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Surgery for anomalous left main coronary artery from right coronary sinus in the asymptomatic adult

2015; Elsevier BV; Volume: 24; Linguagem: Inglês

10.1016/j.hlc.2014.12.121

1444-2892

Mathew Doyle, Claudia Villanueva, Sheen Peeceeyen, Matthew Horton,

Vascular anomalies and interventions

Introduction: Anomalous coronary artery from the opposite sinus (ACAOS) can cause sudden cardiac death, and ACAOS with inter-arterial course requires surgical consideration. Younger patients require surgery due to the risk of sudden cardiac death; however this risk decreases as patient's age and the recommendation for surgery is less certain. Computed-tomography coronary angiography (CTCA) is a non-invasive means of identifying abnormal coronary anatomy, and is useful for pre-operative planning. Case Description: An asymptomatic 47 year-old female had a positive exercise stress. CTCA and coronary artery angiography identified the LMCA originating from the right coronary ostia, with 50% stenosis of her LMCA and an inter-arterial course. She underwent coronary artery bypass grafting with a single vein graft to her left anterior descending artery. She was discharged home 7 days post-surgery with no post-operative complications. Discussion: ACAOS coursing between the RVOT and aorta has a high incidence of sinister sequalae including sudden death, and is often diagnosed either coincidentally or at autopsy. Surgery is recommended for younger patients however there is uncertainty in the literature about managing asymptomatic, older adults. CTCA is a non-invasive imaging modality that has excellent spatial and temporal resolution, allowing superior visualisation of coronary artery anatomy to that of standard angiography. Treatment algorithms based on patients' age, symptomatology and anomalous artery origin and course have been proposed, however these differ for older, asymptomatic patients ( 1Nihan Kayaler et al., "Congenital Coronary Anomolies and Surgical Treatment," Congenital Heart Disease no. 4, no. 4 (July 28, 2009): 239–51.1Nihan Kayaler et al., "Congenital Coronary Anomolies and Surgical Treatment," Congenital Heart Disease no. 4, no. 4 (July 28, 2009): 239–51., 2Roberto Barriales-Villa and Cesar Moris de la Tassa, "Congenital Coronary Artery Anomalies with Origin in the Contralateral Sinus of Valsalva: Which Approach Should We Take?," Revista Española De Cardiología (English Ed.) 59, no. 4 (April 2006): 360–702Roberto Barriales-Villa and Cesar Moris de la Tassa, "Congenital Coronary Artery Anomalies with Origin in the Contralateral Sinus of Valsalva: Which Approach Should We Take?," Revista Española De Cardiología (English Ed.) 59, no. 4 (April 2006): 360–70). Operative technique is dependent on variables including ostial origin of the ACAOS, proximal course of the inter-arterial segment (intra- vs extra-mural) and the presence or absence of concomitant cardiac disease, all of which can be accurately delineated using CTCA. Conclusion: Surgical intervention ACAOS with inter-arterial course of the LMCA remains the gold standard of treatment; however the type and timing of surgery in the asymptomatic and older patient cohort remains unclear. CTCA provides excellent visualisation of coronary artery anatomy in particular the proximal inter-arterial segment of the anomalous coronary artery, which may contribute to the decision of operative timing and technique.