Abnormal Coronary Artery

RAMACHANDRA

Something should go wrong anatomically?• Number• Location of ostium• Diameter• Cross-sectional area • Course• Branches

Hemodynamically wrong

• Major• Minor

Functional anomaly

• Ischemia• Shunt• Nothing

What is normal coronary?

• That is found in more than 1% of a general population• That is found within 2 SD of the µ value for Gaussian distribution

continuous bell curve

Figure 3. Conceptual diagram that shows most of the possible paths (1 through 5) by which the RCA, left anterior descending artery (LAD), and circumflex artery (Cx) can potentially connect

with the opposite coronary cusps.

Angelini P Circulation. 2007;115:1296-1305

Copyright © American Heart Association, Inc. All rights reserved.

Normal Coronary Anatomy

Normal Coronary Angiogram

• Three primary coronary arteries • Left main trunk common stem for LAD and LCX- 90% of cases and is not

essential• LAD & LCX are essential• LAD &LC originate from an aortic area located above the upper or

middle third of the left coronary sinus of Valsalva (also called the left posterior sinus)

• The RCA originates from the upper or middle third of the right sinus of the Valsalva

• Coronary ostium is orthogonal to aortic wall.

Anatomical Classification

Origin Course Vessel wall termination

collateral

Angelini P, Villason S, Chan AV, Diez JG. Normal and anomalous coronary arteries in humans. In: Angelini P, ed. Coronary Artery Anomalies: A Comprehensive Approach. Philadelphia: Lippincott

Williams & Wilkins; 1999: 27–150

Origin

• 0.6% to 1.2% of CAG in adult• LAD & RCA from LCS but different origin[Split]• High/ Low/ Commissural• From neighbouring sinuses• From neighbouring arteries like ALCAPA

Abnormal origin……..(TGA)

Abnormal origin……..(TGA)

Abnormal origin……..(TGA)

Abnormal origin……..(TGA)

Course

• Intramural• Extramural

Intrinsic to any artery

• Stenosis• Ectasia• Dual RCA/LAD• Abnormal septal arteries• Myocardial bridge• Subendocardial• Crossing

Collaterals

• Coronary cameral fistulas

Relationship

• Transposition of the great arteries• Tetralogy of Fallot: 2-9% of tetralogy of Fallot have coronary arterial

anomalies. The most common anomaly is origin of the left anterior descending (LAD) coronary artery from the RCA in approximately 4%

• Pulmonary atresia with intact ventricular septum : absence of effective egress of blood from the cavity of the right ventricle may preserve primitive embryonic sinusoidal connections to coronary vasculature, resulting in the filling of the connections from the right heart in systole and filling from the aorta in diastole

Tests

• Clinical guess• ECG• Echo• TMT• CAG/CTCAG/MR Angio• Nuclear• PET• IVU• OCT

Alarms• Irritability • Poor Feeding • Slowed Or Poor Growth And Development • Dyspnea (Difficulty Breathing) • Wheezing • Diaphoresis (Sweating) /Syncope • Grayish Skin Color In Conjunction With Other Symptoms • Periods Of Pallor (Pale Skin) • Heart Failure• Unexpected Chest Pain• Presentation In Unusual age• SCD

Mortality/Morbidity

• Many coronary anomalies are clinically silent• The incidence of incidental coronary anomalies at autopsy includes a

single coronary artery in 0.024% and coronary arterial fistulae in 0.2%• After hypertrophic cardiomyopathy, coronary artery abnormalities are

the second most common cause of sudden death in young athletes• Race/Sex-No racial predisposition is known.

Treatment Options of symptomatic• Medical treatment/observation• Coronary angioplasty with stent deployment• Surgical repair

Thanks