Coronary Arteries Originating From the Opposite Sinus of Valsalva-In Search of the Evidence

Abstract

Coronary artery anomalies (CAA) represent a heterogeneous group of congenital disorders of the arterial coronary circulation, defined by an anomalous origin of the coronary ostium and/or vessel course. Of particular interest are anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). The interarterial variants (with the anomalous vessel situated between the great arteries) are historically called “malignant,” based on an anticipated higher risk for myocardial ischemia and sudden cardiac death (SCD), especially affecting young patients during strenuous physical activity. However, the interarterial course itself may not be the predominant cause of ischemia, but rather represents a surrogate for other ischemia-associated anatomical high-risk features. As the exact pathophysiology of ACAOS is not well-understood, there is a lack of evidence-based guidelines addressing optimal diagnostic work-up, downstream testing, sports counseling, and therapeutic options in patients with ACAOS. Therefore, treating physicians are often left with uncertainty regarding the clinical management of affected patients. This review focuses on the pathophysiologic consequences of ACAOS on myocardial ischemia and discusses the concept of the interplay between fixed and dynamic coronary stenosis. Further, we discuss the advantages and limitations of the different diagnostic modalities and give an outlook by highlighting the gaps of knowledge in the assessment of such anomalies.

Case report: Dobutamine stress intracoronary physiology and imaging to examine the functional and dynamic properties of an apparent malignant intra-arterial right coronary artery

“…Another study also added volume infusion to improve real-life exercise conditions. 10 The impact of cardiac stress on both the inter-arterial route of the RCA and myocardial ischaemia was examined by using dobutamine stress IVUS, FFR, and CFVR. Intravascular ultrasound has already proven to be highly sensitive to measure cross-sectional area of a stenosis.…”

Computed Tomography Derived Coronary Triangulated Orifice Area—Deduction of a New Parameter for Follow-up After Surgical Correction of Anomalous Aortic Origin of Coronary Arteries and Call for Validation

“…In the setting of AAOCA associated ischemia, future research should also take into account the functional (dynamic) consequences of these anatomical features and correlate CTA findings with functional evaluation at rest and during (physical) stress using a.o. intravascular ultrasound and fractional flow reserve assessment ( 32 ). Adrenalin and dobutamine infusions can be used to mimic physical exercise stress (increasing heart rate and stroke volume) according to the previously published protocols ( 32 , 33 ).…”

“…intravascular ultrasound and fractional flow reserve assessment ( 32 ). Adrenalin and dobutamine infusions can be used to mimic physical exercise stress (increasing heart rate and stroke volume) according to the previously published protocols ( 32 , 33 ). Multicenter studies with standardized preoperative and follow-up protocols are essential in this.…”

Tetralogy of fallot in addition to anomalous aortic origin of a coronary artery in a 1-year-old boy: a case report

“…All types of AAOCA are associated with increased risks of myocardial ischemia and SAD, especially in young athletes [ 8 ]. Studies have reported that the anomalous origin of RCA is more common than the anomalous origin of LCA [ 9 ], while the anomalous origin of LCA carries a higher risk of SAD [ 10 ].…”