Keywords:
Anomalous origin of the left coronary artery from the opposite sinus of
Valsalva; Anomalous Coronary Artery; three-dimensional transoesophageal
echocardiography; coronary ostial morphology.
Text :
A 43 year-old Caucasian male was admitted to our emergency department
for typical chest pain occurring after exercise. The physical
examination and rest electrocardiography were unremarkable. The patient
was a chronic smoker with a history of untreated arterial hypertension.
A coronary CT scan revealed anomalous origin of the left coronary artery
from the opposite sinus of Valsalva with an inter-arterial course,
without significant coronary artery disease (Figure 1). We performed a
complete evaluation of the coronary anatomy with transesophageal
echocardiography (Figure 2). We analyzed specific aspects of the anatomy
of the anomalous coronary artery as described in recent
publications.[1,2] In particular: 1) Proximal course of the coronary
arteries 2) Number of ostia and ostial morphology 3) angle of take-off
and 4) level of take-off of the anomalous coronary artery. Through
coronary CT and transesophageal echocardiography, we detected: 1)
anomalous origin of the left coronary artery from the opposite sinus
with an inter-arterial course 2) A common coronary ostium in the right
sinus of Valsalva, giving rise to the right and left main coronary
arteries, with three- dimensional visualization 3) Acute take-off angle
of the anomalous left coronary artery (defined as less than 45°) with 4)
take-off level below the commissure.
Anomalous origin of the left coronary artery from the opposite sinus of
Valsalva is an important cause of sudden death in young adults[3].
Post mortem studies have described associated acute take-off angle and
slit-like elliptical ostium in the anomalous coronary artery leading to
sudden death in such patients[4]. Abnormal ostial morphology and
acute take-off are considered potential mechanisms of flow obstruction
in the anomalous coronary artery[5]. Cross-sectional coronary
angiography with cardiac CT scan or magnetic resonance is considered
necessary to accomplish 3D visualization of the coronary artery
ostium[1]. We present a proof of concept describing how
three-dimensional transoesophageal echocardiography can be used to
visualise the coronary ostium and proximal course in patients with
anomalous coronary artery. However, the accuracy of such imaging
modality in the routine evaluation of the anomalous coronary artery is
unknown, and further investigation is needed.
Acknowledgements: None.
Financial Support: This research received no specific grant
from any funding agency, commercial or not-for-profit sectors.
Conflict of Interest: None
Author contributions: G.G. designed and directed the project.
M.P. helped supervise the project. G.G. wrote the manuscript. C.A. and
M.P. authors contributed to the final version of the manuscript.