ultima actualización
26 de octubre del 2020

10.993.659 visitantes

Origin of all three major coronary arteries from the right sinus of Valsalva: Clinical, angiographic, and magnetic resonance imaging findings and incidence in a select referral population

Kashyap B. Patel, MD, Himanshu Gupta, MD, Hrudaya Nath, MD, Raed A. Aqel, MD, Gilbert J. Zoghbi, MD, Benigno Soto, MD, Gilbert J. Perry, MD, Steven G. Lloyd, MD, PhD Kashyap B. Patel, MD, Himanshu Gupta, MD, Hrudaya Nath, MD, Raed A. Aqel, MD, Gilbert J. Zoghbi, MD, Benigno Soto, MD, Gilbert J. Perry, MD, Steven G. Lloyd, MD, PhD

Introduction

Anomalous aortic origins of the coronary arteries from sites other than their expected points of origin [i.e., right coronary artery (RCA) from other than the right sinus of Valsalva; left main coronary artery (LMCA) or individual left anterior descending (LAD), or left circumflex (LCF) arteries from other than the left sinus of Valsalva] are well-known clinical entities. In large case series, such anomalies have been reported to occur in 0.3-0.6% of patients referred for cardiac catheterization [[1-5]]. Certain origins and courses are relatively common, while others are rare. Likewise, certain origins and courses are thought to be associated with increased risk of myocardial ischemia, infarction, or sudden death, while others are generally considered benign. The pattern most often thought to be associated with increased clinical risk is that of an ectopic coronary artery arising from an inappropriate sinus of Valsalva (i.e., RCA from the left or LMCA from the right sinus of Valsalva) and passing in the space between the aorta and pulmonary trunk [[5]]. Coronary arteries that pass anterior to the pulmonary trunk, posterior to the aorta, or in the interventricular septum are usually considered benign. Thus, it is important for the angiographer performing cardiac catheterization to recognize the presence and the proximal courses of these anomalous coronary arteries (ACA) during selective coronary angiography, in order to estimate the clinical risk and plan subsequent management of the anomaly. In those cases where the angiographer is not confident of the course of the ACA from angiography alone, referral for cardiac magnetic resonance imaging (MRI) or computed tomographic (CT) angiography might be helpful [[6-8]]; each of these imaging modalities has advantages, with modern CT scanners having excellent spatial resolution and MRI requiring no iodinated contrast or radiation exposure.

ACA with separate RCA, LAD, and LCF all arising from individual ostia in the right sinus of Valsalva has been described as exceedingly rare [[9]], and for the most part only isolated case reports exist in the literature. We report here the results of coronary angiography and cardiac MRI in seven patients referred to our MRI facility for evaluation of the proximal course of an ACA. In each patient, the RCA, LAD, and LCF had distinct and separate ostia in the right sinus of Valsalva, with the LCF and LAD coursing separately to the left side of the heart. This represents the largest series of such cases ever reported and is the first to provide a detailed, systematic analysis of the anatomic pathways these ACAs take by conventional angiography and cardiac MRI. We also report the clinical presentations of these patients and determine the incidence of this pattern of ACA in our referral population. Finally, we review the existing literature on this set of anomalies.

Methods

Patient Population

We retrospectively reviewed our cardiac MRI database for ACA cases evaluated at our institution over the 6-year period between January 2000 and December 2005. These patients were referred for cardiac MRI for further evaluation of ACA recognized during conventional catheter-based coronary angiography; none was known to have ACA prior to angiography. Patients whose RCA, LAD, and LCF originated from three distinct and separate ostia in the right sinus of Valsalva were identified. The study was approved by the local institutional review board.

Definitions of Coronary Arteries and Nomenclature Used

The RCA was defined as the coronary artery that lies in the right (anterior) atrioventricular sulcus, with the LCF defined as the artery lying in the left (posterior) atrioventricular sulcus. The LAD was defined as the vessel lying in the anterior interventricular groove and coursing towards the cardiac apex. An artery positioned between the left atrioventricular sulcus and the anterior interventricular groove and coursing towards the lateral (obtuse) margin of the left ventricle was defined as an obtuse marginal artery if it arose directly from the aorta or from the LCF, or a diagonal artery if it arose from the LAD. The proximal pathways of the vessels are defined as follows [[10]]: A course anterior to the pulmonary artery or right ventricular outflow tract was designated as prepulmonary; a course posterior to the aorta as retroaortic; a course between the great vessels as interarterial; and a course through the interventricular septum as septal. We applied the strict anatomic definition of the interarterial course, which means that an interarterial vessel passes between the aorta and the pulmonary trunk proper (i.e., cranial to the pulmonic valve). The septal course includes all pathways in which the ACA lies anterior to the aorta, but caudal to the pulmonic valve. Such vessels can be either tunneled in the muscular septum or can lie between the aorta and the right ventricular infundibulum.

Coronary Angiography

Cardiac catheterization was performed by the referring cardiologists using the Judkins technique. The cineangiograms were performed in multiple projections and were recorded on a compact disc using the DICOM format. The pathways of the coronary arteries were determined using the systematic methods as described by Ishikawa and Brandt [[10]] and Serota et al. [[11]]. The coronary angiograms were available for our review in 6 of the 7 patients. In the remaining patient, the cineangiogram was recorded on film and the film could not be found; the angiography report was obtained and the origin and course of the ACAs were clearly described in this report, and cardiac MRI performed at our institution was carefully reviewed and corroborated the origin and courses identically as described by the angiographer.

MRI

Cardiac MRI was performed on either a 1.5 Tesla scanner (CV/i, GE Healthcare, Milwaukee, WI) or a 3.0 Tesla scanner (Intera; Philips Medical Systems, Best, The Netherlands), both designed for cardiac studies, and made use of a combination of black-blood spin-echo imaging and bright-blood gradient echo methods with Cartesian and/or spiral k-space trajectories. Spin echo imaging was performed within a single breath hold for each imaging plane while the bright-blood gradient echo imaging made use of a respiratory navigator method to track the motion of the right hemidiaphragm with images obtained at end-expiration. Black-blood spin echo images were a two-dimensional acquisition with slice thickness 5-8 mm while the respiratory-gated gradient echo images were a three-dimensional acquisition using up to 60 slices with typical thickness of 1.5 mm. All images were obtained with ECG gating. In one patient (patient 5) who presented with a non-ST-segment myocardial infarction, additional MRI was performed 10 min following intravenous infusion of 0.1 mmol/kg gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA; Magnevist, Berlex, Wayne, NJ), with a gradient echo inversion-recovery technique to delineate myocardial scar by delayed enhancement imaging [[12]]. One patient (patient 3) ultimately did not undergo MRI due to imbedded ferromagnetic shrapnel. The two- and three-dimensional images were obtained in multiple planes and the images analyzed by cardiologists and/or radiologists with experience in cardiovascular MRI.

Results

Of the 42 patients with ACA referred for cardiac MRI evaluation over the 6-year period from 2000 through 2005, 7 patients (17%) had the three major coronary arteries arise from separate ostia in the right sinus of Valsalva. The pertinent clinical information is shown in Table I. Three patients were female. The mean group age was 49 years (range 36-62 years). The RCA arose from the right sinus of Valsalva and followed the usual pathway to the right atrioventricular sulcus in all patients (Figs. 1A, 2, 3C, and 4A). The LAD course was anterior to the pulmonary artery or the right ventricular outflow tract in four cases (Figs. 1C and 4A) and along the interventricular septum in three cases (Figs. 2 and 3A). The course of the LCF was posterior to the aortic root in all seven patients (Figs. 1B, 2, 3B, and 4A). The three major coronary arteries arose from the right sinus of Valsalva in all cases, but two patients also had marginal arteries arising from the left sinus of Valsalva (Fig. 1D) and coursing toward the lateral wall or obtuse margin of the heart; however, none of these vessels arising from the left sinus of Valsalva met the criteria for designation as an LAD or LCF. Four patients had no angiographically significant atherosclerotic coronary artery disease (CAD); one had only mild nonobstructive single vessel disease and two had severe CAD, defined as greater than 50% diameter stenosis in a major coronary artery (Fig. 3). Of the patients with severe CAD, patient 3 was deemed a poor candidate for percutaneous or surgical revascularization and therefore was managed medically, and patient 5 underwent surgical revascularization. Cardiac MRI was performed in six patients and the results corroborated the course of the ACAs as determined by angiography. Delayed contrast enhancement with Gd-DTPA confirmed myocardial infarction (diagnosed by elevated cardiac troponin I) and delineated the infarct area in patient 5 (Fig. 4).

Figure 1.
Conventional coronary angiograms of patient 2. (A) RCA (left anterior oblique projection); (B) LCF (left anterior oblique projection); (C) LAD (left lateral projection); (D) obtuse marginal (left anterior oblique projection).

Figure 2.
Conventional coronary angiogram of patient 4, right anterior oblique projection. Abbreviations as in the text, except for: C, catheter; pa-c, pulmonary artery catheter; SA, septal artery.

Figure 3.
Conventional coronary angiograms of patient 3. (A) LAD in the right anterior oblique projection. Note the filling of the posterior descending artery by collaterals (arrows). (B) LCF in the left anterior oblique projection. Inset depicts the severe ostial and proximal atherosclerotic stenosis of the vessel. (C) RCA in the left anterior oblique projection. The vessel is occluded.

Figure 4.
(A) Conventional coronary angiogram of patient 5 in the left anterior oblique projection. The ostia of the three vessels are very near each other and all three vessels are opacified. LCF and RCA are indicated; arrow points to severe stenosis (sten) in the LAD prior to the origin of the diagonal artery. Pulmonary artery catheter indicated (pa-c). (B) ECG-gated, inversion recovery gradient echo MRI at 1.5 Tesla, 12 min following infusion of Gd-DTPA as described in the text, 3 days after presentation with myocardial infarction. The image is a short axis view of the left ventricle obtained at the distal ventricle level. Arrowheads indicate the bright region of late contrast enhancement in the anterior septum and anterior wall corresponding to myocardial scar. LV, left ventricular cavity; IW, inferior wall, LW, lateral wall, S, interventricular septum. Scan details: field of view 40 cm, matrix size 256 × 192; Repetition time 7 ms, echo time 3.1 ms, inversion time 200 ms; flip angle 20°, two signal averages.

Table I. Clinical Information of the Seven Patients

Case no. Age (yr) Sex Clinical presentation LAD course LCF course Atherosclerotic coronary artery disease Comments
1 45 F Chest pain, abnormal MPI PP RA None -
2 36 M Chest pain PP RA LCF - mild diffuse disease Single vessel off the LSV giving rise to a septal and marginal artery
3 62 M Chest pain, abnormal MPI S RA LAD - mid 85% stenosis -
LCF - ostial 75% stenosis
RCA - proximal 100% occlusion
4 59 F Chest pain S RA None -
5 45 F NSTEMI PP RA LAD - distal 80% stenosis Single vessel off the LSV giving rise to a marginal artery
6 50 M Palpitations, abnormal SE PP RA None -
7 44 M Chest pain, syncope S RA None -
PP, prepulmonary; IA, interarterial; RA, retroaortic; S, septal; LSV, left sinus of Valsalva; NSTEMI, non-ST segment elevation myocardial infarction; MPI, myocardial perfusion imaging; SE, Stress echocardiography.

Discussion

This study represents the largest reported series of a grouping of coronary artery anomalies in which the LAD and LCF arise from the right sinus of Valsalva and take separate paths to the left side of the heart. Furthermore, it is the only report providing a systematic analysis of the origins and proximal pathways of these vessels in multiple patients using both conventional angiography and MRI. The incidence in this referral population was much greater than previously reported in the literature.

A MEDLINE database search and review of the literature revealed at least 27 reported cases of patients with all three major coronary arteries arising from the right sinus of Valsalva via separate or common ostia in normally formed hearts with the LAD and LCF taking separate pathways to the left side of the heart (Table II). Yamanaka and Hobbs published the largest series of anomalous coronary arteries from consecutive coronary angiograms [[2]], and in their series, at least one case of this pattern was reported (see Fig. 8I-J of their paper). However, the incidence of this pattern, which they refer to as combined-type, was not listed. They did report that the incidence of a left main coronary artery or an LAD with an interarterial pathway was rare, while the septal pathway was most common out of a total of 60 cases of left main coronary artery or LAD arising from the right sinus of Valsalva in their series.

Table II. Reported Cases of Similar Anatomy From the Literature

Report No. of patients Clinical presentation LAD course LCF course No. of ostia in the LSV Atherosclerotic coronary artery disease
Ogden [[13]] 2 NS PP RA - NS
Page et al. [[14]] 1 Angina NS NS - Atherosclerosis of LAD, RCA
Cheitlin et al. [[15]] 2 NS NS NS - NS
Engel et al. [[16]] 4 NS "anterior"a RA - NS
Click et al. [[1]] 3 NS NS NS - NS
Virmani et al. [[17]] 2 1-sudden death S RA 0 b
1-MVC, sepsis S RA 0
Yamanaka and Hobbs [[2]] c NS NS NS - Severe atherosclerosis of RCA, moderate of LAD
Topaz et al. [[3]] 1 Angina NS NS - NS
Pollack et al. [[18]] 1 Atypical angina, Abnormal MPI IA RA - -
Bartorelli et al. [[9]] 1 Atypical angina, Abnormal MPI PP RA - Atherosclerosis of RCA
Warner et al. [[19]] 1 Acute MI; anteroapical WMA NS NS 1 No atherosclerosis
Chang et al. [[20]] 1 Atypical angina PP RA 1 -
Grodman et al. [[21]] 1 Acute MI, post-infarction angina; abnormal MPI IAd Sd - Moderate atherosclerosis of RCA
Rahmatullah et al. [[22]] 1 Atypical angina NS NS - Atherosclerosis of RCA
Lauer and Ritchie [[23]] 1 Dyspnea, Abnormal MPI PP RA -
La Vecchia et al. [24[]] 1 Atypical angina PP RA - -
Harikrishnan et al. [[4]] 1 NS NS NS - NS
Ozeren et al. [[25]] 1 Angina, abnormal MPI "anterior"e "anterior"e - none
Nair et al. [[26]] 1 TIA PP RA 1 -
Miyoshi et al. [[27]] 1 Angina IA PPf - -
Bush et al. [[28]] 1 Dyspnea PP RA - -
   NS, not stated; PP, prepulmonary; IA, interarterial; RA, retroaortic; S, septal; LSV, left sinus of Valsalva; MI, myocardial infarction; TIA, transient ischemic attack; MPI, myocardial perfusion imaging; MVC, motor vehicle crash.
   a Angiogram from one patient is shown in the right anterior oblique view (Fig. 5 of their paper) and suggests the LAD has a septal path.
   b The patient with sudden death was found to have a healed posterior subendocardial infarction and severe atherosclerotic disease of all coronary arteries; the other patient died of noncardiac causes.
   c Number of such cases not given in the report; at least one angiogram depicted.
   d The patient had a common ostium for origin of all coronary arteries, with moderate RCA stenosis; see text for further details.
   e See text for details of the course of these vessels.
   f Angiogram reveals a prepulmonary vessel but it is unclear whether it is best described as the LCF.

 

The largest prior case series in which this pattern of ACA origins and pathways was described in multiple patients is from Engel et al. [[16]], who reviewed 4,250 coronary angiograms and found four cases of all three coronary arteries arising from the right sinus of Valsalva. In all, the LCF course is described as posterior and the LAD as anterior to the aortic root. Figure 5 of their paper depicts angiograms of one patient in which the LCF takes a retroaortic course and the LAD takes a course that appears to be along the interventricular septum. In a report of coronary anomalies from the Coronary Artery Surgery Study, Click et al. [[1]] performed a detailed review of 24,959 patients and reported three cases of all three coronary arteries arising from separate ostia in the right sinus of Valsalva, but the proximal courses of the arteries were not reported. Figure 4 of this paper depicts the angiograms of one such patient, and the courses are described in the figure legend as being a retroaortic LCF and an interarterial LAD. Ogden [[13]] and Virmani et al. [[17]] both published reports describing two patients with these anomalies.

The remaining reports in the literature are all single cases. Harikrishnan et al. [[4]] reviewed 7,400 coronary angiograms and found one such case. In a review of 13,010 consecutive coronary angiograms, Topaz et al. [[3]] found one patient (out of 80 total cases of anomalous coronary arteries) with this configuration.

Of the reported cases, three included a single vessel arising from the left sinus of Valsalva in addition to the three vessels from the right sinus of Valsalva [[19][20][26]]. It is important for the angiographer to recognize that these vessels are accessory arteries, and not the main coronary artery, for if these vessels are mistaken for the LAD or LCF the catheterization procedure might be prematurely terminated prior to visualization of the coronary vessel being sought. In our series, two of the seven patients had a similar vessel originating from the left sinus of Valsalva. The nomenclature used to describe these vessels varies, but they are all relatively small vessels that supply the proximal lateral and possibly septal walls. Chang et al. [[20]] reported a case similar to our patients 2 and 6, with the RCA, the LCF, and a long LAD (which reached the left ventricular apex) arising from the right sinus of Valsalva with a short LAD proper (which did not reach the apex) arising from the left sinus of Valsalva. The long LAD followed a prepulmonary course, while the LCF followed a retroaortic course. Nair et al. [[26]] reported a case with the LCF taking a retroaortic course, the LAD taking a prepulmonary course, and an artery from the left sinus of Valsalva described as a ramus intermedius giving off septal arteries.

Several reports deserve mention because of the unusual paths in which the anomalous coronaries were found to take. Miyoshi et al. [[27]] described a patient with an LAD following an interarterial course and the LCF a course anterior to the pulmonary artery. The LCF has never previously been described in a prepulmonary course. Figures 2 and 3 of their paper reveal a vessel anterior to the pulmonary artery, but it is not apparent whether it reaches the left atrioventricular sulcus, and the vessel they label as the LAD is not clearly seen to reach the apex. Another unusual case was reported by Grodman et al. [[21]], who showed angiograms from a patient with an LAD from the right sinus of Valsalva with a course described as interarterial and a vessel they label as the LCF from the right sinus of Valsalva with a septal course. Figure 1 of their paper shows this vessel and it clearly takes a caudal initial course, gives off a septal artery, and its branches appear to reach the lateral margin of the left ventricle, but it is unclear whether this vessel actually lies in the left atrioventricular sulcus, the requirement for designation as a LCF. However, the vessel they label as LAD does course towards the apex in the anterior interventricular groove, supporting their argument. This is notable because the LCF has not been otherwise reported to take a septal course.

The continued publication of such single case reports implies that this constellation of ACAs (i.e., separate LAD and LCF arising from the right sinus of Valsalva in a single patient) is very rare. In fact, the scarcity of this grouping of ACAs is often mentioned in the case reports themselves. In our experience of patients referred for MRI evaluation of the proximal path of ACAs, however, this arrangement of ACAs is not rare, making up 17% of all such referrals to our institution over a 6-year period. While this is certainly more common than the literature would suggest, it is important to point out that our experience is subject to referral bias, as easily identifiable or less interesting ACAs may not be referred as frequently for further imaging by the cardiologists initially performing coronary angiography, and making our apparent incidence considerably higher than that in the general population or even the population with ACAs. To better understand the true incidence of this constellation of anomalies in our overall patient population, and to remove the effect of referral bias, we investigated the referral pool of patients. We did not have access to information on all patients undergoing catheterization by referring physicians, as these patients were referred from throughout our state and neighboring states. However, we did have access to a complete research database from the cardiac catheterization laboratories of two of the referring institutions. Of our total of seven patients with this anomaly referred for MRI evaluation, one patient from each of these institutions was referred. One additional case of this constellation of anomalies from one of these centers was noted during the interval of our study; this patient was not referred for MRI. From these two institutions, a total of 16,109 different patients underwent diagnostic coronary angiography during the period from 1999 through 2005. Out of these, 97 had aberrant origins of the major coronary arteries, for a total of 0.6% incidence in the population, in line with prior reports. This anatomy therefore represented 3 out of 97 anomalies, or 3.1%. This is significantly lower than that found in our selected population referred for MRI evaluation, but is somewhat higher than the reported incidence of the study by Topaz et al. [[3]], and is frequent enough that the practicing cardiologist should be aware of this kind of anomaly. This knowledge is important for the performance of coronary angiography, since many, if not most, anomalous coronary arteries can be defined from the conventional angiograms if proper and sufficient selective views are obtained. The cardiologist should make every effort to selectively opacify each coronary artery, making knowledge of the possible combinations of anomalies important.

Anomalous coronary arteries have been associated with increased risk of myocardial ischemia, infarction, and sudden cardiac death. Most often this increased risk is thought to be associated with an interarterial course of the ACA; however, myocardial injury or ischemia has occasionally been reported with courses typically thought of as benign [[19][29][30]]. Increased risk of myocardial injury is thought to result from several different etiologies including a narrowed or slitlike ostium of the vessel, acute angle of takeoff, or an interarterial course. An interarterial course of a left main coronary artery or LAD arising from the right sinus of Valsalva is reported to be rare in large case series [[2]]; consistent with this, none of our cases had an interarterial vessel. Two cases in our series were discovered to have severe coronary atherosclerotic disease, of which one presented with non-ST segment elevation myocardial infarction and one with unstable angina. The RCA (with a normal origin and course) was severely diseased in one. Of the cases in the literature with reported coronary atherosclerosis, all had involvement of the normally coursing RCA [[9][14][17][22]]. Whether this finding is of significance is unclear, but it is important to realize that patients with ACA are also subject to atherosclerotic disease, and that any symptoms might be attributable to atherosclerosis instead of (or in addition to) the ACA.

Conclusions

The constellation of a normally arising RCA with ectopic LAD and LCF all arising from separate ostia in the right sinus of Valsalva is frequently said to be very uncommon, but the growing number of case reports and our experience in the current study suggest that this anomaly might not be as rare as previously thought. Among the population referred to our Cardiovascular MRI facility for determination of the proximal course of ACAs, this arrangement represented 17% of all referred cases. Cardiologists should be aware of this pattern of anomalies in order to plan the most appropriate treatment for the patient. References

References

  1. Click RL,Holmes DRJ,Vlietstra RE,Kosinski AS,Kronmal RA. Anomalous coronary arteries: Location, degree of atherosclerosis and effect on survival - A report from the Coronary Artery Surgery Study. J Am Coll Cardiol 1989; 13: 531-537.
  2. Yamanaka O,Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Catheter Cardiovasc Diagn 1990; 21: 28-40.
  3. Topaz O,DeMarchena EJ,Perin E,Sommer LS,Mallon SM,Chahine RA. Anomalous coronary arteries: Angiographic findings in 80 patients. Int J Cardiol 1992; 34: 129-138.
  4. Harikrishnan S,Jacob SP,Tharakan J,Titus T,Kumar VKA,Bhat A,Sivasankaran S,Bimal F,Moorthy KMK,Kumar RP. Congenital coronary anomalies of origin and distribution in adults: A coronary arteriographic study. Indian Heart J 2002; 54: 271-275.
  5. Angelini P,Velasco JA,Flamm S. Coronary anomalies: Incidence, pathophysiology, and clinical relevance. Circulation 2002; 105: 2449-2454.
  6. Bunce NH,Lorenz CH,Keegan J,Lesser J,Reyes EM,Firmin DN,Pennell DJ. Coronary artery anomalies: Assessment with free-breathing three-dimensional coronary MR angiography. Radiology 2003; 227: 201-208.
  7. Datta J,White CS,Gilkeson RC,Meyer CA,Kansal S,Jani ML,Arildsen RC,Read K. Anomalous coronary arteries in adults: Depiction at multi-detector row CT angiography. Radiology 2005; 235: 812-818.
  8. Schmid M,Achenbach S,Ludwig J,Baum U,Anders K,Pohle K,Daniel WG,Ropers D. Visualization of coronary artery anomalies by contrast-enhanced multi-detector row spiral computed tomography. Int J Cardiol 2006; 111: 430-435.
  9. Bartorelli AL,Capacchione V,Ravagnani P,Pepi M. Anomalous origin of the left anterior descending and circumflex coronary arteries by two separate ostia from the right sinus of Valsalva. Int J Cardiol 1994; 44: 294-298.
  10. Ishikawa T,Brandt PWT. Anomalous origin of the left main coronary artery from the right anterior aortic sinus: Angiographic definition of anomalous course. Am J Cardiol 1985; 55: 770-776.
  11. Serota H,Barth CWI,Seuc CA,Vandormael M,Aguirre F,Kern MJ. Rapid identification of the course of anomalous coronary arteries in adults: The dot and eye method. Am J Cardiol 1990; 65: 891-898.
  12. Simonetti OP,Kim RJ,Fieno DS,Hillenbrand HB,Wu E,Bundy JM,Finn JP,Judd RM. An improved MR imaging technique for the visualization of myocardial infarction. Radiology 2001; 218: 215-223.
  13. Ogden JA. Anomalous aortic origin: Circumflex, anterior descending, or main left coronary arteries. Arch Pathol 1969; 88: 323-328.
  14. Page HL,Engel HJ,Campbell WB,Thomas CS Jr. Anomalous origin of the left circumflex coronary artery: Recognition, angiographic demonstration and clinical significance. Circulation 1974; 50: 768-773.
  15. Cheitlin MD,De Castro CM,McAllister HA. Sudden death as a complication of anomalous left coronary origin from the anterior sinus of Valsalva, a not-so-minor congenital anomaly. Circulation 1974; 50: 780-787.
  16. Engel HJ,Torres C,Page HL Jr. Major variations in anatomical origin of the coronary arteries: Angiographic observations in 4,250 patients without associated congenital heart disease. Catheter Cardiovasc Diagn 1975; 1: 157-169.
  17. Virmani R,Chun PK,Rogan K,Riddick L. Anomalous origin of four coronary ostia from the right sinus of Valsalva. Am J Cardiol 1989; 63: 760-761.
  18. Pollack BD,Belkin RN,Lazar S,Pucillo A,Cohen MB,Weiss MB,Herman MV. Origin of all three coronary arteries from separate ostia in the right sinus of Valsalva: A rarely reported coronary artery anomaly. Catheter Cardiovasc Diagn 1992; 26: 26-30.
  19. Warner A,Horowitz JD. Anomalous left anterior descending coronary artery presenting with acute myocardial infarction. Aust N Z J Med 1997; 27: 594-595.
  20. Chang CJ,Cheng NJ,Ko YS,Ko YL,Chiang CW. Dual left anterior descending coronary artery and anomalous aortic origin of the left circumflex coronary artery: A rare and complicated anomaly. Am Heart J 1997; 133: 598-601.
  21. Grodman RS,Vazzana TJ,Chu TN,Satyanarayana A,Bloomfield DA. Anomalous origins of the left coronary arteries from the right sinus of Valsalva with an unusual course. Catheter Cardiovasc Diagn 1997; 42: 437-439.
  22. Rahmatullah SI,Khan IA,Nair VM,Kannan T,Vasavada BC,Sacchi TJ. Separate origins of all three major coronary arteries from the right sinus of Valsalva: A rare coronary artery anomaly. Cardiology 1998; 90: 72-74.
  23. Lauer JE,Ritchie ME. Three separate coronary artery ostia arising from the right coronary cusp: A case report. Catheter Cardiovasc Interv 2001; 52: 496-499.
  24. La Vecchia L,Favero L,Fontanelli A. Anomalous origin of left anterior descending and circumflex coronary artery from two separate ostia in the right aortic sinus. Heart 2002; 88: 322.
  25. Ozeren A,Aydin M,Bilge M,Cam F. Anomalous left coronary artery arising from the right sinus of Valsalva: A case report. Int J Cardiol 2005; 101: 491-493.
  26. Nair K,Tharakan JA,Krishnamoorthy KM. Origin of three coronary arteries from the right sinus, ramus intermedius from the left sinus and hybrid distribution. Can J Cardiol 2005; 21: 367-369.
  27. Miyoshi S,Hara Y,Shigenmatsu Y,Ohtsuka T,Ogimoto A,Ohkura T,Higaki J. Separate origins of three coronary arteries arising from the right sinus of Valsalva. Can J Cardiol 2005; 21: 451-452.
  28. Bush HS,Nolan J,Shen MH. Use of CT angiography for evaluation of 3 coronary ostia originating from the right sinus of Valsalva in a patient with hypertrophic obstructive cardiomyopathy. Tex Heart Inst J 2005; 32: 246-247.
  29. Coyle L,Thomas WJ. Anomalous left anterior descending coronary artery: Malignant hospital course of a not so benign anomaly. Catheter Cardiovasc Interv 2000; 51: 468-470.
  30. Aydin M,Ozeren A,Peksoy I,Cabuk M,Bilge M,Dursun A,Elbey MA. Myocardial ischemia caused by a coronary anomaly: Left circumflex coronary artery arising from right sinus of Valsalva. Tex Heart Inst J 2004; 31: 273-275.

Autor: Kashyap B. Patel, MD, Himanshu Gupta, MD, Hrudaya Nath, MD, Raed A. Aqel, MD, Gilbert J. Zoghbi, MD, Benigno Soto, MD, Gilbert J. Perry, MD, Steven G. Lloyd, MD, PhD Kashyap B. Patel, MD, Himanshu Gupta, MD, Hrudaya Nath, MD, Raed A. Aqel, MD, Gilbert J. Zoghbi, MD, Benigno Soto, MD, Gilbert J. Perry, MD, Steven G. Lloyd, MD, PhD

Fuente: Catheterization and Cardiovascular Interventions

Ultima actualizacion: 3 DE DICIEMBRE DE 2007

© hemodinamiadelsur.com.ar es desarrollado y mantenido por ASAP Web | Consultoria de sistemas
Acuerdo con los usuarios
Get Adobe Reader Get Adobe Flash Player