Case 104

Published on 13/02/2015 by admin

Filed under Cardiovascular

Last modified 22/04/2025

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CASE 104

History: A young man presents with chest pain.

1. What are causes of sudden death in young adults? (Choose all that apply.)

A. Marfan syndrome

B. Anomalous coronary artery

C. Hypertrophic cardiomyopathy

D. Arrhythmogenic right ventricular dysplasia

2. The left main coronary artery (not shown) arises from the left sinus of Valsalva. Which coronary artery is anomalous?

A. Left main

B. Left anterior descending

C. Left circumflex

D. Right

3. What course does the anomalous vessel take?

A. Prepulmonic

B. Retroaortic

C. Septal

D. Interarterial

4. What is the usual treatment or next imaging step for the anomaly seen in this patient?

A. No further evaluation

B. Stress testing

C. Angioplasty and stent

D. Surgery

CASE 104

Anomalous Left Circumflex Coronary Artery with Retroaortic Course

1. A, B, C, and D

2. C

3. B

4. A

Reference

Young PM, Gerber TC, Williamson EE, et al. Cardiac imaging: part 2, normal, variant, and anomalous configurations of the coronary vasculature. AJR Am J Roentgenol. 2011;197(4):816–826.

Cross-Reference

Cardiac Imaging: The REQUISITES, ed 3, pp 225–228.

Anatomy and Clinical Considerations

Anomalous coronary arteries usually arise directly from the aorta. There are several types of coronary artery anomaly. There are four paths that an anomalous left coronary artery can take to supply its myocardial territory. The retroaortic and interarterial courses are the most common.

1. Retroaortic: An anomalous course posterior to the aorta (retroaortic) does not cause symptoms; it is considered to be a normal variant that does not need treatment (Figs. A–D).

2. Prepulmonic: This is also a benign variant. This vessel has an increased risk of accelerated atherosclerosis and can be injured if the patient undergoes median sternotomy, especially for repair of tetralogy of Fallot.

3. Interarterial: The interarterial course can lead to ischemia, with possible angina, arrhythmia, syncope, or sudden death, suggesting the need for surgical correction. Surgical options for correction include bypass graft, unroofing, or reimplantation of the anomalous artery.

4. Septal: This variant is often confused with the interarterial course; however, in the septal path, the artery travels through the myocardium in the proximal interventricular septum. Stress testing helps determine the clinical significance of this lesion. Patients who develop ischemia are treated surgically.

Imaging

X-ray coronary angiography can detect a coronary anomaly but often cannot definitively identify the course of the vessel. Electrocardiogram-gated CT (Figs. A–D) is used to map the course of the anomalous vessel. Charting the course of the vessel aids in management.