Heart & vascular pathology
Ischemic disease
Anomalous coronary artery
Author: R. Amita, M.D.
Last author update: 1 February 2015
Last staff update: 31 December 2020
Copyright: 2015-2024, PathologyOutlines.com, Inc.
PubMed Search: Anomalous coronary artery [title]
Table of Contents
Definition / general | Epidemiology | Pathophysiology | Clinical features | Diagrams / tables | Diagnosis | Radiology description | Case reports | Treatment | Clinical images | Gross description | Additional referencesCite this page: Amita R. Anomalous coronary artery. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/heartanomalouscoronary.html. Accessed April 19th, 2024.
Definition / general
- A coronary anomaly is defined as any coronary pattern with a feature (number of ostia, proximal course, termination, etc.) "rarely" encountered in the general population
Epidemiology
- Coronary anomalies affect 1% of the general population
- Necropsies yield an even lower incidence (0.3%)
- According to the Sudden Death Committee of the American Heart Association, coronary anomalies cause 19% of deaths in athletes (Circulation 1996;94:850)
- Burke et. al. reported that in 14 to 40 year olds, coronary anomalies are involved in 12% of sports related sudden cardiac deaths versus 1.2% of non sports related deaths (Am Heart J 1991;121:568)
Pathophysiology
- Anomaly: right and left coronary arteries both originate from the same sinus of valsalva
- Normally, the coronary ostia are round to oval in shape but in this anomaly, the coronary artery has an acute takeoff angle that makes the ostium slit like in shape
- With increased cardiac output (e.g., exercise), the aorta dilates and upon aortic wall stretching, this slit like ostium becomes severely narrowed
- Anomaly: high takeoff of coronary arteries
- Normally, the coronary ostia are located within the sinuses of Valsalva which permits maximal opportunity for coronary artery diastolic filling
- Location of the ostia in the tubular portion of the aorta (i.e., high takeoff position) may be associated with decreased coronary perfusion
Clinical features
- Signs / symptoms: chest pain, sudden death, cardiomyopathy, syncope, dyspnea, ventricular fibrillation, myocardial infarction
Diagrams / tables
Images hosted on other servers:
Classification of coronary anomalies
Diagnosis
- Thallium exercise stress test may be used for diagnosis but is not sufficiently sensitive to show myocardial perfusion defects
Radiology description
- Coronary angiography and transesophageal echocardiography are useful
- Contrast enhanced electron beam tomography: offers excellent spatial resolution and identifies most anomalies of coronary vessels but it uses ionizing radiation and potentially nephrotoxic or allergenic contrast agent
- MRI: avoids radiation and contrast agents and yields excellent images in determining coronary origination, especially in patients with congenital defects
- Its greatest limitation is in determining the distal coronary course
- Hence it is less helpful in evaluating fistulas, coronary origination outside the normal sinuses (e.g. from a ventricle or pulmonary artery) and collateral vessels, and visualization of the posterior descending branch
Case reports
- 5 year old girl with anomalous origin of left coronary artery (Clinics (Sao Paulo) 2010;65:1215)
- 56 year old man with anomalous origin of right coronary artery (Internet Journal of Cardiology 2006;5(1))
- 71 year old man with myocardial ischemia caused by an anomalous circumflex coronary artery (Rev Esp Cardiol 2002;55:200)
- 73 year old man with myocardial ischemia caused by a coronary anomaly (Tex Heart Inst J 2004;31:273)
Treatment
- If diagnosed antemortem, surgery is the treatment of choice in most cases
- Takeuchi procedure: used to correct the infantile form of anomalous origin of coronaries by creating a communication between the aorta and the left coronary ostium through the pulmonary artery using tubular material (graft) (J Cardiothorac Surg 2008;3:33)
- Usually, this technique is performed when direct implantation of the anomalous artery into the aorta is difficult due to unfavorable conditions
- In the adult form, ligation of the origin of the coronary artery at the pulmonary artery is performed in a combined manner so that flow is either restored or persists through a connection with either the internal thoracic artery or a saphenous vein graft from the ascending aorta
Clinical images
Images hosted on other servers:
MRI during cardiac systole and end diastole
Coronary arteries with 3D reconstructions
Gross description
- Myocardial bridges ("tunneled" epicardial coronary artery)
- The coronary arteries which normally course over the epicardial surface of the heart may dip into the myocardium to travel for varying lengths and then reappear on the heart surface
- The muscle overlying the intramyocardial segment of the epicardial coronary artery is termed a "myocardial bridge" and the artery coursing within the myocardium is called a "tunneled" artery
- Congenital coronary artery aneurysms are found most commonly in the right coronary artery
- Abnormal flow patterns within the aneurysm may lead to thrombus formation with subsequent vessel occlusion, distal thromboembolization and myocardial infarction
