Anomalous left coronary artery from pulmonary artery: Case series and brief review

Anomalous origin of left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary anomaly. In this study, we present all the ALCAPA patients which were admitted at our institution during April 2007-December 2010. Retrospective review of these patients regarding their clinical presentation and the use of diagnostic modalities will be presented in this series. There were total of five patients, three male and 2 female, with age range of 2 - 12 months. The most common symptoms at presentation were tachypnea (4/5) and poor feeding with irritability (3/5). Electrocardiogram was abnormal in 2/5 cases and chest X ray revealed cardiome-galy with pulmonary congestion in 4/5 patients. Echocardiogram showed mitral valve regurgitation in 5/5 cases (3 with moderate and 2 with mild to moderate), Left ventricular dilatation/dysfunction in 4/5 patients, echogenic left ventricular papillary muscles in 4/5 patients and prominent right coronary with strong suspecision of ALCAPA in 4/5 patients. Coronary angiography was performed in 4/5 cases to confirm the diagnosis. We conclude that by thorough clinical assessment along with ECG and CXR, the diagnosis of ALCAPA can be strongly suspected. Echocardiogram can almost always make the diagnosis of ALCAPA and coronary angiography can confirm the diagnosis in rare atypical cases.

“Treat-Repair-Treat”:Management of Left Main Coronary Compression by a Pulmonary Artery Aneurysm in a Patient with Atrial Septal Defect and Significant Pulmonary Hypertension

Left main coronary compression syndrome(LMCS)may complicate pulmonary artery aneurysms(PAA),usually developed in the context of pulmonary arterial hypertension(PAH).We report the case of a 51-year-old female patient with an atrial septal defect(unsuitable for device closure)complicated by a PAA generating a 90%left main stenosis.The significant PAH held us back from immediate surgery.After specific dual PAH-targeted therapy(sildenafil and bosentan),the atrial septal defect could be closed with a unidirectional valved patch;the PAAinduced LMCS was treated by reductive arterioplasty.The postoperative course was uneventful.Follow-up showed clinical improvement,but PAH treatment was still needed.After three months,coronary angiography showed only an insignificant residual left main stenosis,proving that reductive pulmonary arterioplasty was effective in treating LMCS.Any PAA requires further evaluation for LMCS,a dangerous but treatable complication.The“treat-repair-treat”strategy and shunt-closure with a unidirectional valved patch can both improve surgical prospects of LMCS with shunt-related PAH.

A Case of Pediatric Heart Failure Caused by Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery: Case Report and Literature Review

A female patient aged 3 months and 10 days was admitted to the cardiology department because of symptoms of heart failure.According to the echocardiography results,the patient received a diagnosis of primary endocardial fi broelastosis and was treated withγ-globulin,prednisone,digoxin,and diuretics.Coronary computed tomographic angiography and coronary angiography were performed as there was no improvement after 2 months of treatment.Finally,the patient received a diagnosis of anomalous origin of the left coronary artery from the pulmonary artery(ALCAPA).ALCAPA is a rare congenital heart defect that can cause severe heart failure during infancy,and is easily misdiagnosed clinically.In this report,we show the process of misdiagnosis of the case and consult the relevant literature,hoping to improve the understanding and early diagnosis of ALCAPA.

Consideration of the Necessity of Prophylactic Bypass Grafting for Anomalous Origin of the Right Coronary Artery—Based on a Case with Concomitant Left Main Trunk Disease Resuscitated from Cardiopulmonary Arrest

Anomalous origin of the right coronary artery is a rare congenital anomaly, but is associated with sudden death. Originating from the opposite sinus of Valsalva, an interarterial?course and an intramural course are especially considered as the risk factor for fatal cardiac events. Surgical indication remains controversial because many patients are asymptomatic. A 52-year-old man with anomalous origin of the right coronary artery with an interarterial?course concomitant with the left main trunk disease was resuscitated from cardiopulmonary arrest. It was likely to be attributed to the left main trunk disease, but anatomical structure of the right coronary artery suggests its possible involvement. Prophylactic bypass grafting for the right coronary artery was performed using saphenous vein graft without ligating native vessel to prevent future cardiac events, as well as revascularization of the left main trunk disease. All grafts were patent in one-year follow-up coronary angiography. Any cardiac event has not occurred.

Late surgical correction of anomalous left coronary artery from pulmonary trunk in children, using autogenous aortic and pulmonary endotheliazed tube

Background: Direct re-implantation of an anomalous left coronary artery into the aorta is the preferred surgical option for creating a dual coronary arterial system in patients in whom the anomalous artery originated from the pulmonary trunk. This technique, however, is applicable only when the anomalous ar- tery arises from the left posterior pulmonary sinus. We report the successfully late follow-up of series of patients employing a new technique using combined autogenous aortic and pulmonary endotheliazed tube. Patients and Methods: We have treated 3 patients, aged 2 months, 6 months and 8 months respectively, who presented with anomalous origin of the left coronary artery from the left posterior pulmonary sinus and moderated mitral valve insufficiency by left ventricle dysfunction. We used a trapdoor like coronary artery elongation with autogenous aortic and pulmonary endotheliazed tube to connect the left coronary ostium to ascending aorta, avoiding the mitral valve intervention. Results: There was no early or late death. All patients are in functional class I, with good biventricular function and competent mitral valve at a median follow-up of 94 months, ranged from 108 to 132 months. Postoperative Computerized tomogramphy of aorta in our 1st patient showed good arterial flow, without any distortion. A local and distal stenosis of the left pulmonary artery was observed and submitted to stent treatment. Conclusions: The potential benefits of the trapdoor like and its modification technique are excellent operative exposure. The use of autogenous endothelized tube is a viable tissue capable of further growth, avoidance of injury to the aortic and pulmonary valvar apparatus or production of obstruction within the right ventricular outflow tract.

Anomalous origin of left pulmonary artery branch from the aorta with Fallot's tetralogy:one case report

我们报导经常与呼吸窘迫介绍了的一个十岁的男孩的案例后来出生。胸 X 光检查显示出一个扩大右室。Echocardiography 证明 Fallot 的四联剧和左肺的动脉的典型特征不能被设想。然而，心导管插入术透露左肺的动脉在上升主动脉有异常起源。病人经历了缺点的全部的外科的修正。九天以后，他被解除。我们在场发生的文学评论的结果， physiopathological，这稀罕疾病的临床、诊断、外科的特征。

Chest Pain on Exertion: Origin of the Right Coronary Artery from the Left Coronary Sinus, through the Aortic Pulmonary Sulcus with Squeezed, or Anterior Descending Branch Borderline Coronary Lesion?

The prognosis of patients in whom the right coronary artery (RCA) arises from the left coronary sinus (LCS) is unequal. An initial intramural course of the coronary artery within the aortic media is considered to cause myocardial ischemia in cases of coronary anomalies. In this case report, we present one patient admitted due to chest pain on exertion that suggested angina. Her only risk factor for coronary artery disease was hypertension. Clinical examination findings that the origin of the right coronary artery from the LCS, through the aortic pulmonary sulcus with atherosclerotic narrowing and squeezed of the RCA critical ostial, stenosis at the ostium of the RCA and the middle of left anterior descending (LAD) coronary, intravascular ultrasonography (IVUS) showed LAD and RCA minimal lumen area were 3.9 mm2, 5.9 mm2;plaque burden 66%, 65% respectively. We inserted EXCEL 3.0 × 18 mm stent in LAD stenosis. No complaints and adverse events were noticed during a 1-year follow-up.

Urgent Off-Pump Revascularisation in ACS and Cardiogenic Shock with Anomalous Origin of Right Coronary Artery from Left Anterior Descending Artery: A Case Report

A 55-year-old female known case of essential hypertension and diabetes was brought to the Emergency Department in a drowsy state with cardiogenic shock. At presentation systolic BP was 70 mm Hg, pulse rate was 44/min and random blood sugar was 239 mg/dl. Troponin I was 8.07. Electrocardiography showed junctional rhythm and bradycardia. Ejection Fraction (LVEF) was 15% - 20%. Coronary angiography was done which revealed single vessel disease in LAD with anomalous origin of RCA from midsegment of LAD. Patient was immediately taken up for Off-pump Coronary Artery Bypass Grafting (OPCAB). Right saphenous vein graft was harvested and anastomosed proximally to aorta and distally to LAD on beating heart using Medtronic Octopus heart stabilizer and coronary shunts. Wound closed in layers after achieving complete hemostasis. Patient was taken off ventilatory support on first post-operative day and discharged in a stable condition on fourth post-operative day. Post-operative Echocardiography showed LVEF increased from 15% - 20% at time of admission to 38% and 52% after 3 months and 12 months of surgery respectively.

Fractional flow reserve measured via left internal mammary artery after coronary artery bypass grafting:Two case reports

BACKGROUND The fractional flow reserve(FFR)has made the treatment of coronary heart disease more precise.However,there are few reports on the measurement of FFR via the left internal mammary artery(LIMA).Herein,we described the determination of further treatments by measuring FFR via the LIMA in 2 cases after coronary artery bypass grafting(CABG).CASE SUMMARY Case 1 was a 66-year-old male who was admitted due to“chest tightness after CABG.”The patient underwent CABG 7 years prior due to coronary heart disease.Coronary artery angiography showed complete occlusion of the left anterior descending artery(LAD),and subtotal occlusion of the third segment of the right coronary artery.On arterial angiography,there was 85%stenosis at the distal end of the anastomosis of the LIMA-LAD graft.FFR via LIMA was determined at 0.75.Thus,balloon dilation was performed in Case 1.FFR after balloon dilation was 0.94.Case 2 was a 60-year-old male who was admitted due to“chest tightness after CABG.”The patient underwent CABG 6 years prior due to coronary heart disease.There was 60%segmental stenosis in the middle segment of LAD and 75%anastomotic stenosis.FFR measured via LIMA was 0.83(negative);thus the intervention was not performed.Case 2 was given drug treatments.At the 3-mo follow-up,there was no recurrence of chest tightness or shortness of breath in both cases.They are currently under continual follow-up.CONCLUSION We provided evidence that FFR measurement via grafted blood vessels,especially LIMA,after CABG is a good method to determine the intervention course.

Compression of Left Main Coronary Artery in Patients with Pulmonary Artery Aneurysm and Pulmonary Hypertension

Background: Pulmonary artery aneurysm (PAA) is an unusual finding and its association with left main coronary (LMCA) compression is even more infrequent. Cardiac CT evaluates of presence and size of PAA and the degree of LMCA compression. The aim of this study is to describe two cases of adults with compression of LMCA with PAA associated with PDA and pulmonary hypertension. Case presentation: The first case is a 27-year-old man with PAA (78 mm diameter) and LMCA compression of 70% between the aortic sinus and the PAA. He presented angina as a manifestation of the LMCA compression. During follow-up the patient died. The second case is a 28-year-old man with PAA (110 mm diameter) that compresses LMCA in 55%, he rejected surgical treatment, but he is in close follow-up with medical treatment. Conclusion: Cardiac computed tomography played an important role both in the diagnosis and identification of high-risk PAA patients.

Percutaneous revascularization in a patient with anomalous origin of left main coronary artery

Anomalous origin of the coronary artery from opposite coronary sinus is infrequently observed during coronary angiography. Percutaneous coronary intervention (PCI) of anomalous coronary artery is technically difficult and challenging. It requires appropriate selection of guide catheters for adequate stability, coaxial alignment and backup support during the intervention. We hereby report a rare case of anomalous origin of left main coronary artery (LM) from the right coronary sinus, having a retro-aortic course to the left side before its bifurcation into left anterior descending (LAD) and circumflex artery. The 59-year-old man had successful PCI of atherosclerotic LAD lesions. A 64-slice Multi-Detector Computed Tomography (MDCT) performed at 4 years of follow-up demonstrated patency of coronary stents and also delineated the origin and course of the anomalous LM. The case illustrates the rarity of anomalous LM, and describes technical issues during PCI and the role of MDCT in coronary anomaly imaging.

Rare multiple fistulas with large saccular aneurysms originating from left anterior descending artery and left main coronary artery

A 49-year-old female patient consulted us for a cardiac evaluation before undergoing colon adenocarcinoma surgery. Three years prior, the patient underwent coronary angiography for dyspnea. The coronary angiography examination revealed a fistula originating from the left anterior descending artery and left main coronary artery, which had soft aneurysmal sacs and most likely drained into the pulmonary artery. Parasternal short axis echocardiography revealed a color flow that could be related to the fistula, but the other echocardiographic findings were normal. The patient did not accept the proposed examination and invasive treatment.

Device closure of fistula from left lower pulmonary artery to left atrium using a vascular plug:A case report

BACKGROUND Pulmonary artery-to-left atrial fistula is a variant of pulmonary arteriovenous fistula and is a developmental anomaly.Delayed presentation,cyanosis and effort intolerance are some of the important features.The diagnosis is confirmed by computed tomography or pulmonary artery angiography.Catheter-based closure is preferred to surgery.CASE SUMMARY Left pulmonary artery-to-left atrial fistula is rare.A 40-year-old male presented with effort intolerance,central cyanosis,and recurrent seizures.He had a large and highly tortuous left pulmonary artery-to-left atrial fistula associated with a large aneurysmal sac in the course.Catheter-based closure was performed using a vascular plug.CONCLUSION Left pulmonary artery-to-left atrial fistula is relatively uncommon compared to right pulmonary artery-to-left atrial fistula.Percutaneous closure by either a transeptal technique or guide wire insertion into the pulmonary vein through the pulmonary artery is preferred.The need for an arteriovenous loop depends on the tortuosity of the course of the fistula and the size of the device to be implanted because a larger device needs a larger sheath,necessitating firm guide wire support to facilitate negotiation of the stiff combination of the delivery sheath and dilator.

How much can be inferred from the left main coronary artery?

Atherosclerotic diseases is a diffuse process that involves the coronaries, carotids, renals and all other peripheral arteries owing to the systemic nature of atherosclerotic pathophysiology. This systemic precipitants that promote aggressive atherogenesis have been confirmed in multiple studies showing a relationship between atherosclerotic disease in one vascular bed with disease in another. However, the strength of this relationship varies from patient to patient. Thus, the practical utility of the diffuse nature of atheresclerosis is questionable. Ge and colleagues have proposed the use of left main (LM)coronary artery disease as a potential marker for left anterior descending (lAD) atherosclerotic disease. At first thought, this seems useless since the evaluation of the LM (by angiography or IVUS) can just as easily be performed in the LAD so why bother searching for such a surrogate? However, newer (non-invasive) imaging modalifies are making great gains and will be able to reliably image the LM sooner than the LAD (especially the distal LAD) so such a surrogate could have practical applications.

Long-Term Outcomes of Systemic-to-Pulmonary Artery Shunt in Patients with Functional Single Ventricle and Heterotaxy Syndrome

Objectives: We sought to determine the long-term outcomes and mortality-associated factors after systemic-topulmonaryartery shunt (SPS) in patients with heterotaxy syndrome. Methods: We retrospectively analyzed allpatients with a functional single ventricle and heterotaxy syndrome who underwent SPS at our center from January2001 to April 2022. Results: This study involved 84 patients. Restrictive pulmonary blood flow requiringearly modulation was presented in 34 (40%) patients. Compared with patients without restrictive pulmonaryblood flow (N = 50 [60%]), the postnatal survival of these 34 patients was significantly lower at 10 years (log rank:p = 0.04), but the statistical significance disappeared at 20 years (log rank: p = 0.18). Among 31 patients whounderwent SPS, 11 (35%) had extracardiac total anomalous pulmonary venous connection (TAPVC). The survivalrate after SPS was 80% at 10 years. Cox regression analysis showed that extracardiac TAPVC (hazard ratio6.44, 95% confidence interval 1.23–33.7, p = 0.03) and pulmonary venous obstruction (PVO) at TAPVC repair(hazard ratio 11.2, 95% confidence interval 2.13–58.5, p = 0.004) were significantly associated with death. In25 patients who underwent bidirectional cavopulmonary shunt (BCPS), surgical interventions on the pulmonaryartery (PA) were performed after SPS in 7 of 9 patients with PA coarctation, 3 of 4 with non-confluent PAs, and4 of 12 with normal PAs. At SPS, primary central PA plasty was performed in three patients with PA coarctationand 2 with non-confluent PAs. There was no significant difference in the PA index before BCPS between patientswith and without primary central PA plasty (p = 0.49). Among 20 patients who underwent total cavopulmonaryconnection (TCPC), adverse events occurred in 7 (35%) patients, including death in 1 (5%), intervention for pulmonaryarteriovenous malformation (PAVM) in 3 (15%), and surgical intervention for PVO in 3 (15%). TheB-type natriuretic peptide concentration was significantly higher in patients with than without adverse events(p = 0.02). The adverse event-free survival rate after TCPC was 69% at 10 years. Conclusion: ExtracardiacTAPVC and PVO at TAPVC repair were significantly associated with death after SPS in patients who had heterotaxysyndrome with a single ventricle. Surgical interventions on the PA were frequently required after SPS inpatients with PA coarctation or non-confluent PAs. Although satisfactory survival was achievable after TCPC,late-onset PAVM and PVO remain concerns.

Real-time Three-dimensional Echocardiographic Assessment of Left Ventricular Remodeling Index in Patients with Hypertensive Heart Disease and Coronary Artery Disease

Left ventricular remodeling index （LVRI） was assessed in patients with hypertensive heart disease （HHD） and coronary artery disease （CAD） by real-time three-dimensional echocardiography （RT3DE）. RT3DE data of 18 patients with HHD, 20 patients with CAD and 22 normal controis （NC） were acquired. Left ventricular end-diastolic volume （EDV） and left ventricular end-diastolic epicardial volume （EDVepi） were detected by RT3DE and two-dimensional echocardiography Simpson biplane method （2DE）. LVRI （left ventricular mass/EDV） was calculated and compared. The results showed that LVRI measurements detected by RT3DE and 2DE showed significant differences inter-groups （P〈0.01）. There was no significant difference in NC group （P〉0.05）, but significant difference in HHD and CAD intra-group （P〈0.05）. There was good positive correlations between LVRI detected by RT3DE and 2DE in NC and HHD groups （t=0.69, P〈0.01; r=0.68, P〈0.01）, but no significant correlation in CAD group （r=0.30, P〉0.05）. It was concluded that LVRI derived from RT3DE as a new index for evaluating left ventricular remodeling can provide more superiority to LVRI derived from 2DE.

Percutaneous coronary intervention for ostial lesions of the left main stem in a patient with congenital single left coronary artery: A case report

BACKGROUND Single coronary artery(SCA)originating from a solitary ostium in the aorta and perfusing the entire myocardium is a very rare congenital anomaly of the coronary artery.Furthermore,a right coronary artery(RCA)arising from the mid segment of the left anterior descending artery(LAD)is an extremely uncommon variation of SCA.CASE SUMMARY A 76-year-old woman presented a 5-mo history of exertional angina.Selective coronary angiography revealed an SCA,with severe ostial stenosis that originated from the left sinus of Valsalva and bifurcated normally into the LAD and circumflex coronary artery.In addition,an anomalous RCA originated from the mid segment of the LAD as a separate branch.Successful balloon angioplasty and stenting for the SCA ostial stenosis were performed on the patient.CONCLUSION Percutaneous coronary intervention(PCI)of the main trunk for SCA is very similar to PCI of an unprotected left main coronary artery.Although technical difficulties and risks do exist,PCI for severe ostial stenosis of the main trunk is safe and efficacious in selected SCA patients.

Stenting for left main coronary artery occlusion in adolescent: A case report

Acute total or subtotal occlusion of left main coronary artery (LMCA) is a catastrophic and mostly fatal event. Patients may present with cardiogenic shock and die whenever this event occurs. Survival is strongly dependent on the presence of collateral blood flow to the left coronary artery or a dominant right coronary artery, and emergency intervention for preserving the left ventricular function. Here, we present a case of a 14-year-old boy with subtotal occlusion of the LMCA accompanying acute myocardial infarction probably caused by congenital syphilis according to his positive serum syphilis antibody. His survival was closely associated with a dominant right coronary artery and timely thrombolytic therapy. Finally, he was treated with angioplasty and paclitaxel-eluting stent implantation. He was followed up after stenting and was doing quite well at the time when we wrote this paper.

Off-pump versus on-pump coronary artery bypass surgery for the treatment of left main with triple coronary artery disease

Objective：To obtain early results of off-pump coronarE~ artery bypass grafting（OPCAB） in patients with significant left main coronary artery（LMCA） and triple vessels stenosis by comparing with those of a similar group undergoing conventional coronary artery bypass surgery（CCAB）. Methods：Data for patients with significant LMCA and triple vessels stenosis who underwent CCAB or OPCAB were collected retrospectively between January 1999 and May 2006. Non-randomized, retrospective data analysis included demo- graphic and preoperative risk factors, operative details, clinical outcome and early follow-up. Results： The number of distal anastomo- sis and grafts varied from 3 to 6. The average number per patient was similar in the two groups （OPCAB group：3.76 ± 0.98, CCAB group：3.81 ± 1.02）. Thirty-day mortality occurred to one patient in the OPCAB group whereas two early deaths were observed in the CCAB group but did not reach statistical significance （P 〉 0.05）. The frequency of atrial fibrillation （AF）, IABP usage, mediastinitis, re-operation for bleeding （or tamponade） were similar in the two groups （P 〉 0.05）. Postoperative inotropic requirements, peak CKMB, ventilation time, blood loss, FFP, RBC transfusion need and the length of ICU-stay were all significantly lower in the OPCAB group compared with CCAB group（P 〈 0.05）.Conclusion： Significant LMCA and triple-vessel stenosis can safely and effectively undergo myocardial revascularization using OPCAB surgery. LMCA should no longer be seen as a contraindication to perform OPCAB grafting.

Off-pump coronary artery bypass grafting versus on-pump coronary artery bypass grafting： which is better in patients with chronic obstructive pulmonary disease？

To evaluate the clinic outcome of off-pump coronary bypass grafting (OPCABG) of patients with coronary heart disease and chronic obstructive pulmonary disease, we collected and analyzed 1998-2002 data on 28 patients with these two diseases who had received off-pump coronary bypass operation in our hospital, and compared with data on those who also had the same two diseases but received on-pump coronary artery bypass at same time. There were no operation-related death;one died of respiratory failure 14 days after operation while staying in hospital; there were more respiratory complications in the conventional coronary artery bypass grafting group (CCABG) than in the OPCABG group; and the PaO2/FiO2 in the CCABG group was higher than that in the OPCABG group during operation because of CPB, but lower than that in the OPCABG group 6-12 hours after operation. OPCABG seemed more suitable than CCABG for coronary artery disease patients with chronic obstructive pulmonary disease due to less damage to their oxygen-exchange capability and the fewer respiratory complications.