Table 16.1 Classification of Coronary Anomalies
potential. This anomaly is especially critical to recognize because of its mortality implications in the young, specifically in athletes and military recruits, as well as because of its potential to cause disabling angina, dyspnea, and syncope. Anatomists have long debated the mechanisms and specific anatomic features of ACAOS that may lead to critical ischemia. Initially, a slit-like orifice, tangential orientation of the origin, a passage between the aorta and the pulmonary artery, or ostial fibrous ridges were implicated in the causation of ischemia in ACAOS cases. More recently, accurate in vivo imaging of such anomalies by intravascular ultrasound (IVUS), as well as some anatomic evidence, has led to the clear conclusion that the intramural proximal course of the ectopic ACAOS coronary artery, inside the aortic wall, is the recurrent and quantifiable mechanism of ACAOS-related ischemia (Figures 16.2, 16.3, 16.4, 16.5 and 16.6).