Anomalous origination of a coronary artery from the opposite sinus

Abstract

Anomalous origination of a coronary artery from the opposite sinus (ACAOS) is estimated to be present in 0.2–2.0% of the population. In the majority of individuals, ACAOS has no hemodynamic or prognostic implications, but in a minority of cases, typically where the anomalous coronary artery takes an interarterial course to reach its correct myocardial territory, it can precipitate ischemia and sudden cardiac death (SCD). With the growing use of CT coronary angiography (CTCA) in the investigation of ischemic heart disease, we can expect increasing rates of incidental detection of this anomaly. Although CTCA and magnetic resonance coronary angiography can effectively characterize these lesions anatomically, they fail to describe and quantitatively assess the basic defect that leads to coronary insufficiency, such as mural intussusception. The key challenge lies in the identification of which patients are at risk of SCD and, therefore, who should be offered corrective surgical or (potentially) percutaneous intervention. Conventional, noninvasive stress testing has limited sensitivity, but emerging, invasive stress tests, which utilize intravascular ultrasonography and measurements of fractional flow reserve, show the potential to provide more-accurate hemodynamic and prognostic assessment.

Key Points

  • Anomalous origination of a coronary artery from the opposite sinus (ACAOS) is a recognized cause of sudden cardiac death (SCD), typically associated with exercise

  • Insights from intravascular ultrasonography (IVUS) studies suggest that the pathophysiological mechanism by which ACAOS causes SCD involves systolic compression of the anomalous artery within the aortic wall

  • Cardiac catheterization was regarded as the gold standard for diagnosis and anatomical characterization of ACAOS, but has been superseded by CT and magnetic resonance coronary angiography

  • Standard, noninvasive stress tests have limited sensitivity in predicting the risk of SCD in patients with ACAOS

  • Invasive stress tests using IVUS and measurements of fractional flow reserve might provide a means of establishing the hemodynamic and prognostic significance of ACAOS

  • Case reports of successful percutaneous coronary intervention for treatment of ACAOS exist, but surgery remains the first-line treatment of choice

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Figure 1: Anomalous origination of the left coronary artery from the right coronary sinus: variations in the course of the anomalous artery.
Figure 2: CT coronary angiograms of anomalous origination of a coronary artery from the opposite sinus.
Figure 3: Two options for surgical repair of ACAOS with an intramural course.
Figure 4: Proposed algorithm for assessment and management of patients with ACAOS.

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C. P. Vega, University of California, Irvine, CA, USA is the author of and is solely responsible for the content of the learning objectives, questions, and answers of the Medscape, LLC-accredited continuing medical education activity associated with this article.

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All the authors contributed substantially to the research, discussion, writing, and editing of this article.

Correspondence to Steve Ramcharitar.

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Lim, J., Beale, A. & Ramcharitar, S. Anomalous origination of a coronary artery from the opposite sinus. Nat Rev Cardiol 8, 706–719 (2011). https://doi.org/10.1038/nrcardio.2011.147

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