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Received: March 15^th 2013

Accepted: May 20^th 2013

Anomalous origin of the left coronary artery from the opposite breast. Pathological case

Jesús Salvador Valencia-Sánchez,^a Alejandra Moreno-Vázquez,^b Belinda González-Díaz,^c Beatriz Elizabeth Valencia-Palacios^d

^aDirección de Educación e Investigación en Salud, UMAE Hospital de Cardiologia, Centro Médico Nacional Siglo XXI

^bServicio de Anatomopatología, UMAE Hospital de Cardiologia

Centro Médico Nacional Siglo XXI

^cServicio de hemodinamia, UMAE Hospital de Cardiología

Centro Médico Nacional Siglo XXI

^dMédico Pasante en Servicio Social, Unidad de Medicina Familiar No. 18

Instituto Mexicano del Seguro Social, Distrito Federal, México

Communication with: Jesús Salvador Valencia-Sánchez

Telephone: 01 (52) 5627 6900, extension 22007

Email:: jesus.valencia@imss.gob.mx, jsalvado_valencia@yahoo.com.mx

Background: Anomalous origin of the left coronary artery from right coronary sinus ACAOS is characterized because the left main coronary artery anomalously originates from the right sinus of valsalva aortic coronary and whose journey can follow four different paths to the left side of the heart.

Case report: a 73 years old men, who was admitted at the hospital for chest pain of oppressive type, intensity 10/10 with irradiation to left arm and neck, accompanied by diaphoresis and nausea. The diagnosis was an ischemic syndrome acute coronary undergo therapy thrombolytic, the evolution was not satisfactory due to different complications that led to the death.

Conclusions: The diagnosis of anomalous coronary artery left the opposite breast origin (ACAOS), is established basically through methods of diagnostics as computed cardiac angiography or cardiac catheterization as part of the approach of an acute coronary ischemic syndrome that allow to establish the morphological characteristics of coronary as the different anatomic variants and their characteristics with respect to adjacent structures.

Keywords: Coronary sinus; Heart defects; congenital; Coronary artery

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The term coronary artery anomalies (CAA) covers a wide spectrum of morphological variants of coronary anatomy that often result from abnormalities in the uterus, most of which cause no symptoms and have no prognostic implications. However, in certain coronary anomalies an association has been established with sudden cardiac death (SCD), especially in young patients.¹ According to various reports in the literature, coronary anomalies affect about 1% of the general population, according to data obtained from angiographic studies performed on patients with suspected coronary arterial disease.^2-4 In autopsy studies, Alexander and Griffith5 documented in 18,950 studies, a total of 54 coronary anomalies, corresponding to 0.3%. According to criteria established by Angelini et al., in an ad hoc study in 1950 of consecutive angiography cases to evaluate coronary artery disease, the incidence was found at 5.64%.^6,7 Many estimates of the prevalence of coronary anomalies have been established on the basis of data from studies of cardiac catheterization and autopsy studies, so that they have their limitations, since they are only performed in patients with suspected coronary artery disease and are not representative of the general population.

Within the universe of coronary artery anomalies, anomalous coronary artery arising from the opposite sinus (ACAOS) is a scenario that is often discovered during an invasive investigation of signs of chest angina.¹ The incidence particularly of anomalous origin of the right coronary artery from the left sinus in the report by Angelini et al. was of 0.92%, and 0.15% for the anomalous origin of the left coronary artery from the right coronary sinus, for an overall ACAOS incidence of 1.07%.⁵

When the left main coronary artery arises anomalously from the right coronary aortic sinus of Valsalva, its trajectory may follow one of four different paths to the left side of the heart,^8,9 (Figure 1) which can be:

• Inter-arterial course, the coronary artery passes between the aorta and trunk of the pulmonary artery,^10,11 or between aortic valve and the right ventricular infundibulum immediately adjacent to the pulmonary valve;¹²
• The artery crosses the surface of the anterior free wall of the right ventricular outflow tract;^13-15
• Aortic retro course, the artery then passes around the aortic root in the transverse pericardial sinus;^16,17
• Septal course, the artery runs through an intramuscular path through the conus septum (infundibular), through the floor of the right ventricular outflow tract and proximal to the pulmonary valve.¹⁸

According to Angelini’s classification,⁵ ACAOS is only one category in the broad spectrum of coronary anomalies, and can be further subdivided into four categories: anomalous origin of the right coronary artery from the left coronary sinus, anomalous origin of the left coronary artery from the right coronary sinus, anomalous origin of the left descending anterior coronary artery or left circumflex artery from the right coronary sinus, and anomalous origin of the right or left coronary artery from the non-coronary sinus.

Of the four courses to reach the dependent territory of the myocardium (anterior, inter-arterial, septal and retro aortic), the interarterial or more specifically intramural course can have a malignant behavior and cause sudden cardiac death.

For the authors, coronary artery anomalies with an intramural course are called AAOCA, which means anomalous aortic origin of a coronary artery from the opposite sinus with an intramural course between the great arteries; while others refer to it as anomalies of the arteries with an inter-arterial course, using the term ALCA, anomalous origin of the left coronary artery from the right coronary sinus with inter-arterial course and/or ARCA, anomalous origin of the right coronary artery from the left coronary sinus with inter-arterial course.^19,20

Through other methods such as computerized heart tomography, ACAOS incidence was 0.84% ​​and in particular the use of this served to establish some characteristics of ACAOS: location of ostium cleft, the characteristics of the exit angle, the intramural course, and the degree of compression between the aorta and the pulmonary artery trunk.²¹

Anomalous origin of the right coronary artery from the left coronary sinus and the anomalous origin of the left circumflex artery from the right coronary sinus, represent two of the most commonly reported anomalies.

Clinical case

Male 73 years old with high blood pressure 12 years of development, treated with telmisartan 40 mg every 24 hours and amlodipine 5 mg every 24 hours, grade II obesity and smoking for 45 years at a rate of 20 cigarettes a day. Carrier of chronic obstructive pulmonary disease (COPD) for 2 years with treatment with salbutamol and ipratropium bromide. No prior history of cardiovascular disease.

The current signs and reason for his hospitalization and study were oppressive chest pain, intensity 10/10 with irradiation to the left arm and neck, accompanied by sweating and nausea. The diagnosis of acute myocardial infarction with elevated posterior inferior ST segment was established, for which he received thrombolytic therapy with streptokinase 1,500,000 in 60-minutes with indirect criteria of reperfusion by decline of ST segment > 50%. During his hospital course he presented cardiac arrest associated with ventricular fibrillation that required management with advanced CPR and use of norepinephrine-type vasoactive amines at doses of 0.05 µg per minute and dopamine at 10 mg/kg/minute. He also presented with uncontrolled metabolic glucose levels of 321 mg/dL, creatinine of 2.2 mg/dL and potassium of 6.1Meq/L. The enzyme curve showed a total CPK peak of 9670 U and MB CPK of 987 U. His development was unstable with inotropic support and ventilatory mechanical assistance. Due to complications presented: ventilator-associated nosocomial pneumonia, acute renal failure AKIN 3 and sepsis, the patient again presented cardiorespiratory arrest, manifested as pulseless electrical activity, with another round of CPR for 30 minutes and death.   

The angiographic findings reported were: anomalous origin of the left coronary artery from the right coronary sinus, atheromatous disease crossing with subocclusive right coronary plaque, moderate mitral regurgitation, and left ventricle ejection fraction (LVEF) of 45% (Figures 2, 3 and 4).

The pathological findings showed anomalous origin of the left main coronary artery from the opposite sinus (Figures 5 and 6). Data are represented in Figure 7, where the artery subsequently passes around the aortic root through the transverse pericardial sinus. Among the findings was significant atherosclerotic obstruction with recent thrombosis of residual light in the distal third of the right coronary and associated infarction area (Figure 8).

Conclusions

This is a pathological case that exemplifies the correlation of anomalous origin of the left main coronary artery from right aortic coronary sinus of Valsalva, with course after its emergence from the right coronary sinus, corresponding to retro aortic type, where the artery passes behind and around the aortic root through the transverse pericardial sinus.

According to clinical and electrocardiographic data of initial clinical presentation, the patient underwent a cardiac catheterization study where atheromatous disease was demonstrated by the presence of an obstruction by subocclusive plaque of the right coronary artery with an ejection fraction of 45% and moderate mitral regurgitation and anomalous origin of the left coronary artery from the opposite sinus. The pathological findings also showed: anomalous origin of the left coronary artery from the right sinus, significant atherosclerotic obstruction with recent thrombosis of residual light in the distal third of the right coronary and associated infarction area.

According to the most-used classification for cataloging coronary arterial anomalies, the anomalous origin of the left coronary artery from the opposite sinus (ACAOS) is one of the most commonly reported coronary abnormalities. Its presentation is a scenario that is often discovered during an invasive investigation of signs of angina or presentation of an acute ischemic coronary syndrome as in this case. Although there are other methods such as computerized cardiac tomography, where the incidence of ACAOS has been reported up to 0.84% ​​and that on the other hand allows for features such as the location of the ostium cleft, features of the exit angle, intramural course, and the degree of compression between the aorta and the pulmonary artery trunk.   

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