Three different situations and approaches in the management for anomalous origin of the right coronary artery from the left coronary sinus: case report

Abstract

Anomalous origin of the right coronary artery from the left coronary sinus is rare but potentially dangerous if any ischemic signs are present. Multiple therapeutic options were advocated so far. We experienced three different situations and surgical approaches to these anomalies, and reviewed retrospectively. For the first case, we made a neo-ostium on the right sinus of Valsalva and anastomosed with the right coronary artery after arteriotomy. For the second and third cases, we applied coronary artery bypasses emergently: patient 2 the gastroepiploic artery during off-pump coronary artery bypass and patient 3 the left internal thoracic artery during surgery for acute aortic dissection. For the better outcomes, it is important to understand anatomic and hemodynamic characteristics of each patient and select the surgical options considering each characteristic.

Expert consensus guidelines: Anomalous aortic origin of a coronary artery

“…Cardiac catheterization is indicated if the anatomy cannot be defined with noninvasive imaging and in adults with suspected or echocardiographically defined anomalous vessels, for both complete definition of the anatomy and concomitant evaluation for coronary atherosclerotic disease. 1,[33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52] Obviously, it is not used for routine screening in the absence of ischemic symptoms or clues from other imaging studies. The best method for initially identifying AAOCA is a carefully performed transthoracic echocardiogram with Doppler color flow mapping.…”

“…Cardiac catheterization should be performed in those individuals with anomalous origin of a coronary artery if the anatomy cannot be defined with noninvasive imaging, and in adults with risk factors for coexistent atherosclerotic coronary artery disease. (Class I, Level of Evidence B-supporting references 1,[33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52]…”

Right coronary artery anomaly originating in the contralateral sinus of Valsalva interpreted by the angiographic rapid identification method

“…Entre as diversas técnicas cirúrgicas destacam-se o procedimento de destelhamento (unroofing procedure), que representa a estratégia de escolha quando há um componente intramural do trajeto inicial; a reimplantação coronariana; a cirurgia de revascularização do miocárdio com uso de enxerto venoso ou arterial; a translocação da artéria pulmonar; e a criação de um novo óstio. 15,18,25 O tratamento conservador é advogado por alguns autores 26 em situações de negativação da isquemia em testes provocativos, após a instituição do tratamento medicamentoso, mais comumente o uso de betabloqueadores. Mais recentemente, a intervenção coronariana percutânea tem se apresentado como técnica alternativa às limitações e aos riscos do procedimento cirúrgico, com bons resultados descritos no seguimento de curto prazo.…”

“…Mais recentemente, a intervenção coronariana percutânea tem se apresentado como técnica alternativa às limitações e aos riscos do procedimento cirúrgico, com bons resultados descritos no seguimento de curto prazo. 25 O uso de stents farmacológicos e a escolha criteriosa do cateter guia, somados a outros dispositivos que proporcionem maior suporte terapêutico e o procedimento guiado por USIC, podem contribuir para sustentar o sucesso a longo prazo. 27,28…”

Surgical Treatment of Anomalous Origin of Right Coronary Artery in a Patient with Mitral Stenosis

“…Anomalous origin of the coronary artery from the opposite coronary sinus of Valsalva occurs with a very low incidence in the general population, but there is a high risk of sudden death due to myocardial ischemia and the resultant arrhythmias associated with them. Various mechanisms have been postulated to cause ischemia, including: origin in an acute angle resulting in a slit-like orifice and kinking or occlusion caused by the angulation at the point of coronary artery, coronary spasm resulting from its torsion movement, mechanical compression of the coronary artery between the pulmonary and aortic trunks during physical exertion [ 7 - 9 ]. The majority of these complications may be exacerbated during or immediately after exercise, as exercise leads to compression of coronary arteries as well as increasing the pre-existing angulation of the proximal portion of anomalous vessel.…”