A Rare Case of Anomalous Original Left Circumflex Artery Stenosis After Artificial Mitral Valve Replacement
A 72-year-old woman was admitted because of progressive 9-year chest tightness. Nine years ago, she underwent mitral valve replacement using a Hancock II porcine mitral valve bioprosthesis (size 27) (Medtronic, Minneapolis, Minnesota) for posterior mitral valve prolapse. Preoperative coronary angiogram showed anomalous origin of left circumflex artery (LCx) without stenosis ( Fig. 1.1 A, Online ). Postoperative echocardiography showed a left ventricular ejection fraction of 51%.
However, recent echocardiography showed a decreased left ventricular ejection fraction of 36% and segmentally weakened motion of the inferior and lateral wall. Single-photon emission computed tomography showed myocardial ischemia of the inferior and lateral wall. Diagnostic coronary angiogram identified a severe proximal LCx stenosis with distal slow flow ( Fig. 1.1 B, Online ). Both the left anterior descending and right coronary arteries appeared normal. Then percutaneous coronary intervention was performed with a 6F catheter Amplatz L 1.0 guide catheter. After predilation of stenosis with a 2.5-15-mm balloon, intravascular ultrasound catheter detected a marked reduction of vessel lumen without significant atherosclerotic plaques ( Fig. 1.2A–B, Online ). We then delivered a 3.5–36-mm drug-eluting stent to the proximal LCx. The final angiogram ( Fig. 1.1 C, Online ) and intravascular ultrasound ( Fig. 1.2 C, Online ) showed a good result. Six days later, computed tomography coronary angiography showed that the LCx ectopically originated from the right sinus of Valsalva, coursed posteriorly to the aorta, then traveled tightly around the mitral annulus ( Fig. 1.3 ). The patient has been well after discharge until now.
This is a rare case of anomalous original LCx stenosis after mitral valve replacement. We speculate that compression of the mitral valve bioprosthesis suture ring against the surrounding tissues of the mitral annulus might cause the LCx stenosis. The long-term outcome of artificial mitral valve replacement in such patients should be followed up.
Anomalous Origin of the Common Left Coronary Artery From the Right Coronary Sinus: An Unusual Anatomic Variation
A 56-year-old male patient who was hypertensive and without diabetes had chest discomfort on exertion for the past 3 months. The electrocardiogram result was normal, and two-dimensional echocardiography revealed normal left ventricular function and no left ventricular regional wall motion abnormalities. Hence, he underwent a stress test, results of which were positive for inducible ischemia at low workload.
Coronary angiography showed a small rudimentary left coronary artery. To our surprise, while searching for the left coronary artery its origin was found to be from the right coronary sinus. It had a main stem artery giving separate origins to the left anterior descending, diagonal, and obtuse marginal (first to fifth) coronary arteries. There was an eccentric 80% stenosis of the main stem of the left coronary artery before the origin of the first obtuse marginal artery. The right coronary artery had a normal course, and the posterior descending artery showed 99% stenosis of the proximal segment ( Fig. 1.4 A–D).
Before planning the patient’s revascularization strategy, we performed computed tomography coronary angiography for better delineation of the anatomy of the coronary arteries. Computed tomography coronary angiography determined the coursing of the anomalous left coronary artery and showed no interarterial or intramyocardial course of the coronary arteries ( Fig. 1.5A–D) .
Percutaneous transluminal coronary angioplasty was performed using two drug-eluting stents to the main stem left coronary artery and posterior descending artery stenoses.
The origin of the left main coronary artery in the right coronary sinus has been described in 0.02% of autopsy series and from 0.05% to 0.19% in angiographic series. A main stem of the left coronary artery arising from the right sinus of Valsalva has four anatomic courses :
Anterior course: turns anterior in front of right ventricular outflow tract, as in our case.
Interarterial course: between the great vessels, aorta, and pulmonary artery.
Septal course: intramyocardial septal continuation.
Posterior course: turns posterior behind the aorta.
Percutaneous angioplasty was performed in view of no interarterial course of the coronary arteries.
1. Alexander RW, Griffith GC: Anomalies of the coronary arteries and their clinical significance.Circulation 1956; 4: pp. 800-805.
2. Kimbiris D: Anomalous origin of the left main coronary artery from the right sinus of Valsalva.Am J Cardiol 1985; 55: pp. 765-769.
3. Madea B, Dettmeyer R: Sudden death in cases with anomalous origin of the left coronary artery.Forensic Sci Int 1998; 96: pp. 91-100.
Anomalous Acute Left Main Myocardial Infarction Owing to Compression Between the Pulmonary Artery and the Aorta by Acute Pulmonary Thromboembolism
A 62-year-old female tourist without significant cardiovascular risk factors was first seen with acute chest pain. She had arrived from the United States to Japan 5 days earlier by plane. When she had been transferred to our emergency department by ambulance, she was in cardiogenic shock and her initial blood pressure was 63/48 mm Hg. The electrocardiogram demonstrated widespread ST-segment depression plus ST-segment elevation in lead aVR ( Fig. 1.6 A). The echocardiogram showed severe hypokinesis of left ventricular wall motion with a paradoxical interventricular septum (Online ). The emergent coronary angiogram showed very tight narrowing in an anomalous left main coronary artery (LMCA) arising from the right coronary cusp ( Fig. 1.6 B). A drug-eluting stent (Ultimaster 3.5/18 mm, Terumo Corporation, Tokyo, Japan) was successfully implanted in the LMCA lesion with intraaortic balloon counterpulsation ( Fig. 1.6 C). Blood pressure, hypotension, and electrocardiogram changes were recovered after primary percutaneous coronary intervention. Two weeks later we could see the patent LMCA stent, which was sandwiched between the pulmonary artery (PA) and aorta by computed tomography imaging ( Fig. 1.6D–E). In addition, we could find a lot of thrombus in both pulmonary arteries ( Fig. 1.6 F–G). We hypothesized that her LMCA was compressed between the ascending aorta and PA because the PA pressure had risen suddenly as the result of a massive acute pulmonary thromboembolism. The pulmonary thrombus improved by use of an anticoagulation drug after a few weeks. The echocardiogram demonstrated good LV function with complete resolution of the right ventricular dysfunction (Online ). This case illustrates an unusual etiology of myocardial infarction in LMCA.
Anomalous Origin of Left Main Coronary Artery From Innominate Artery
A 73-year-old woman was admitted with progressive chest pain for 2 years. She had a history of hypertension for 9 years. Findings on physical examination were normal. Her low-density lipoprotein cholesterol level was 3.04 mmol/L. Electrocardiography and echocardiography results were normal. Cardiac computed tomographic coronary angiography showed an anomalous origin of the left main coronary artery (LMCA) from the innominate artery with ostial severe calcification ( Fig. 1.7 A).
The patient underwent coronary artery angiography, which confirmed the abnormal origin of the LMCA from the innominate artery and ostial severe stenosis of the LMCA ( Fig. 1.7 B, Online ). The LMCA bifurcated into the normal left anterior descending and left circumflex coronary arteries. The right coronary artery had a 50% stenosis (Online ). Intravascular ultrasound was performed to evaluate the LMCA lesion. The intravascular ultrasound image showed that the LMCA ostium had severe stenosis and calcification. The minimal luminal cross-sectional area was 2.87 mm 2 ( Fig. 1.7 C). A Resolute Integrity 4.0 × 30 mm stent (Medtronic, Minneapolis, Minnesota) was implanted ( Fig. 1.7 D, Online ). Repeat intravascular ultrasound showed complete stent apposition and full stent expansion.
An anomalous origin of the LMCA from the innominate artery is rare. This patient represented the third published case but the patient was the first to undergo percutaneous coronary intervention. , Combined computed tomography and coronary angiography are reliable for the diagnosis of LMCA origin from the innominate artery.
1. Santucci PA, Bredikis AJ, Kavinsky CJ, Klein LW: Congenital origin of the left main coronary artery from the innominate artery in a 37-year-old man with syncope and right ventricular dysplasia.Catheter Cardiovasc Interv 2001; 52: pp. 378-381.
2. Duran NE, Duran I, Aykan AC: Congenital anomalous origin of the left main coronary artery from the innominate artery in a 73-year-old woman.Can J Cardiol 2008; 24: pp. e108.
Anomalous Origin of the Left Internal Mammary Artery From the Aortic Arch
A 67-year-old man with diabetes who had a pacemaker for symptomatic bradycardia underwent cardiac catheterization for unstable angina 19 years after coronary artery bypass graft surgery. There were bilateral pedicled internal mammary grafts—from the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) and from the right internal mammary artery to the posterior descending coronary artery—as well as a saphenous venous graft to an obtuse marginal circumflex branch. Angiography revealed a patent right internal mammary artery and posterior descending coronary artery, and a culprit diseased saphenous venous graft (obtuse marginal). The LIMA–LAD could not be engaged at its expected origin from the left subclavian artery ( Fig. 1.8 A, Online ). The LAD was not collateralized, and there was no resting anterior wall motion defect. This prompted examination with cardiac computed tomographic angiography (CCTA) to clarify the origin of an anomalous LIMA.
CCTA revealed a patent pedicled LIMA graft with an unusual origin and course. It arose distal to the left subclavian artery and tracked anteriorly and vertically before looping down the anterior chest wall to supply the LAD ( Fig. 1.8 B). This was not mentioned in the surgical report. Angiography was resumed; the LIMA graft was selectively engaged uneventfully ( Fig. 1.8 C, Online ).
The LIMA arises from the intrascalenic course of the subclavian in 92% of patients, is interscalenic in 7%, and extrascalenic in 1%. To our knowledge, this is the first described case of an entirely separate origin of the LIMA from the distal aortic arch.
LIMAs have also been reported arising at the junction of the left subclavian and aorta or from an aberrant vertebral artery. , This case illustrates the potentially variable origin of the LIMA and the utility of CCTA in difficult graft studies. It also highlights the importance of looking for collaterals, as their absence in this case prompted further investigation for an anomalous vessel.
1. Henriquez-Pino JA, Gomes WJ, Prates JC, Buffolo E: Surgical anatomy of the internal thoracic artery.Ann Thorac Surg 1997; 64: pp. 1041-1045.
2. Chavez J, Osborn LA: Anomalous origin of left internal mammary artery from the lateral junction of the left subclavian artery and aorta.Cathet Cardiovasc Diagn 1996; 37: pp. 168-169.
3. Kirsch J, Williamson EE: Aberrant left internal mammary artery off an aberrant vertebral artery.Eur Heart J 2008; 29: pp. 1782.
Anomalous Origin of the Nonculprit Right Coronary Artery From the Left Anterior Descending Artery in a Patient With Anterolateral ST-Segment Elevation Myocardial Infarction
A 47-year-old man was admitted with anterolateral ST-segment elevation myocardial infarction ( Fig. 1.9 ) and underwent emergency coronary angiography ( Fig. 1.10 ) through the right radial artery. Attempts to cannulate the nonculprit right coronary artery (RCA) were unsuccessful, and subsequent contrast injection into the right sinus of Valsalva showed that the RCA did not arise from its usual position. Left coronary angiography showed a proximally occluded left anterior descending artery (LAD).
Coronary anomalies are usually found incidentally during coronary angiography, as the majority of these anomalies are benign and the patients remain asymptomatic. We present a rare coronary anomaly of an RCA originating from the midsegment of the left LAD. Very few similar cases have been reported in the published data to date. , A recent study shows that the prevalence of an anomalous RCA arising from the LAD has been 0.018% in patients undergoing coronary angiography, which is only 6% of all anomalies of coronary artery origin and course. In this anomaly the aberrant RCA usually has a course in front of the pulmonary artery and is associated with a good prognosis.
To our knowledge, this is the first reported case of acute occlusion of an aberrant RCA arising from the LAD as the result of acute thrombosis of proximal LAD. However, our patient had codominant circulation with the anomalous RCA providing a small posterior descending branch, and therefore he had no evidence of acute inferior wall ischemia (no inferior ST-segment elevations, no inferior wall motion abnormality with quick bedside echocardiography before the procedure, and no hemodynamic instability).
Interventional cardiologists must be aware of this rare coronary anomaly. In a setting of emergency catheterization for ST-segment elevation myocardial infarction, revascularization of the culprit artery should be performed promptly if the nonculprit artery cannot be readily cannulated first. In rare cases, the nonculprit coronary artery may have an anomalous origin from the culprit artery.
1. Yamanaka O, Hobbs RE: Coronary artery anomalies in 126,595 patients undergoing coronary angiography.Cathet Cardiovasc Diagn 1990; 21: pp. 28-40.
2. Hourani R, Haddad N, Zughaib M: Anomalous origin of the RCA from the proximal LAD and a single coronary artery anomaly: two case reports of two rare coronary anomalies.J Invasive Cardiol 2009; 21: pp. E216-E217.
3. Yuksel S, Meric M, Soylu K, et. al.: The primary anomalies of coronary artery origin and course: a coronary angiographic analysis of 16,573 patients.Exp Clin Cardiol 2013; 18: pp. 121-123.
4. Teragawa H, Okada K, Sueda T: Anomalous origin of the right coronary artery from the left anterior descending coronary artery.Heart 2004; 90: pp. 1492.
Concomitant Anomalous Right Coronary Artery and Iatrogenic Left Circumflex Artery Entrapment Treated Successfully With Percutaneous Coronary Intervention
The incidence of anomalous coronary arteries is approximately 1% with heterogeneous clinical outcomes. Left circumflex coronary artery (LCx) entrapment is an infrequently reported complication of mitral valve surgery and correlates to the dominance and the distance of the artery from the mitral annulus. Nearly all reported cases occur intraoperatively or immediately postoperatively. Our patient was seen 14 years after mitral valve annuloplasty with long-standing chest pain and dyspnea on exertion. Myocardial perfusion imaging showed a large area of inferolateral ischemia. Computed tomography angiography revealed an anomalous right coronary artery arising from the left cusp and coursing between the great arteries with a narrowed proximal segment. It also showed a severe focal stenosis of the LCx with traction of the artery toward the mitral valve, suggestive of an iatrogenic entrapment ( Fig. 1.11 ).
Cardiac catheterization confirmed the anomalous origin of the right coronary artery and the high-grade stenosis of the mid LCx ( Fig. 1.12 ). Intravascular ultrasound imaging of the LCx revealed a highly fibrotic, high-grade stenosis of the mid vessel. This lesion was treated with serial low-pressure balloon inflations using a compliant balloon. Stent implantation was performed using a 4.5 × 15 mm bare-metal stent (Vision, Abbott Vascular, Abbott Park, Illinois) followed by postdilation with a noncompliant balloon. The patient is completely symptom free at 6-month follow-up.
This is an unusual case of these two abnormalities occurring in the same patient with a late presentation, albeit with long-standing symptoms. In the literature, management of both conditions is largely anecdotal, and percutaneous coronary intervention is infrequently used.
1. Angelini P, Velasco JA, Flamm S: Coronary anomalies: incidence, pathophysiology, and clinical relevance.Circulation 2002; 105: pp. 2449-2454.
2. Grande AM, Fiore A, Massetti M, Viganò M: Iatrogenic circumflex coronary lesion in mitral valve surgery: case report and review of the literature.Tex Heart Inst J 2008; 35: pp. 179-183.
Dual Anomalous Origins of the Thyrocervical Trunk and Left Internal Mammary Artery
A 56-year-old man with diabetes and a history of triple coronary artery bypass graft surgery (left internal mammary artery [LIMA] to left anterior descending [LAD] artery, saphenous vein grafts to the posterior descending artery and the obtuse marginal artery) underwent coronary catheterization for unstable angina. Left main coronary artery angiography showed competitive follow in the distal left anterior descending coronary artery ( Fig. 1.13 , Online ). However, the LIMA could not be visualized despite multiple angiographic images of the left subclavian artery. Aortic arch angiography showed an artery coming off the aortic arch just distal to the origin of the subclavian artery ( Fig. 1.13 , Online ).
This artery appeared to be the anomalous origin of the thyrocervical trunk ( Fig. 1.14 ), and selective engagement of this branch was performed. The LIMA was seen to arise as a branch from this thyrocervical trunk ( Fig. 1.14 , Online ) and to supply the distal LAD. The right internal mammary artery was normal angiographically and arose from the proximal right subclavian artery ( Fig. 1.14 , Online ). The thyrocervical trunk usually originates from the upper part of the first subclavian artery segment, and the LIMA arises from the proximal part of the subclavian artery in 92% of cases, from the mid portion in 7% of cases, and from the distal part of the subclavian artery in 1% of cases. Anomalous origins of LIMA from the lateral junction of the left subclavian artery and aorta, from an aberrant vertebral artery, and from the aortic arch have been reported.
To our knowledge, this dual anomalous origin of the thyrocervical trunk and origin of the LIMA from it has not been reported. These rare anomalies should be considered before concluding that this important vessel is occluded. Competitive flow in LAD was an important clue in our case that this vessel was patent, although anomalous.
1. Lischka MF, Krammer EB, Rath T, Riedl M, Ellböck E: The human thyrocervical trunk: configuration and variability reinvestigated.Anat Embryol (Berl) 1982; 163: pp. 389-401.
2. Chavez J, Osborn LA: Anomalous origin of left internal mammary artery from the lateral junction of the left subclavian artery and aorta.Cathet Cardiovasc Diagn 1996; 37: pp. 168-169.
3. Kirsch J, Williamson EE: Aberrant left internal mammary artery off an aberrant vertebral artery.Eur Heart J 2008; 29: pp. 1782.
4. Hailan A, Obaid D, Zaidi A, Smith D: Anomalous origin of left internal mammary artery arising directly from the aortic arch.BMJ Case Rep 2014; bcr2014206583
Multimodality Imaging of an Anomalous Connection of the Right Coronary Artery With Aortic Intramural Course
A 47-year-old man underwent a medical examination. He was a professional firefighter, with no notable medical history, who regularly performed high-grade aerobic exercise. He denied any specific symptom at rest or during efforts. Results of his physical examination were unremarkable. An electrocardiogram showed nonspecific repolarization abnormalities in the lateral leads. Single-photon emission computed tomography revealed a small reversible defect in the inferolateral wall during stress. The workup was completed with a cardiac computed tomography, which showed a moderate stenosis of the distal left anterior descending artery and an anomalous connection of the right coronary artery from the left coronary sinus ( Fig. 1.15 A) with a narrowing of the initial segment through an aortic intramural course ( Fig. 1.15 B). The patient was referred for a coronary angiogram, which confirmed the anomalous connection of the right coronary artery and a typical nonatherosclerotic narrowing in right anterior oblique projection owing to the intramural course ( Fig. 1.15 C). Intravascular ultrasonography and optical coherence tomography demonstrated the oblong shape of the initial intramural lumen of the right coronary artery ( Fig. 1.15 D–E) with a 50% reduction in lumen surface compared with the proximal extramural lumen. The fractional flow reserve was 0.81 after administration of intravenous adenosine. Because of the evidence of an aortic intramural course associated with inducible ischemia and the potential risk for sudden cardiac death, it was decided to perform coronary bypass surgery of the right coronary artery with the right internal mammary artery. The operation was uncomplicated and the recovery was uneventful.
This report illustrates the capability of multimodality imaging in providing essential anatomic information on coronary arteries with anomalous origin and, more specifically, to demonstrate the presence of an aortic intramural course, a well-known at-risk anatomy, which is often confused in the literature with a compression between the aorta and pulmonary artery
1. Warnes C, Williams R, Bashore T, et. al.: ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease).J Am Coll Cardiol 2008; 52: pp. e143-e263.
Origin of Right and Left Coronary Arteries From the Right Sinus of Valsalva as a Common Coronary Trunk
A 71-year-old woman with a history of rheumatoid arthritis, pulmonary fibrosis, pericardiectomy, and a heavily calcified tricuspid aortic valve stenosis was referred for coronary angiography for preoperative evaluation for aortic valve replacement. The coronary angiogram demonstrated an anomalous coronary anatomy, with the origin of the right coronary artery and left main stem from the right sinus of Valsalva as a common coronary trunk (single coronary artery) ( Fig. 1.16 ). Multislice computed tomography confirmed the presence of a single coronary artery arising from the right sinus of Valsalva, with a posterior course of the main stem that turns behind the aorta in an inferoposterior direction ( Fig. 1.17 ). The coronary arteries were free of atherosclerotic disease. Because there was an unacceptable high surgical risk the patient was successfully treated with percutaneous aortic valve implantation.
The overall incidence of coronary anomalies in humans is 0.6% to 1.3%. An aberrant origin of the main stem from the right sinus of Valsalva represents one of the rarest forms of all coronary anomalies, and the situation of a single coronary artery is an extremely rare congenital anomaly that is seen in only 0.0024% to 0.044% of the population.
In the case of a single coronary artery arising from the right coronary sinus, the main stem takes one of four aberrant pathways to reach its proper vascular territory. These pathways are designated as type A (anterior to the right ventricular outflow tract), type B (between the aorta and pulmonary trunk), type C (cristal, coursing through the crista supraventricularis portion of the septum), and type D (dorsal or posterior to the aorta).
1. Liberthon RR, Dinsmore RE, Bharati S, et. al.: Aberrant coronary artery origin from the aorta: diagnosis and clinical significance.Circulation 1974; 50: pp. 774-779.
2. Yamanaka O, Hobbs RE: Coronary artery anomalies in 126,595 patients undergoing coronary angiography.Cathet Cardiovasc Diagn 1990; 21: pp. 28-40.
3. Desmet W, Vanhaecke J, Vrolix M, et. al.: Isolated single coronary artery: a review of 50,000 consecutive angiographies.Eur Heart J 1992; 13: pp. 1637-1640.
Primary Percutaneous Intervention in a Patient With Anterior and Inferior Wall Myocardial Infarction Because of a Rare Coronary Artery Anomaly
A 40-year-old male smoker had acute myocardial infarction involving the anterior and inferior walls at presentation. Electrocardiography showed ST-segment elevation in the anterior leads and the inferior leads, suggesting a probable occlusion of a type III left anterior descending coronary artery (LAD). Coronary angiography showed a single coronary artery originating from the left sinus of Valsalva. The LAD showed thrombus containing 95% long-segment stenosis after the first diagonal with thrombolysis in myocardial infarction (TIMI) flow grade 2 ( Fig. 1.18 ). A large vessel originating from the mid LAD just after the stenosis and after the course of the right coronary artery (RCA) had a TIMI flow grade 2 ( Fig. 1.18 A). Percutaneous coronary intervention of the LAD was performed by implanting a drug-eluting stent. TIMI flow grade 3 was achieved in both the anomalous RCA and the LAD ( Fig. 1.18 B). A computed tomography coronary angiogram obtained later revealed the anomalous RCA originating from the mid LAD that coursed to the right, anterior to the pulmonary artery and the right ventricular outflow tract ( Fig. 1.19 ). The anomalous origin of the RCA from the mid LAD is one of the rarest coronary anomalies reported to date. , Most anomalies of the RCA originating from the LAD are generally considered benign. However, ischemia because of this anomaly may be caused by the acute angle made by the anomalous RCA to turn toward the right atrioventricular groove, thereby causing reduced flow velocity. The course between the great arteries leading to compression of anomalous artery and atherosclerotic involvement of the vessels (jeopardizing a large amount of myocardium, as in the present case) may also cause angina or infarction. While performing primary percutaneous coronary intervention in such an anomaly, certain technical considerations such as protection of the anomalous RCA with a wire, use of a flexible and steerable wire (keeping in mind the angulated origin of the RCA), and mandatory kissing balloon technique despite good flow in the RCA, (this being a major epicardial artery and not a branch) should be kept in mind. This variant has not been listed in the classification of such an anomaly, but it resembles the IB1 category type of Shirani and Roberts’ classification.
1. Yiangou K, Georgiou G, Avraamides P, Kassianides M, Henein M: Anomalous origin of right coronary artery from the mid-left anterior descending artery.Int J Cardiol 2008; 129: pp. e59-e60.
2. Amasyali B, Kursaklioglu H, Kose S, Iyisoy A, Kilic A, Isik E: Single coronary artery with anomalous origin of the right coronary artery from the left anterior descending artery with a unique proximal course.Jpn Heart J 2004; 45: pp. 521-525.
3. Shirani J, Roberts WC: Solitary coronary ostium in aorta in the absence of major congenital cardiovascular anomalies.J Am Coll Cardiol 1993; 21: pp. 137-143.
Right Aortic Arch With Left-Sided Arteria Lusoria: A Challenge for Radial Interventionalists
A 67-year-old male, hypertensive nonsmoker was admitted with unstable angina. He had a history of acute anterior wall myocardial infarction 4 months earlier for which he underwent primary percutaneous coronary intervention (PCI) with stenting of the left anterior coronary artery (LAD). During primary PCI, an incidentally isolated right aortic arch ( Fig. 1.20 A, Online ) was noticed, and there was difficulty in hooking both right and left coronary arteries. However, the primary PCI with stenting of the culprit vessel LAD was performed by a transradial approach, and the left circumflex coronary artery (LCx) lesion was medically managed. During readmission, in view of the difficulties in the previous intervention owing to the right aortic arch, it was decided to perform coronary angiography by a left radial artery approach. Surprisingly, the guidewire was repeatedly entering the descending thoracic aorta, which was situated on the right of the spine. The TIG catheter (Terumo Corporation, Tokyo, Japan) was used to enter the arch and ascending aorta. With the M -shaped loop of the catheter ( Fig. 1.20 B, Online and ), it was realized that the left subclavian artery was arising anomalously from the descending thoracic aorta with a retroesophageal course. There was difficulty in hooking both right and left coronary arteries ( Fig. 1.20 C, Online ) with the TIG catheter. Coronary angiography showed a patent stent in the mid LAD with progression of the LCx lesion. Using a 6F extra backup guide catheter with gentle manipulation using the reverse end of a 0.035-in (190-cm) guidewire, we were successful in engaging the left coronary artery. The culprit lesion in the distal LCx was stented using a 2.5 × 24-mm drug-eluting stent. A later esophagogram using diluted contrast showed a severe indentation on the posterior aspect of the esophagus ( Fig. 1.20 D, Online ) caused by the retroesophageal course of the anomalous left subclavian artery. A computed tomography aortogram confirmed the right aortic arch ( Fig. 1.20 E) with an aberrant left subclavian artery arising from the descending thoracic aorta following a retroesophageal course ( Fig. 1.20 F), resulting in a prominent compression of the esophagus, a finding consistent with left-sided arteria lusoria. The sequential branching patterns of the arch of the aorta were left common carotid artery, right common carotid artery, and right subclavian followed by the anomalous left subclavian artery ( Fig. 1.20 G–H). A virtual computed tomography esophagogram showed significant compression of esophagus caused by the retroesophageal course of the left subclavian artery ( Fig. 1.20 ). However, the patient had never experienced dysphagia in the past despite significant compression of the esophagus.
Most patients with an aberrant subclavian artery are asymptomatic, and with increasing use of transradial access to perform coronary angiography, arteria lusoria may be discovered as an incidental surprise. Transradial coronary angiography and interventions in patients with arteria lusoria, though challenging, are feasible. To our knowledge, this is the first description of incidental discovery of right aortic arch with left-sided arteria lusoria in an adult during a transradial intervention.
Right Coronary Artery With Anomalous Origin: The Role of Imaging Techniques
A 19-year-old woman with no relevant medical history came to the hospital with typical chest pain that had started while she was running. Her electrocardiogram showed significant ST-segment elevation in inferior and V 4 to V 6 leads ( Fig. 1.21 ). In the transthoracic echocardiogram examination the left ventricle (LV) inferior segments were hypokinetic and the right ventricle (RV) systolic function was mildly impaired. Urgent coronary angiography was performed, revealing right coronary artery (RCA) arising from a single ostium in the left sinus of Valsalva ( Fig. 1.21 , Online ). Computed tomography coronary angiography confirmed this finding, demonstrating a sharpened proximal RCA coursing between the aortic root and pulmonary artery ( Fig. 1.22A –B). A significant increase of myocardial necrosis marker was observed (total creatine kinase 1207 IU/L, troponin I 271.73 μg/L). Cardiac magnetic resonance showed a subendocardial area of delayed gadolinium enhancement in the inferior LV wall and the RV ( Fig. 1.22C –D).
Given these findings, intervention was justified; therefore, a complete evaluation was performed to establish the treatment options. A second coronary angiography with intravascular ultrasound (IVUS) was performed for further evaluation. The IVUS results proved systolic compression and diastolic decompression of the proximal 20 mm of RCA. A 3 × 28-mm drug-eluting stent was directly implanted in the site of the compression with optimal angiographic result and adequate expansion demonstrated by IVUS ( Fig. 1.23 , Online – ). Before discharge, an exercise stress test result was normal and systolic LV and RV function was normalized on the echocardiogram. The patient was treated with instructions to take dual-antiplatelet therapy for at least 6 months. In symptomatic patients with anomalous origin of the RCA, intervention is indicated. In this case, integration of clinical presentation with the findings in imaging techniques was essential to decide the best management strategy.
A Giant Coronary Artery Aneurysm Treated With a New-Generation Drug-Eluting Stent
A 40-year-old man came to our facility with progressive angina 1 month after an unsuccessful attempt at right coronary artery (RCA) revascularization after a non–ST-segment elevation myocardial infarction. Coronary angiography revealed a dominant RCA with a very large aneurysm in the mid segment that was totally occluded ( Fig. 1.24). The distal vessel was large, with mild atherosclerotic disease filling via bridging collateral vessels. The left anterior descending and circumflex coronary arteries were ectatic and large vessels.
The RCA was treated with a Synergy (Boston Scientific, Natick, Massachusetts) 4.0/38-mm stent with excellent angiographic results. Computed tomography angiography confirmed the presence of a giant aneurysm measuring 12.9 × 19 mm ( Fig. 1.25 ). Angiography at 6 months showed a patent stent with good distal flow and no flow into the aneurysm ( Fig. 1.26 ).
Covered stents have been used for percutaneous treatment of coronary aneurysms despite poor short- and long-term outcomes. In view of our patient’s age, we decided to treat the thrombosed aneurysm with a drug-eluting stent. This novel use of a drug-eluting stent in symptomatic, young patients with a coronary aneurysm and complex anatomy proved to be a successful and relatively safe approach with potentially better long-term outcomes.
1. Boyer N, Gupta R, Schevchuck A, et. al.: Coronary artery aneurysms in acute coronary syndrome: case series, review, and proposed management strategy.J Invasive Cardiol 2014; 26: pp. 283-290.
2. Heuser RR, Diethrich EB, Papaoglou C, Reynolds GT: Endoluminal grafting for percutaneous aneurysm exclusion in an aortocoronary saphenous vein graft: the first clinical experience.J Endovasc Surg 1995; 2: pp. 81-88.
3. Heuser RR: Treatment for coronary aneurysms: twenty years of experience with covered stents.J Invasive Cardiol 2015; 27: pp. E36.
Acute Myocardial Infarction Caused by Left Main Coronary Artery Compression as a Result of a Mycotic Aneurysm of the Sinus of Valsalva
An 83-year-old woman with a history of fever had severe chest pain progressing to cardiogenic shock. Her electrocardiogram showed evidence of anteroseptal myocardial infarction (MI). Urgent coronary angiography, with intraaortic balloon pump support, indicated total occlusion of the left main trunk (LMT) ( Fig. 1.27 A). Drug-eluting stents were successfully implanted from the LMT into the proximal left anterior descending (LAD) coronary artery ( Fig. 1.27 C). Subsequently, computed tomography (CT) angiography was performed to understand the etiology of acute MI, because the LAD with no plaque was determined to be compressed from the outside, on the basis of preprocedural intravascular ultrasonography ( Fig. 1.27 B, a–d). CT demonstrated a 4 × 3 cm aneurysm with a 1-cm wide neck from the left sinus of Valsalva (SVA) causing external compression of the LMT ( Fig. 1.28 ). Because subsequent SVA rupture may have led to acute hemodynamic instability, early elective surgical treatment of the SVA was considered. Surgery (aortocoronary bypass surgery and aortic root reconstruction) was performed successfully and confirmed the presence of the SVA, which contained organized thrombus and pus and was directly compressing the LMT. Because antibiotics were administered before surgery, acquired etiologic factors were not detected. Echocardiography after the operation showed a normal aortic root with no aortic regurgitation, and left ventricular function had improved. The patient died as a result of deterioration of interstitial pneumonia 2 weeks after surgery.
Acute MI resulting from compression of the LMT associated with a left mycotic SVA is extremely rare and often carries a poor prognosis. The proposed pathophysiologic mechanism in this case was that the infective aneurysm of the left coronary cusp in the SVA may have caused weakness in the tunica media layer, leading to rapid expansion. This, in turn, may have precipitated the MI, as well as the cardiogenic shock. Both intravascular ultrasound and CT can play an important role in achieving an accurate and rapid diagnosis.
1. Lijoi A, Parodi E, Passerone GC, Scarano F, Caruso D, Iannetti MV: Unruptured aneurysm of the left sinus of Valsalva causing coronary insufficiency: case report and review of the literature.Tex Heart Inst J 2002; 29: pp. 40-444.
2. Ott DA: Aneurysm of the sinus of Valsalva.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2006; 9: pp. 165-176.
3. Regueiro Abel M, Penas Lado M, López Ciudid V, Castro Beiras A: Sinus of Valsalva aneurysm as a cause of acute myocardial infarction [in Spanish].Rev Esp Cardiol 2002; 55: pp. 77-79.
4. Hausinger P, Sasi V, Volford G, et. al.: Unruptured aneurysm of the left sinus of Valsalva compressing the left main coronary artery: successful percutaneous treatment.Herz 2014; 39: pp. 770-773.
Formation of Infectious Coronary Artery Aneurysms After Percutaneous Coronary Intervention in a Patient With Acute Myocardial Infarction as the Result of Septic Embolism
A 68-year-old man who underwent aortic valve replacement (biological valve, Carpentier-Edwards Perimount Magna aortic bioprosthesis 21 mm, Edwards Lifesciences, Irvine, California) for aortic valve regurgitation without coronary artery disease 5 months earlier was admitted to our institution because of prolonged fever. Fifteen hours after admission, he suddenly experienced severe chest pain with ST-segment elevation in the lateral and aVR leads. Emergency coronary angiography (CAG) showed a contrast medium filling defect for the left main trunk (LMT), the proximal left anterior descending coronary artery (LAD), the ostial left circumflex coronary artery (LCx), and the ramus intermedius artery (RA) ( Fig. 1.29 , Online ). Owing to insufficient intracoronary aspiration, a stent was implanted at the LMT and proximal LAD. After using the kissing balloon technique for the LAD and LCx, acceptable coronary flow for the LAD and LCx was obtained, although the RA was occluded ( Fig. 1.30 A–B, Online and ). On the basis of the Duke criteria (i.e., more than two positive blood cultures [ Staphylococcus epidermidis ], predisposing heart condition, fever, and major arterial embolism), a diagnosis of prosthetic valve endocarditis and subsequent myocardial infarction as the result coronary artery septic embolism was made. The infection was controlled by intravenous vancomycin administration for more than 2 months. CAG performed 1 year later showed a giant aneurysm with coronary flow disturbance in the RA and a small aneurysm in the LMT ( Fig. 1.30 C–D, Online and ). Repeated CAG performed after 5 years of careful clinical follow-up showed that the giant coronary artery disappeared in association with the RA occlusion, and the small aneurysm in the LMT remained unchanged ( Fig. 1.30 E–F, Online and ).
Although some reports have previously described coronary embolization caused by infectious endocarditis, none showed aneurysm formation in the culprit coronary artery during follow-up. The possible mechanism responsible for the aneurysm formation was infectious embolism. In the current case, long-term angiographic follow-up demonstrated that the infectious aneurysms did not deteriorate.
1. Jeremias A, Casserly I, Estess JM, Smedira NG, Topol EJ: Acute myocardial infarction after aortic valve endocarditis.Am J Med 2001; 110: pp. 417-418.
2. Bracco D, Noiseux N, Duong P, Prieto I, Basile F: Aortic vegetation and acute coronary embolism.Can J Cardiol 2006; 22: pp. 113.
3. Motreff P, Roux A, Souteyrand G: Aspiration therapy in septic coronary embolism complicating infectious endocarditis.Heart 2010; 96: pp. 809.
4. Roxas CJ, Weekes AJ: Acute myocardial infarction caused by coronary embolism from infective endocarditis.J Emerg Med 2011; 40: pp. 509-514.
Left Internal Mammary Artery Graft Decompression by Covered Stent Treatment of an Adjacent Saphenous Vein Graft Pseudoaneurysm
A 75-year-old man with a history of coronary artery bypass grafting and recent pacemaker site infection was transferred to our institution for treatment of a descending aortic pseudoaneurysm. A computed tomography scan performed on arrival also revealed a suspected mycotic aneurysm of the saphenous vein bypass graft to the circumflex coronary artery. After consultation with infectious disease specialists, the descending aortic pseudoaneurysm was treated with an endograft, and the patient underwent cardiac catheterization. This revealed not only the pseudoaneurysm of the saphenous vein bypass graft to the circumflex artery ( Fig. 1.31 ), but also associated compression of the left internal mammary artery graft to the left anterior descending coronary artery ( Fig. 1.32 ). Additionally, the patient was found to have an ischemic cardiomyopathy with an ejection fraction of 30% and anteroapical hypokinesis. Ventricular function had been normal just a few months earlier. The patient was deemed not to be a surgical candidate. After a complete course of antibiotic therapy for methicillin-susceptible Staphylococcus aureus , repeat discussion with infectious disease specialists, and institutional review board approval for their off-label use, two Jostent GraftMaster (Abbott Vascular, Abbott Park, Illinois) stents were implanted in the saphenous vein graft to the native circumflex coronary artery ( Fig. 1.33 ). This excluded the pseudoaneurysm, restored normal flow to the distal native circumflex artery ( Fig. 1.34 ), and within 1 week resulted in decompression of the left internal mammary artery to the left anterior descending artery ( Fig. 1.35 ). The patient was discharged home using long-term dual-antiplatelet and suppressive antibiotic therapy. Follow-up echocardiography revealed normal left ventricular function.
Mycotic aneurysms remain an uncommon clinical occurrence, usually in the setting of infective endocarditis or endovascular infections. There are only a few case reports of mycotic aneurysms of the native coronary arteries and fewer in bypass grafts. Surgical treatment has been the mainstay of therapy but carries a high risk for those patients with multiple comorbidities. The percutaneous approach used in this patient offers a suitable alternative to surgery, but the long-term risk of recurrent infection is unknown.
1. Kapur NK, Conte JV, Wittstein IS: Successful management of an unruptured mycotic coronary aneurysm.J Invasive Cardiol 2007; 19: pp. E366-368.
2. Le MQ, Narins CR: Mycotic pseudoaneurysm of the left circumflex coronary artery: a fatal complication following drug-eluting stent implantation.Catheter Cardiovasc Interv 2007; 69: pp. 508-512.
3. Geneidy AA, Weise WJ: Coronary artery bypass graft mycotic aneurysms in a dialysis patient.Am J Kidney Dis 2005; 46: pp. 962-1926.
4. Hirsch GA, Johnston PV, Conte JV, Achuff SC: Mycotic aortocoronary saphenous vein graft aneurysm presenting with unstable angina pectoris.Ann Thorac Surg 2004; 78: pp. 1456-1458.
Recurrent Myocardial Infarctions as a Result of Thrombosis of a Coronary Aneurysm in Neurofibromatosis Type 1: Is Antiplatelet Treatment Enough?
A 68-year-old woman was admitted for an anterolateral myocardial infarction (MI). She had neurofibromatosis type 1 and 2 previous hospitalizations for non–ST-segment elevation MI that was medically treated. In those episodes, aneurysmal coronary arteries with fresh thrombus in left anterior descending artery were described.
Emergent coronary angiography revealed a giant aneurysm in the mid left anterior descending artery with multiple small fresh thrombi ( Fig. 1.36 A–C, Online – ). There was thrombolysis in myocardial infarction grade flow 3 and no significant stenosis. Aneurysmal dilations without significant stenosis were also observed in the right coronary and circumflex arteries ( Fig. 1.36 A–D). Triple-antiplatelet therapy (aspirin, clopidogrel, abciximab [intracoronary bolus and 12-hour perfusion]) and anticoagulation (enoxaparin 60 mg twice a day) medications were administered.
One week later, scheduled coronary angiography showed a complete angiographic resolution of the thrombus ( Fig. 1.36 E–F, Online and ). No percutaneous coronary intervention was performed. Given that this episode was the third MI in aneurysmal coronary arteries, we decided to continue permanent anticoagulation and double-antiplatelet therapy for 1 year. Fourteen months later, the patient remains asymptomatic without any event.
Vascular manifestations of neurofibromatosis type 1 consist of aneurysmal and stenotic abnormalities that can affect different arterial territories. Although effects on coronary arteries are extremely rare, coronary aneurysms have been described and can cause MI by thrombosis, vasospasm, and stenosis. No consensus exists regarding the treatment, and several percutaneous coronary interventions (thromboaspiration, stent implantation) and antithrombotic regimens have been used. If thrombolysis in myocardial infarction grade flow 3 is preserved and no significant stenosis exists, a conservative management with antithrombotics and permanent anticoagulation may be the best option and could reduce further events.
1. Trevelyan J, Been M, Patel R: Multiple coronary aneurysms in a patient with neurofibromatosis type 1: case report and intravascular ultrasound of aneurysm.Postgrad Med J 2001; 77: pp. 45-47.
2. Syed M, Lesch M: Coronary artery aneurysm: a review.Prog Cardiovasc Dis 1997; 40: pp. 77-84.
3. Smith A, Araoz PA, Kirsch J: Coronary arterial aneurysms in neurofibromatosis 1: case report and review of the literature.J Thorac Imaging 2009; 24: pp. 129-131.
Salmonella Enteritidis Mycotic Aneurysm of Stented Saphenous Vein Graft to Coronary Artery
A 67-year-old man with a history of hypertension and coronary artery disease (requiring aortocoronary bypass 18 years earlier and multiple percutaneous coronary interventions) came to a referring hospital with chief symptoms of fever, chills, and diaphoresis after a recent gastrointestinal illness. Blood cultures obtained revealed Salmonella bacteremia. Transesophageal echocardiography revealed no evidence of endocarditis and he was treated with intravenous ciprofloxacin.
One month after discharge, he returned with recurrent fevers with blood cultures revealing recurrent Salmonella growth. He started an outpatient course of intravenous ceftriaxone before developing increased shortness of breath prompting his return. His physical examination showed increased jugular venous pressure and marked crackles in both lungs; a chest radiograph showed pulmonary edema and enlargement of the left atrium ( Fig. 1.37A ). Troponin I was elevated at 63 ng/mL. A transthoracic echocardiogram revealed a reduced ejection fraction of 30% to 35%. Coronary angiography showed severe native 3-vessel disease with a patent left internal mammary graft to the left anterior descending artery, saphenous vein graft (SVG) to the right coronary artery, as well as an occluded vein graft to the diagonal. More notably, angiography of the SVG to the first obtuse marginal branch showed a large aneurysm ( Fig. 1.37 B) around a previously stented segment in the body that had ruptured into the left atrium/left atrial appendage (Online ).
The patient was transferred subsequently to our institution for further evaluation and surgical treatment. Transesophageal echocardiography ( Fig. 1.37 C) revealed a 6.5 × 5 cm mass invading the left atrial appendage. A computed tomography angiogram of his chest ( Fig. 1.37 D–F) was obtained and showed a large thick-walled contrast collection along the left margin of the main pulmonary artery, which appeared to communicate with the left atrial appendage. Direct observation during surgery revealed a ruptured SVG aneurysm communicating with the pulmonary artery and left atrial appendage. The SVG aneurysm was resected successfully with repair of the left atrial appendage and the main pulmonary artery. Culture of his saphenous venous aneurysm identified Salmonella enteritidis. He had an uncomplicated postoperative course and was discharged 7 days after surgery receiving intravenous ceftriaxone for 6 weeks followed by chronic suppressive therapy with oral amoxicillin-clavulanic acid. A repeat computed tomography angiogram was performed 2 months after surgery, which showed no new signs of fluid collection or infection.
Coronary stent infection is a rare complication with only 17 documented cases from 1990 to 2012. Nontyphoidal Salmonella is a rare cause of bacteremia and an even rarer cause of mycotic aneurysms in atherosclerotic vessel. A stented vessel may be an additional risk factor for developing such a complication, and a high index of suspicion should be maintained for patients not clearing Salmonella bacteremia despite optimal antimicrobial therapy. Multiple imaging modalities may be needed to confirm a diagnosis of coronary stent infection. Transesophageal echocardiography may reveal an aneurysm, but coronary angiography/computed tomography angiography is almost always required to confirm the diagnosis and detect complications such as vessel aneurysm or pseudoaneurysm. Positron emission tomography computed tomography is an active area of interest in diagnosis because it may be used to reveal occult inflammation surrounding the stent. Surgical excision is almost always required, especially in stent-related infections that occur remotely after implantation.
1. Elieson M, Mixon T, Carpenter J: Coronary stent infections: a case report and literature review.Tex Heart Inst J 2012; 39: pp. 884-1849.
2. Wang JH, Liu YC, Yen MY, et. al.: .Clin Infec Dis 1996; 23: pp. 743-747.
3. Sekhar S, Vupputuri A, Nair RC, Palaniswamy SS, Natarajan KU: Coronary stent infection successfully diagnosed using 18F-flurodeoxyglucose positron emission tomography computed tomography.Can J Cardiol 2016; 32: pp. 1575.e1-1575.e3.
Sinus of Valsalva Aneurysm Causing Extrinsic Compression of the Left Main Coronary Artery
An 84-year-old woman with aortic valve stenosis was seen after a month-long history of midsternal chest pain with exertion that was relieved with rest. Stress testing was performed and revealed possible ischemia in the anterior wall. She then underwent coronary angiography and was found to have a giant aneurysm of the left sinus of Valsalva ( Fig. 1.38 ) causing critical left main coronary artery compression ( Fig. 1.39 ). Computed tomographic angiography revealed similar findings, which led to the diagnosis of crescendo angina secondary to extrinsic compression of the left main coronary from the giant sinus aneurysm ( Fig. 1.40 ). She was emergently taken to the operating room, and the aorta was opened obliquely with wide exposure of the aortic root and aortic valve leaflets. The “mouth” of the aneurysm was identified, and the rim of the aneurysm was noted to be involved with the annular segment of the left coronary leaflet, as well as with the bottom of the left coronary ostia ( Fig. 1.41 ). A tailor patch of the native pericardium was sewn in to completely close the mouth of the aneurysm.
Aneurysms of the left sinus of Valsalva are extremely rare, and compression of the coronary artery causing coronary insufficiency and anginal symptoms is an uncommon complication. These cases require an aggressive surgical approach once the diagnosis is made to prevent serious cardiac ischemia. Patients with this rare malformation who do not undergo prompt surgical correction are at risk for further aneurysmal dilation, malignant arrhythmias, left ventricular failure, and sudden death with rupture. ,
1. Takach TJ, Reul GJ, Duncan JM, et. al.: Sinus of Valsalva aneurysm or fistula.Ann Thorac Surg. 1999; 68: pp. 1573-1577.
2. Bjursten H, Harnek J, Cunha-Goncalves D , Koul B: Giant aneurysm in the sinus of Valsalva presenting as an acute coronary symptom.Interact Cardiovasc Thorac Surg 2013; 17: pp. 193-195.
3. Lijoi A, Parodi E, Passerone GC, Scarano F, Caruso D, Iannetti MV: Unruptured aneurysm of the left sinus of Valsalva causing coronary insufficiency.Tex Heart Inst J 2002; 29: pp. 40-44.
A Beating Left Main Coronary Artery
A 37-year-old man with a history of active smoking and heroin addiction was admitted after successful prehospital intravenous fibrinolysis for ST-segment elevation myocardial infarction. Coronary angiography ( Fig. 1.42 ) performed systematically after fibrinolysis showed a dynamic severe systolic compression ( black arrow ) of the left main coronary artery (LM) with a “milking effect” (Online ) and a thrombotic lesion ( white arrow ) of the left circumflex artery. Intracoronary optical frequency domain imaging showed a thrombotic lesion of the left circumflex coronary artery ( Fig. 1.43 A) and an ovoid deformation of the LM ( Fig. 1.43 B) that was free of atherosclerosis. Cardiac multislice computed tomography ( Fig. 1.44 ) showed that the LM originated near the right coronary artery with an initial course between the aorta and the pulmonary artery. Because of the assumed high risk for sudden cardiac death, the patient underwent coronary artery bypass surgery with native vessel ligation, confirming the ectopic course of the LM ( Fig. 1.45 ).
Ectopic origin of the LM arising from the right aortic coronary sinus is a rare condition, found in 0.025% to 0.15% of patients undergoing coronary angiography. The inter-aorticopulmonary course of the LM is associated with a high risk for sudden cardiac death and requires adequate correction. Surgical options are bypass grafting, pulmonary artery translocation, ostium reimplantation, or an unroofing technique in case of an intramural aortic segment. LM stenting has also been performed as an alternative with a risk for stent compression.
The unusual location of a milking effect on the LM should lead to adequate imaging modalities for the detection and correction of an ectopic inter-aorticopulmonary course of the LM.
1. Taylor AJ, Rogan KM, Virmani R: Sudden cardiac death associated with isolated congenital coronary artery anomalies.J Am Coll Cardiol 1992; 20: pp. 640-647.
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