Interarterial course of anomalous right coronary artery: role of symptoms and surgical outcomes

Abstract

Anomalous origin of right coronary artery with interarterial course (ARCA-IA) is a risk factor for sudden death and other cardiac complications. Surgical correction remains its gold standard treatment. We describe clinical characteristics, workup, surgical techniques and outcomes of ARCA-IA at our center. A retrospective analysis of cardiovascular database was performed. From March 2005 through January 2011, 11 patients with mean age of 53 ± 18 years were diagnosed with ARCA-IA. Reported symptoms included chest pain (64%), arrhythmia [27%; i.e. atrial flutter (9%), recurrent supraventricular tachycardia (9%), ventricular tachycardia (9%)], syncope (18%), dyspnea (9%) and aborted sudden cardiac death (9%). Chest pain (n = 7) was episodic and lasted longer than 6 months before diagnosis. Initial diagnosis was made at coronary computed tomography in two patients and at cardiac catheterization in nine patients. Four patients had positive stress test and were subsequently found to have ARCA-IA at cardiac catheterization. There was no operative mortality. Surgery (bypass with ligation of native vessel or translocation and reimplantation) was performed in seven patients. Three patients refused surgery, and in one patient, surgery was not considered due to comorbidities. Symptom relief was noted in all surgical patients. At mean follow-up of 36 months, two patients had noncardiac-related deaths whereas nine were asymptomatic. There were no deaths reported in patients treated surgically. Definitive surgery is indicated in symptomatic ARCA-IA and is associated with excellent long-term outcome. RCA dominance in ARCA-IA is an adverse marker with increased symptoms; this hypothesis should be tested in larger studies.

New Application of FFRCT in Clinical Practice: Evaluation of Interarterial Anomalous Coronary Course

“…There is also an increase in rates of arrhythmia, sudden death, and acute myocardial infarction. 4,6 Sudden death is the main complication of this anatomical variant, occurring in approximately 30% of patients. 3,4,6 In these cases, the narrowing and stretching of the anomalous ostium, mainly during physical exercise and in stressful situations, with consequent reduction in coronary flow, is the substrate for potentially fatal ischemic alterations.…”

“…4,6 Sudden death is the main complication of this anatomical variant, occurring in approximately 30% of patients. 3,4,6 In these cases, the narrowing and stretching of the anomalous ostium, mainly during physical exercise and in stressful situations, with consequent reduction in coronary flow, is the substrate for potentially fatal ischemic alterations. 3,4,6 Since electrocardiogram, in most cases, does not reveal ischemic alterations, diagnosis is generally made through an incidental finding on imaging exams.…”

“…3,4,6 In these cases, the narrowing and stretching of the anomalous ostium, mainly during physical exercise and in stressful situations, with consequent reduction in coronary flow, is the substrate for potentially fatal ischemic alterations. 3,4,6 Since electrocardiogram, in most cases, does not reveal ischemic alterations, diagnosis is generally made through an incidental finding on imaging exams. 4 These exams are of great importance, especially coronary CTA, which, in addition to being a non-invasive exam with high negative predictive value, allows detailed anatomical visualization (angle of the origin, presence of intramural trajectory in the aorta, degree of ostial/proximal luminal reduction) and the correct classification in relation to the pulmonary valve plane (suprapulmonary versus subpulmonary).…”

Anomalous Aortic Origin of the Right Coronary Artery: A Case Report and Review of the Literature

“…Also, the question as to whether venous or arterial grafts provide superior outcomes still needs clarification. Although saphenous vein grafts exhibit higher resting blood flow, ITA is known to have better long-term efficacy [ 10 ] . As this anomaly is relatively uncommon, it may be difficult to conduct larger studies to directly compare each graft type and surgical technique.…”

Reimplantation for anomalous right coronary artery

“…Because of their abnormal morphology, AAORCAs tend to be longer than normal RCAs and often need to be reimplanted higher in the right coronary sinus or in the very proximal ascending aorta. 5 RCA kinking following reimplantation is a pitfall of this operation that can result from selecting a reimplantation site that is too low in the right coronary sinus. To avoid this complication, we recommend selecting the site of the proximal RCA anastomosis while the heart is beating and on cardiopulmonary bypass.…”