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International Journal of Cardiology 74 (2000) 39–46 www.elsevier.com / locate / ijcard Primary congenital anomalies of the coronary arteries: a coronary arteriographic study Naveen Garg DM, DNB, Satendra Tewari MD, DM, Aditya Kapoor MD, DM, Deepak Kumar Gupta MD, Nakul Sinha MD, DM* Department of Cardiology, Sanjay Gandhi PGIMS, Lucknow, India Received 8 June 1999; received in revised form 1 February 2000; accepted 11 February 2000 Abstract Geographic variations in the incidence of different congenital coronary anomalies are well known, but infrequently studied in the Indian population. Among 4100 adult patients who underwent diagnostic coronary arteriography, 39 (0.95%) patients (34 males, 5 females) had one or more anomalous coronary arteries. Their mean age was 46.468.2 years (range, 26–68 years). Thirty-five (89.74%) had anomalies of origin and distribution, while the remaining four (10.25%) had coronary artery fistulae. Right coronary artery was the commonest anomalous vessel, involved in 19 (48.74%) patients. It was originating from the left sinus of Valsalva in 15 and from the non-facing aortic sinus in four patients. Anomalous left circumflex artery was the second commonest anomaly, seen in 14 (35.89%) patients. Anomalous left anterior descending artery and anomalous left coronary artery from pulmonary artery were seen in one patient each. Among patients with coronary fistulae, two had fistulae between the left anterior descending artery and the main pulmonary artery, one between the conal artery and the right atrium, while the fourth patient had fistulae from the right coronary as well as from the left anterior descending artery to the left atrium. Atherosclerotic plaques in the anomalous arteries were seen in only 13 (33.33%) patients, much less than the overall incidence of coronary artery disease in patients with congenital coronary anomalies in this series (66.66%). In four (10.25%) patients, only the anomalous vessels were involved in coronary artery disease. Thus, in a small subgroup there does not appear to be an increased risk for development of atherosclerotic coronary artery disease in anomalous coronary arteries. Recognition of coronary anomalies is important in patients undergoing coronary arteriography, coronary interventions and cardiac surgery. Variations in the frequency of primary congenital coronary anomalies may possibly have a genetic background. 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Coronary anomalies; Congenital; Coronary arteriography; Coronary artery disease 1. Introduction Primary congenital anomalies of the coronary arteries occur as isolated anomalies and are not necessarily associated with other types of congenital heart diseases [1]. These could be haemodynamically *Corresponding author. Tel.: 91-552-440-700 / 900, ext. 2223; fax: 191-522-440-973 / 440-017. E-mail address: [email protected] (N. Sinha). significant by leading to abnormal myocardial perfusion, while haemodynamically insignificant anomalies are principally those of abnormal aortic origin or distribution of coronary arteries, and myocardial perfusion is usually not altered in these individuals. Widespread application of coronary arteriography has resulted in more frequent detection of patients with anomalous coronary arteries, and their clinical significance is becoming better appreciated [2–9]. 0167-5273 / 00 / $ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 00 )00243-6 N. Garg et al. / International Journal of Cardiology 74 (2000) 39 – 46 40 Unrecognised coronary anomalies may lead to errors in clinical diagnosis and surgical problems [10–12]. When planning coronary angioplasty on anomalous coronary arteries, there is an even greater need to accurately define the origin and course of these vessels [13,14]. Certain anomalous coronary arteries are associated with sudden cardiac death, myocardial infarction and anginal syndrome [2,5,6,15,16]. Primary congenital coronary anomalies are detected in about 0.6–1.3% of adult patients undergoing coronary arteriography [2,4,6–9]. Geographic variations in the frequency of different coronary anomalies are well known [7,17–21]. There is paucity of Indian data on this aspect. In this report we present our experience with primary coronary anomalies detected during routine coronary arteriography. diagnostic coronary arteriography during the study period. Thirty-nine patients had primary congenital coronary anomalies. The indication for arteriography was evaluation of coronary artery disease in all the patients. 3.2. Incidence The incidence of primary coronary anomalies was 0.95% (39 out of 4100 patient) in our angiographic population. Thirty-five (89.74%) patients had anomalies of origin and distribution, while four (10.25%) had coronary artery fistulae (Table 1). There were 34 (87.17%) males and only five (12.85%) females. The mean age was 46.468.2 years (age range, 26–68 years). 3.3. Classification 2. Material and methods We reviewed the database of our cardiac catheterisation laboratory. All patients who underwent coronary arteriography from January 1990 to December 1998 were included. Informed consent was obtained from each patient. The catheterisation reports were analysed, and those with anomalous coronary arteries were selected for further assessment. Angiograms were reviewed by at least two experienced independent observers, who reached a consensus on the origin and course of the anomalous coronary arteries. Patients with separate origin of conus artery from right sinus of Valsalva, separate ostia for left anterior descending artery and left circumflex artery in left sinus of Valsalva and high ‘take-off’ of coronary arteries were excluded. Patients with coronary anomalies occurring as part of congenital heart disease were also not included in this study. Patients were categorised as having single, double or triple vessel disease when a significant lesion (defined as more than 50% narrowing of intraluminal diameter) was present in one or more coronary arteries or in a major branch [7]. 3. Results 3.1. Patient population The study included 4100 patients who underwent Table 2 depicts incidence of different coronary anomalies in our angiographic population. 3.3.1. Anomalous right coronary artery Anomalous right coronary artery was the commonest coronary anomaly and was present in 19 (48.71%) patients with angiographic incidence of 0.46%. In 15 patients, this vessel originated from left sinus of Valsalva and coursed between the aorta and the pulmonary artery (Fig. 1). In four patients it originated from the non-facing aortic sinus and coursed retroaortically (Fig. 2). Final distribution was normal in all cases. Origin and distribution of the left coronary artery was normal in all these cases. 3.3.2. Anomalous left circumflex coronary artery The second commonest anomaly was an anomalous left circumflex coronary artery, and was present in 14 (35.89%) patients with angiographic incidence Table 1 Incidence of congenital coronary anomalies (n54100) Total coronary arteriograms Total coronary anomalies Anomalies of coronary origin and distribution Coronary artery fistulae Number of patients Angiographic incidence (%) Anomaly incidence (%) 4100 39 35 0.95 0.85 89.74 4 0.09 10.25 N. Garg et al. / International Journal of Cardiology 74 (2000) 39 – 46 41 Table 2 Incidence of different congenital coronary anomalies in angiographic population (n54100)a Serial Number Coronary anomaly Number of patients (n539) Angiographic incidence (%) Anomaly incidence (%) (A) Anomalies of origin and distribution Anomalous origin of RCA from LCS / NAS Anomalous origin of LCX from RCS / RCA Anomalous LAD from RCS ALCAPA 35 0.85 89.74 19 0.46 48.74 14 0.34 35.89 1 0.02 2.56 1 0.02 2.56 Coronary artery fistulae 4 0.09 10.25 1. 2. 3. 4. (B) a RCA, right coronary artery; LCS, left coronary sinus; NAS, non-facing aortic sinus; LCX, left circumflex artery; RCS, right coronary sinus; LAD, left anterior descending artery; ALCAPA, anomalous left coronary artery from pulmonary artery. of 0.34%. It originated from the right sinus in 12 patients (Fig. 3) and from the right coronary artery in two patients. Its initial course was retroaortic in all cases. Peripheral distribution of the left circumflex artery was normal in all of them. The left anterior descending coronary artery in all of them originated from a separate ostium in the left sinus and had a normal distribution. 3.3.3. Anomalous left anterior descending coronary artery Anomalous left anterior descending coronary artery Fig. 1. Left anterior oblique view showing anomalous right coronary artery originating from the left coronary sinus near the origin of the left coronary artery. Note the position of the Amplatz catheter tip between the ostia of the right and left coronary artery. 42 N. Garg et al. / International Journal of Cardiology 74 (2000) 39 – 46 Fig. 2. Left anterior oblique view showing anomalous right coronary artery originating from non-facing aortic sinus. Note the abnormal hooking position of the Amplatz catheter. was present in one (2.56%) patient with angiographic incidence of 0.02%. This anomalous left anterior descending artery was originating from the right sinus and coursing anterior to the right ventricular outflow tract with normal peripheral distribution. The left circumflex artery was originating from the left sinus through separate ostium with normal peripheral distribution. 3.3.4. Anomalous left coronary artery from pulmonary artery Anomalous left coronary artery from pulmonary artery (ALCAPA) was present in one (2.56%) patient with angiographic incidence of 0.02%. During coronary arteriography, the left coronary artery could not be hooked while the right coronary artery was grossly dilated. The left coronary artery filled retrogradely through the right coronary artery and was draining into the main pulmonary artery. Coronaries were free of atherosclerotic coronary artery disease. On oximetry, there was no significant step-up. 3.3.5. Coronary artery fistulae Coronary artery fistulae were present in four (10.25%) patients with angiographic incidence of 0.09%. In two patients fistulae were present between the proximal left anterior descending artery and the main pulmonary artery (Fig. 4). In one patient there was a fistulous connection between the conal artery and the right atrium. This conal artery was originating separately from the right sinus and was connected to the right atrium through an atrial branch. The fourth patient had multiple small fistulae from the proximal left anterior descending artery as well as from the proximal right coronary artery to the left atrium. There was no significant step-up on oximetry in any case. 3.4. Coronary artery disease in anomalous coronaries Table 3 depicts incidence of atherosclerotic coronary artery disease in patients with coronary anomalies. The overall incidence was 66.66% (26 of N. Garg et al. / International Journal of Cardiology 74 (2000) 39 – 46 43 Fig. 3. Left anterior oblique view showing an anomalous left circumflex artery originating from the right coronary sinus traversing in a retroaortic course. Note the severe coronary stenosis in its proximal part. 39 patients). The anomalous coronary arteries were involved in coronary artery disease in 33.33% (13 of 39 patients). Coronary artery disease was restricted to anomalous vessel in only four (10.25%) patients — two of the anomalous left circumflex and one each of the anomalous right coronary artery and the anomalous left anterior descending coronary artery. Out of 19 cases of anomalous right coronary artery, six (31.57%) had significant coronary artery disease in the anomalous vessel, while this was 28.57% (four of 14 patients) for patients with anomalous left circumflex artery. Proximal segment was involved in three (15.78%) patients with anomalous right coronary artery and three (21.42%) with anomalous left circumflex artery. The solitary patient with anomalous left anterior descending artery had coronary artery disease restricted to the anomalous vessel only. There was only one patient with anomalous left coronary artery from the pulmonary artery (ALCAPA), and he was free from coronary artery disease. Out of four patients with coronary artery fistulae, three had obstructive coronary artery disease and out of these three patients two had coronary artery disease in the vessels involved in fistulous connections (both left anterior descending artery to main pulmonary artery), while in none of them coronary artery disease was restricted to the left anterior descending coronary artery. 4. Discussion We found an overall incidence of 0.95% among patients undergoing diagnostic coronary arteriography; this is in agreement with 0.6–1.3% incidence as reported in different series [2,4,6–9]. More men than women had anomalous coronaries, possibly because more angiograms were done in male patients. However, it is to be noted that we have not included patients with congenital heart disease and patients with common innocuous variations in the coronary arterial pattern (separate conal artery, separate ostia for left anterior descending and left circumflex artery and high ‘take-off’ of coronary arteries). These N. Garg et al. / International Journal of Cardiology 74 (2000) 39 – 46 44 Fig. 4. Left coronary angiogram in right anterior oblique view showing coronary artery fistulae in between proximal left anterior descending artery and main pulmonary artery. Note severe coronary stenosis in mid left anterior descending artery. variations have been included in a few studies [8,9], while excluded in others [6,7,22]. The commonest anomaly in our series was an anomalous right coronary artery. Only Topaz et al. [7] had similar findings, but they had also included patients with congenital heart diseases, and their study group was predominantly of Hispanic origin. All other reports [6,22,23] have placed the anomalous Table 3 Incidence of atherosclerotic coronary artery disease in patients with congenital coronary artery anomalies (n539)a Serial Number Congenital coronary artery anomaly Patients with CAD 1. Anomalous RCA (n519) Anomalous LCX (n514) Anomalous LAD (n51) ALCAPA (n51) Coronary artery fistulae (n54) 14 (73.68%) 6 (31.57%) 1 (5.2%) 8 (57.14%) 4 (28.57%) 2 (14.28%) 1 (100%) 1 (100%) 1 (100%) 2 (50%) – – 2. 3. 4. 5. Total (n539) a – Anomalous vessel with CAD – 3 (75%) 26 (66.66%) 13 (33.33%) Only anomalous vessel with CAD 4 (10.25%) CAD, coronary artery disease; RCA, right coronary artery; LCX, left circumflex artery; LAD, left anterior descending artery; ALCAPA, anomalous left coronary artery from pulmonary artery. N. Garg et al. / International Journal of Cardiology 74 (2000) 39 – 46 left circumflex as the commonest anomaly. The high incidence of the anomalous right coronary artery in our study is a cause of some surprise. This discrepancy may reflect the inevitable nature and bias of a retrospective study. Other possible reasons may be a smaller number of patients [3,23], a selective collection of cases from diverse sources [24] or the artery originating from the non-facing aortic sinus misdiagnosed as a total occlusion at the ostium [25]. Another possible explanation is genetic and geographic variations in the coronary arterial pattern which are well known [17–21]. Our study is the largest from this part of the world and the study population may be genetically different from that in other series. The second commonest anomaly, in concurrence with Topaz et al. [7], was an anomalous left circumflex artery. Its course was retroaortic, as reported in all other previous series [6–9,22,23]. The third commonest anomaly in our series was coronary artery fistulae (10.25%), quite similar to the Cleveland clinic series [8], which is the largest study of anomalous coronaries to date. We encountered only one patient with an anomalous left coronary artery from the pulmonary artery, a potentially serious coronary artery anomaly. Since 90% of these patients die in infancy of myocardial infarction, congestive heart failure or sudden cardiac death [26], it is not surprising that in our predominantly adult population we found only one such patient. Anomalous left anterior descending artery is one of the rarest anomalies, and we found it in only one patient. The functional significance of this anomaly is unknown. It was reported to occur more commonly in association with tetralogy of Fallot [2]. There was not a single patient with this anomaly in the Hungarian series of primary congenital anomalies [9]. However Topaz et al. reported an 11% incidence of this anomaly in their series, but associated congenital heart diseases were present in 44% of patients [7]. Involvement of anomalous coronaries in atherosclerotic disease is at best controversial. Previous studies have reported a greater degree of atherosclerotic involvement of anomalous left circumflex artery, especially in its proximal segment, and it is suggested to be due to its retroaortic course [27]. But in our study, only 28% of these patients had evidence of atherosclerosis (significant stenosis of proximal 45 vessel in 21% patients only), thus corroborating Topaz et al. [7] and Page et al. [3]. Our study is in agreement with others [7,27], in that there is no predisposition for atherosclerotic involvement of the proximal segment of the anomalous right coronary artery. From a clinical standpoint, there are reports of chest pain, myocardial infarction and sudden cardiac death related to coronary anomalies [2,5,6,15,16]. The origin of the left coronary artery from the contralateral sinus or artery, with subsequent passage between the aorta and right ventricular outflow tract has been clearly shown to be a dangerous lesion [5,28]. The magnitude of the ischemic risk depends on the angulation of the coronary artery after its origin from the aorta, with acute angulation often associated with a slit-like ostium [28,29]. With increased cardiac output (i.e., exercise), the aorta dilates and, upon aortic wall stretching, this slit-like ostium further becomes severely narrowed leading to myocardial ischemia. Acute myocardial infarction as well as sudden death have been reported, even when the course of the artery was anterior to the pulmonary trunk or posterior to the aorta [30,31]. The origin of the right coronary artery from the contralateral sinus or artery with passage between the aorta and right ventricular outflow tract is somewhat less dangerous [32], though presumably through the same mechanism. Other anomalies which can lead to these events include single coronary artery, anomalous coronary origin from pulmonary artery, coronary artery fistula and atresia of coronary ostium [1,16,26]. Angiographic recognition of coronary anomalies prior to cardiac surgery is of great importance. Surgical problems may follow if an anomalous vessel is excluded from perfusion during cardiopulmonary bypass or if the surgeon unwittingly incises the anomalous vessel [10]. Failure to recognise them can also lead to inadequate or prolonged procedures [33]. During valve replacement surgery, the ostium of the anomalous vessel can be inadvertently obstructed or the anomalous vessel may be compressed along its course by a valvular prosthesis [11,12]. Accurate identification of origin and course of anomalous coronaries is mandatory before planning coronary interventions also [13,14], so that an appropriate guiding catheter, wire advancement and balloon systems may be selected. 46 N. Garg et al. / International Journal of Cardiology 74 (2000) 39 – 46 5. Conclusions In summary, the incidence of isolated congenital coronary anomalies in our population is mostly the same as in others but, contrary to them, an anomalous right coronary artery is the commonest anomaly in our series, as in Hispanics. They do not appear to be associated with an increased risk for development of coronary atherosclerosis. Angiographic recognition of these vessels is important because of their clinical significance and applied importance in patients undergoing coronary angioplasty or cardiac surgery. References [1] Levine DC, Fellow KE, Abrams HL. Haemodynamically significant primary anomalies of the coronary arteries: angiographic aspects. Circulation 1978;58:25–34. [2] Liberthson RR, Dinsmore RE, Bharti S et al. Aberrant coronary artery origin from the aorta. Circulation 1974;50:774. [3] Page Jr. HL, Engle HJ, Campbell WB, Thomas Jr. CS. Anomalous origin of left circumflex coronary artery: recognition, angiographic demonstration and clinical significance. Circulation 1974;50:768. [4] Engle HJ, Torres C, Page HL. Major variations in anatomic origin of the coronary arteries. Cathet Cardiovasc Diagn 1975;1:157. [5] Chietlin MD, De Castro CM, Mc Allister HA. Sudden death as a complication of anomalous left coronary origin from the anterior sinus of Valsalva. Circulation 1974;50:780. [6] Chitman BR, Lesperance J, Saltiel J, Bourassa MG. Clinical angiographic,and haemodynamic findings in patients with anomalous origin of the coronary arteries. Circulation 1976;53:122. [7] Topaz O, De Marchena EJ, Perin E, Sommer LS, Mallon SM, Chahine RA. Anomalous coronary arteries: angiographic findings in 80 patients. Int J Cardiol 1992;34:129–38. [8] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28–40. [9] Kardos A, Balsai L, Rudas L et al. Epidemiology of congenital coronary artery anomalies: a coronary arteriographic study on a Central European population. Cathet Cardiovasc Diagn 1997;42:270–5. [10] Longenecker CG, Reentsma K, Creech Jr. O. Surgical implications of single coronary artery: a review and two case reports. Am Heart J 1961;61:382. [11] Robert WC, Morrow AG. Compression of anomalous left circumflex coronary arteries by prosthetic valve rings. J Thorac Cardivasc Surg 1969;57:834–7. [12] Dc Morchena EJ, Russo CD, Wazniak PM, Kessler KM. Compression of an anomalous left circumflex coronary artery by a bioprosthetic valve ring. J Cardiovasc Surg 1990;31:52–4. [13] Bass TA, Miller AB, Rubin MR, Stowers SA, Perryman RA. Transluminal angioplasty of anomalous coronary arteries. Am Heart J 1986;112:610–3. [14] Topaz O, Di Sciascio G, Goudrean E et al. Coronary angioplasty of anomalous coronary arteries: notes on technical aspects. Cathet Cardiovasc Diagn 1990;21:106–11. [15] Benson PA. Anomalous aortic origin of coronary artery with sudden death: case report and review. Am Heart J 1970;79:254. [16] Pachinger OM, Vanden HP, Judkins MP. Single coronary artery — a cause of angina pectoris. Eur J Cardiol 1974;2:161. [17] Symmers WSC. Note on accessory coronary arteries. J Anat 1907;41:141. [18] Chaudhry MS. Some observations on coronary artery pattern and intercoronary anastomoses in human hearts. Medicus Karachi 1965;30:162–72. [19] Schlesinger MG, Zoll PM, Wessler S. The conus artery: a third coronary artery. Am Heart J 1949;38:823–36. [20] Topaz O, Di Sciascio G, Cowley MJ et al. Absent left main coronary artery; Angiographic findings in 83 patients with separate ostia of left anterior descending and circumflex arteries at the left aortic sinus. Am Heart J 1991;12:447–52. [21] Kurja HJ, Chaudhry MS, Olsen TR. Coronary artery variations in a native Iraqi population. Cathet Cardiovasc Diagn 1986;12:386–90. [22] Kimbris D, Iskandrian AS, Segal BL, Bemis CE. Anomalous aortic origin coronary arteries. Circulation 1978;58:606–15. [23] Ogden JA. Congenital anomalies of coronary arteries. Am J Cardiol 1970;25:474–9. [24] Click RL, Holmes Jr. DR, 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;13:531–7. [25] Cohen DJ, Kim D, Baim DS. Origin of left main coronary artery from the non-coronary sinus of Valsalva. Cathet Cardivasc Diagn 1991;22:190–2. [26] Wesselhoeft H, Fawcett JS, Johnson AL. Anomalous origin of the left coronary artery from the pulmonary trunk; its clinical spectrum, pathology, pathophysiology, based on a review of 140 cases with seven further cases. Circulation 1968;38:403–25. [27] Wilkins CE, Betancourt B, Mathur VS et al. Coronary artery anomalies. Texas Heart J 1988;15:166–73. [28] Mustafa I, Gula G, Radley Smith R, Durrer S, Yacoub M. Anomalous origin of the left coronary artery from the anterior aortic sinus: a potential cause of sudden death. J Thorac Cardiovasc Surg 1981;82:297–300. [29] Robert III CW, Robert WC. Left main coronary artery originating from the right sinus of Valsalva and coursing between aorta and pulmonary trunk. J Am Coll Cardiol 1986;7:366–8. [30] Murphy DA, Roy DDL, Sohal M, Chandler BM. Anomalous origin of left main coronary artery from the anterior sinus of Valsalva with myocardial infarction. J Thorac Cardiovasc Surg 1978;75:282–5. [31] Robert WC, Kragel AH. Anomalous origin of either the right or left main coronary artery from the aorta without coursing of the anamolistically arising artery between aorta and pulmonary trunk. Am J Cardiol 1988;62:1263–7. [32] Robert WC, Siegel RJ, Zipes DP. Origin of the right coronary artery from the left sinus of Valsalva and its functional consequences: analysis of 10 necropsy patients. Am J Cardiol 1982;49:863–8. [33] Donaldson RM, Raphael MJ. Missing coronary artery. Br Heart J 1982;47:62–70.