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Ann Thorac Surg 2004;78:1829-1831
© 2004 The Society of Thoracic Surgeons

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Case report

Surgery for Anomalous Origin of the Right Coronary Artery From the Left Aortic Sinus

^a Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA

Accepted for publication August 13, 2003.

^* Address reprint requests to Dr Byrne, Brigham & Women's Hospital, Division of Cardiac Surgery, 75 Francis St, Boston, MA 02115, USA
jbyrne{at}partners.org

	Abstract

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This case report illustrates the presentation, diagnosis, and surgical management of an anomalous origin of the right coronary artery from the left coronary sinus in a young adult in whom the right coronary artery was reimplanted directly onto the aorta, rather than bypassed, as is typically done.

	Introduction

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The clinical significance of anomalous origin of the right coronary artery from the left coronary sinus has been controversial. Initially thought to be a benign and rare condition, anomalous origin of the right coronary artery (RCA) is now regarded as a potentially pathologic entity that may require surgical intervention [1]. In this article, we report a patient with this anomaly who underwent reimplantation of the RCA directly onto the aorta rather than being bypassed.

A 28-year-old man was evaluated for an episode of syncope that occurred when he had participated in a basketball game. There were no risk factors for coronary artery disease. He had no prior syncopal episodes, chest pain, or dyspnea on exertion. He denied cocaine or other illicit drug use.

Initial electrocardiogram and subsequent echocardiogram were nondiagnostic. A modified Bruce protocol revealed no abnormalities. During recovery, 2 mm down-sloping segment elevation depressions in leads II, III, and AVF were noted without symptoms. The changes persisted for several minutes and then were completely resolved.

On coronary angiography, the left coronary system was normal. The right coronary artery could not be located in its usual position. An aortogram showed that the right coronary artery originated from the left coronary sinus (Fig 1). The right coronary artery appeared to pass between the aorta and the pulmonary artery. A magnetic resonance imaging angiogram confirmed this anatomical relationship (Fig 2). The patient was referred for surgical correction of the anomaly.

View larger version (138K): [in this window] [in a new window]   Fig 1. Coronary angiography demonstrating the origin of the right coronary artery (straight arrow) from the left coronary sinus and the left main trunk (curved arrow). (Ao = aorta.)

View larger version (105K): [in this window] [in a new window]   Fig 2. Axial magnetic resonance imaging demonstrating anomalous right coronary artery (straight arrow) passing between pulmonary artery (P) and aorta (A) and the left main trunk (curved arrow).

In the second month after surgery, a repeat treadmill test was performed. The patient remained asymptomatic with no restrictions on full physical activity. Seven years later the patient remains symptom free.

	Comment

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An anomalous RCA may present with sudden death, evidence of myocardial ischemia, or syncope [2]. An anomalous RCA may also be asymptomatic and an incidental finding at autopsy. If clinically significant, the RCA is usually dominant as in our patient.

The frequency of anomalous origin of the RCA in the adult population is rare, found between from 0.019% to 0.17% of autopsies [2]. Angiography can identify the anomalous origin of the coronary artery, but the course of the anomalous artery and the relationship to the right ventricular outflow tract can be difficult to determine. This was the main reason to proceed to magnetic resonance imaging in our patient. Alternatively, in patients in whom coronary angiography or magnetic resonance imaging are inconclusive, multi-slice computed tomography may be useful for assessment of an anomalous coronary artery [3]. The passage of the RCA between the aorta and the pulmonary artery trunk and its cyclic compression was the cause of the clinical symptoms in our patient. The mechanism of the syncope appears to be ischemia of the sinus node, inducing bradycardia. Other mechanisms have been postulated for the myocardial ischemia induced by this anomaly. These include a distorted slit-like ostium (kinking at the take-off of the anomalous RCA or stretching of its intramural proximal segment) and exercise-induced compression by the commissure between the right and left coronary cusps [4]. Correct surgical repair depends on precise determination of anatomy and the mechanism of ischemia.

When a slit ostium is found at the origin of an anomalous right coronary artery, Rinaldi and colleagues [5] recommend widening the orifice of the origin, which reduces the compression of the intramural segment. Although this operation has yielded good results, not all patients have a narrow ostium. The preferred approach by many surgeons is coronary artery bypass grafting with venous conduit [6] or internal mammary arteries [1]. The latter seems to be a better choice due to the superior long-term patency, especially in this type of anomaly, which is frequently seen in young adults. Coronary reimplantation is also possible. We know of only one other such case in the literature of an adult patient who underwent successful coronary reimplantation of an anomalous right coronary artery [7]. The reimplantation was performed after the left internal mammary artery was harvested and discovered to be of small caliber and inadequate flow. We believe that a reimplantation of the artery should be attempted in patients who have an anomalous RCA with a sizable lumen. The advantages over the right internal mammary artery and RCA bypass lies in the sparing of the right internal mammary artery as a conduit in a young adult who may have coronary artery disease develop later. There are two major pitfalls in reimplanting the RCA onto the aorta: (1) care should be taken to insure the new ostium has no kinks or angulations, and (2) adequate mobilization and length of the distal anastomotic site is critical to avoid this problem, which may become evident during the filling of the right heart as previously described [5]. This case illustrates the importance of recognizing this anomaly and its surgical treatment. Reimplantation of the RCA can be successfully performed with adequate mobilization of the anomalous coronary artery from the aortic annulus. Coronary artery bypass grafting using the right internal mammary artery or the proximal RCA may be an alternative treatment in those patients who have CAD or if there is insufficient length after mobilization to reimplant.

	References

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1. Cohen AJ, Grishkin BA, Helsel RA, Head HD. Surgical therapy in the management of coronary anomalies: emphasis on utility of internal mammary artery grafts. Ann Thorac Surg. 1989;47:630–637[Abstract/Free Full Text]
2. Kragel AH, Roberts WC. Anomalous origin of either the right or left main coronary artery from the aorta with subsequent coursing between aorta and pulmonary trunk: analysis of 32 necropsy cases. Am J Cardiol. 1988;62:771–777[Medline]
3. Dirksen MS, Bax JJ, Blom NA, et al. Detection of malignant right coronary artery anomaly by multi-slice CT coronary angiography. Eur Radiol 2002;12:S
4. Ghosh PK, Agarwal SK, Kumar R, Chandra N, Puri VK. Anomalous origin of right coronary artery from left aortic sinus. J Cardiovasc Surg (Torino). 1994;35:65–70[Medline]
5. Rinaldi RG, Carballido J, Giles R, Del Toro E, Porro R. Right coronary artery with anomalous origin and slit ostium. Ann Thorac Surg. 1994;58(3):829–832[Medline]
6. Bett JH, O'Brien MF, Murray PJ. Surgery for anomalous origin of the right coronary artery. Br Heart J 1985;53:549–461.
7. Di Lello F, Mnuk JF, Flemma RJ, Mullen DC. Successful coronary reimplantation for anomalous origin of the right coronary artery from the left sinus of Valsalva. J Thorac Cardiovasc Surg. 1991;102(3):455–456[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marzia Leacche Tomislav Mihaljevic James D. Rawn John G. Byrne Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rogers, S. O. Articles by Byrne, J. G. Search for Related Content PubMed PubMed Citation Articles by Rogers, S. O., Jr Articles by Byrne, J. G. Related Collections Coronary disease