UvA-DARE (Digital Academic Repository) Biochemical risk assessment and invasive strategies for acute coronary syndromes without ST-segment elevation Riezebos, R.K. Link to publication Citation for published version (APA): Riezebos, R. K. (2011). Biochemical risk assessment and invasive strategies for acute coronary syndromes without ST-segment elevation General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: http://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl) Download date: 18 Mar 2019
Chapter11 Ramus Circumflexissimus - a coronary anomaly detected by using computed tomography angiography Femke M. van de Sandt 1, Robert K. Riezebos 2, Victor P.M. van der Hulst 3 1 Hofpoort Ziekenhuis, Woerden, The Netherlands; Department of Cardiology 2 Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; Department of Cardiology 3 Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; Department of Radiology Congenital Heart Disease 2011 Jul 1 [Epub ahead of print]
Chapter 11 Abstract A case is presented of a case of L-1 type solitary (left) coronary artery in a female patient with chest pain. It was detected using coronary computed tomography angiography and then confirmed by an invasive coronary angiography. The L-1 subtype was considered to be a benign type. Solitary coronary artery anomalies are rare. 170
A rare coronary anomaly detected by CTA A 52-year-old female was presented to the emergency department with chest pain provoked by emotion. Her ECG and troponin levels were normal. As the echocardiogram was normal, it was decided to perform an exercise test. The test however proved inconclusive. As the likelihood for an NSTE-ACS was estimated to be low, coronary computed tomography angiography (CCTA) was performed, revealing a solitary coronary artery originating from the left sinus of Valsalva. This single coronary artery had a normal take-off and proximal course, dividing into an anterior descending branch and a circumflex branch. After providing blood flow to the posterior descending artery, the superdominant left coronary artery continued into the right posterior atrioventricular groove, supplying marginal branches to the right ventricle and terminating near the right sinus of Valsalva. The right coronary ostium was absent (figure 1). Invasive coronary angiography confirmed these findings (figures 2A and 2B). Coronary artery anomalies are encountered in 0.6-1.3% of those patients referred for invasive coronary angiography. 1 Contrast-enhanced computed tomography offers additional possibilities to detect coronary anomalies, with the advantage of being non-invasive and providing three-dimensional imaging of the coronary arteries in relation to their surroundings. A rare subset of coronary artery anomalies are the single coronary artery (SCA) anomaly. Isolated SCA anomalies (in the absence of associated cardiovascular anomalies) have been reported with an incidence of 0.04-0.06%. 1,2 In 1979, A useful classification of SCA anomalies was proposed by Lipton et al, later to be modified by Yamanaka and Hobbs. 1,3 Our case represents a L-1 type anomaly, originating from the left sinus of Valsalva and following the anatomical course of a normal left coronary artery. The majority of cases of L-1 type SCA described in the literature were detected as a coincidental finding on autopsy or coronary angiography. Typically, its take-off and proximal course do not differ from those of a normal left coronary artery. Kinking or other abnormalities at its origin have not been described. In some cases found during autopsy, a dimple was found in the right sinus of Valsalva and in one case, a fibrous chord connected this dimple with the most distal part of the SCA. 4,5 It is considered that this dimple represents the embryonic bud of the (absent) right coronary artery, which either failed to develop or canalize, or became atretic during an early phase of coronary 11 171
Chapter 11 artery development. The L-1 type SCA is believed to be a benign anomaly. Like our case, most of the patients reported did not develop symptoms or signs of cardiac dysfunction. 6-15 However, since the entire heart is supplied by a single coronary artery, the occurrence of atherosclerosis or other pathology in the coronary artery carries an increased risk. 16-19 Even in the absence of coronary atherosclerosis or thrombosis, ventricular tachycardia and sudden death have both been described in infants as well as in adults with L-1 type SCA. The relationship between the coronary anomaly and the clinical picture of these patients remains unclear and is not supported by evidence of ischemia or by infarction in these reports. 20-22 Given the relatively small number of known cases and the limited information available on long-term survival in these patients, a definitive statement about the prognosis and optimal treatment of the L-1 type SCA cannot be made. However, in our opinion the risk of cardiovascular events in adult patients with L-1 type SCA will mainly depend upon the development of atherosclerosis in the single coronary artery. Strict regulation of risk factors is therefore of paramount importance as these patients rely opon just a single coronary artery. 172
A rare coronary anomaly detected by CTA Figure 1 Three-dimensional, reconstructed CCTA images showing the solitary left coronary artery, its ramus circumflexissimus extending to right ventricular territory. LAD = left anterior descending; PDA = posterior descending artery; RCxCx = ramus circumflexissimus. 11 173
Chapter 11 Figure 2 Solitary left coronary artery on invasive coronary angiography images. 2A: right anterior oblique view. 2B: caudal left anterior oblique view. 174
A rare coronary anomaly detected by CTA References 1. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28-40 2. Desmet W, Vanhaecke J, Vrolix M, van de Werf F, Piessens J, Willems J, de Geest H. Isolated single coronary artery: a review of 50,000 consecutive coronary angiographies. Eur Heart J 1992;13:1637-1640 3. Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology 1979;130:39-47 4. Smith JC. Review of single coronary artery with report of 2 cases. Circulation 1950;1:1168-1175 5. Ogden JA, Goodyer AVN. Patterns of distribution of the single coronary artery. Yale J Biol Med 1970;43:11-21 6. Tavernarakis A, Voudris V, Ifantis G, Tsaganos N. Anomalous origin of the right coronary artery arising from the circumflex artery. Clin Cardiol 1986;9:230-232 7. Sheth M, Dovnarsky M, Cha SD, Kini P, Maranhao V. Single coronary artery: right coronary artery originating from distal left circumflex. Cathet Cardiovasc Diagn 1988;14:180-181 8. Ayala F, Badui E, Murillo H, Madrid R, Almazan A, Rangel A, Gutierrez-Vogel S. Right coronary ostium agenesis with anomalous origin of the right coronary artery from an ectasic circumflex artery. A case report. Angiology 1995;46:637-639 9. Shammas RL, Miller MJ, Dabb JD. Single left coronary artery with origin of the right coronary artery from distal circumflex. Clin Cardiol 2001;90-92 10. Turhan H, Duru E, Yetkin E, Atak R, Senen K. Right coronary artery originating from distal left circumflex: an extremely rare variety of single coronary artery. Int J Cardiol 2003;88:309-311 11. Kang WC, Han SH, Ahn TH, Shin EK. Unusual dominant course of left circumflex coronary artery with absent right coronary artery. Heart 2006;92:657 12. Kahraman G, Bildirici U, Ural E, Komsuoglu B. Asymptomatic single coronary artery in patient with severe peripheric artery disease. Int J Cardiovasc Imaging 2007;23:273-276 11 175
Chapter 11 13. Tanrıverdi H, Şeleci D, Kuru Ö, Semiz E. Right coronary artery arising as a terminal extension of the left circumflex artery (a rare coronary artery anomaly). Can J Cardiol 2007;23:737-738 14. Choi HJ, Kim JW, Moon JM. Unusual dominant course of left circumflex artery to right coronary artery territory with absent right coronary artery. J Cardiol 55;117-119 15. Chung SK, Lee SJ, Park SH, Lee SW, Shin WY, Jin DK. An extremely rare variety of anomalous coronary artery: right coronary artery originating from the distal left circumflex artery. Korean Circ J 2010;40:465-467 16. Vrolix MC, Geboers M, Sionis D, de Geest H, van de Werf F. Right coronary artery originating from distal left circumflex: an unusual feature of single coronary artery. Eur Heart J 1991;12:746-747 17. Asha M, Sriram R, Mukundan S, Kurudammanil AA. Single coronary artery from the left sinus with atherosclerosis. Asian Cardiovasc Thorac Ann 2003;11:163-164 18. Chou LP, Kao C, Lee MC, Lin SL. Right coronary artery originating from distal left circumflex artery in a patient with an unusual type of single coronary artery. Jpn Heart J 2004;45:337-342 19. Ariki M, Miyamoto M. Acute myocardial infarction of the right coronary artery originating from the distal left circumflex artery. Circ J 2008;72:2092-2095 20. Nielsen BD, Frøbert O. Single coronary artery, ventricular tachycardia, and a family history of sudden death. Cardiol Rev 2005;13:263-265 21. Blake HA, Manion WC, Mattingly TW, Baroldi G. Coronary artery anomalies. Circulation 1964;30:927-940 22. Moore L, Byard RW. Sudden and unexpected death in infancy associated with a single coronary artery. Pediatr Pathol 1992;12:231-236 176