CORONARY A ANOMALY.....................................pptx

HEALTH

1. CAA can be defined as a abnormal coronary pattern or feature that is encountered in around 1 % of the general population.

2. IMPORTANCE OF coronary anomalies awareness Difficulty during cannulation Needs to know before going to any thoracic surgery especially in congenital heart disease Some anomaly can cause ischemia and prone for atherosclerosis More importantly some can cause SCD Increased risk of bacterial endocarditis- Coronary fistula. Ischemic cardiomyopathy Volume overload

3. Anomalies of origin Absent left main trunk ( split or separate origination of LCA ) Occurs in about 1% More frequent with BAV and left dominance No clinical consequences Coronary ostia are smaller

4. High Low Commissural High : It is defined as origin of a coronary artery more than 1 cm above the stj . It usually does not present with clinical problem , however the preoperative identification of this anomaly is important in case of ascending aorta surgery may cause difficulties engagement coronary ostium within aortic root or near proper aortic sinus Anomalies of origin

5. Single coronary artery Incidence 0.024% Single ostium with absence of an ostium in opposite sinus No other coronary artery from an ectopic site 40% associated with cardiac malformations(TGA, TOF, TA, coronary-cameral fistulas, and BAV) Anomalies of origin

6. A L CA P A , Bland-White-Garland syndrome (BWG) LCA arises from PA usually from left posterior facing sinus Fetus-both coronary arteries receive forward flow Early after birth - Anterolateral infarct and slight retrograde flow from LCA to PA 15% of patients-myocardial blood flow can sustain myocardial function at rest or even during exercise Adult-Enlarged RCA and collaterals and significant retrograde flow into PA . Anomalies of origin

7. Clinical features Paroxysmal attacks of acute discomfort precipitated by feeding CHF at 2 to 3 month Physical examination-CHF,MR Abnormal Q waves in leads I, aVL, and precordial leads V4 to V6 Older children and adults -may be asymptomatic or have dyspnea, syncope, or exertional angina Sudden death after exertion

8. Echo Abnormal origin of LCA Flow passes from RCA into PA Enlarged RCA RWMA and mitral regurgitation

9. Aortic root angiography Dilated RCA Absence of left coronary osteum large collaterals-filling of LAD and Lcx Later MPA and LMCA filled by LAD and LCX branch

10. Anomalous Origin of LCA the from Pulmonary Artery (

11. Treatment Ligation of LCA at its origin Direct reimplantation of origin of LCA into aorta (with a button of PA around the origin) Ligation of origin of LCA and reconstitution of flow through it with subclavian arterial or SVG Takeuchi procedure- aortopulmonary window is created and a tunnel fashioned that directs blood from aorta to LCA

12. other artery Anomalous Origination of RCA, LAD or Cx Artery From PA Typically recognized by atypical angina, systolic heart murmur , abnormal stress test or angiography In absence of major clinical manifestations not an indication for surgery

13. Anomalous origination of coronary artery from the opposite sinus (ACAOS ) uncommon , Its incidence is around 1.07% . RCA from left aortic sinus LAD from right aortic sinus Cx from right aortic sinus LMS from right aortic sinus ARCA~ 6 times more prevalent than ALCA ALCA has a higher risk of SCD and have anomalous course: interaterial, prepulmonic, intraseptal, retroaortic, posterior atrioventricular groove or retrocardiac, postero- anterior interventricular groove

14. Right coronary originating from the left coronary sinus Right coronary artery originating from the left coronary sinus or as a branch of a single coronary artery is found in 0.03% to 0.17% of the individuals submitted to angiography. The most common proximal pathway of the right coronary in such cases is interarterial, and can be associated with sudden cardiac death in up to 30% of patients

15. LCA from right anterior sinus, with anomalous course Between aorta and PA Anterior to PA Retroaortic Intraseptal Posterior AV groove Postero-anterior interventricular groove

16. RCA from left sinus , with anomalous course(ARCA) Posterior AV groove or retrocardiac Retroaortic Between aorta PA ( Most common, 30% mortality ) Intraseptal Anterior to pulmonary outflow Posteroanterior interventricular groove (wraparound)

17. Both right and left ACAOS have significant clinical consequence if the ectopic artery has an interarterial course or intramural intussusception A constant relationship is observed between left ACAOS and sudden death or ischemia during extreme exercise . Right ACAOS with an interarterial course is a type of ACAOS which poses high risk for myocardial ischemia or sudden death as well Most of ACAOS patients are asymptomatic. Atypical chest discomfort is the most prevalent symptom urging patients to refer to the health facility and to perform the coronary angiography to detect ACAOS

18. SUDDEN DEATH H a r d activi t y c auses dil at a tion o f aortic r o o t and pul m ona r y t runk which compresses slit-like ostium or particular segment of ectopic coronary artery. This occurs especially in individuals with sufficient aortic distensibility, such as in young people or sportsmen.

19. Sudden cardiac death associated with four risk factors Slit-like coronary orifice Acute angle of take-off from aorta Presence of aortic intramural coronary arteries Inter-arterial course between aorta and PA

20. Left coronary trunk originating from the right coronary sinus Left coronary trunk originating from the right coronary sinus or as a branch of a single coronary artery occurs in 0.09% to 0.11% of the individuals submitted to angiography . Proximal interarterial course occurs in 75% of such patients

21. Anterior descending or circumflex arteries originating from the right coronary sinus circumflex artery is the one that most commonly presents anomalous origin, occurring in 0.32% to 0.67% of the population. Retroaortic pathway is its most common course, and there is no association with sudden death. The anterior descending artery with anomalous origin rarely occurs in individuals with a normal cardiac anatomy. It is generally associated with Fallot’s tetralogy, complex transposition and double right ventricular output tract

22. Surgical and Catheterization-Based Intervention Both su r gi c al r e v asculari z a tion ( e g , m a r supiali z a tion, c o r ona r y b ypa s s , or coronary reimplantation) and limited cases of transcatheter stenting have been reported to have short-term stability, without long-term follow-up

23. Anomalous course of coronary artery approximately 80% of anomalous coronary artery courses are benign and asymptomatic. However, on rare occasions, it can result in ischaemia, arrhythmias or sudden death. Pathology It may be associated with a "slit-like" orifice in which an acute angle course at the ostium is more prone to occlusion. During physical activity, the artery may be compressed, and the flow within it may be compromised.  malignant course interarterial (i.e. between the aorta and the pulmonary artery): this is the most dangerous as it carries a high risk of sudden cardiac death  benign course retroaortic prepulmonic septal ( subpulmonic )

24. Treatment benign course rarely need surgical treatment . Symptomatic patients with an inter-arterial course may require surgical "re-implantation" of the anomalous coronary artery or "de-roofing" if an intramural course is present.

25. Intramural course (or myocardial bridge) Intramural coronary artery (muscular bridge) More than 1-5% of incidence Most commonly associated with ventricular hypertrophy(HOCM) Coronary artery segment of variable length covered by myocardial fibers Angiographic recognition of systolic narrowing Phasic narrowing of a coronary aftery may also occur in ventricular aneurysms or pericardial fibrous bands

26. U sign- Artery's accentuated descent from its subepicaardial location Most commonly involve proximal LAD Systolic stenosis is unlikely to cause coronary flow reduction Rare reports of spasm, thrombus and atherosclerotic change

27. Flg u re 2A · 2B , Coronary angiograp i'f showed signi cant myocardial bridg i ng across tha m i ddle segment o the left an1erior descend i ng artery (LAD ).

28. By intravascular ultrasound clinically significant myocardial bridges are characterized by - phasic systolic vessel compression, persistent reduction in diastolic lumen, increased blood flow velocities, retrograde systolic flow, and decreased coronary flow reserve. management- surgical de-bridging and even stent implantation have been successfully carried out in symptomatic cases

29. CORONARY FISTULAS A sizable communication between a coronary artery and a cardiac cavity or any segment of systemic or pulmonary circulation

30. Fistulas from RCA, LCA, or infundibular artery to RV,RA,CS , SVC, PA, PV,LA, LV, Multiple(right+left ventricles) Originate from left coronary artery system (50-60%), right coronary artery system (30-40%), or both (2-5%) Most fistulas (90%) drain into right heart The haemodynamic consequences of CA fistulae depend mainly on the resistance (which is determined by fistula size, tortuosity, and length) and on the site of drainage.

31. Compli ca tions Aneurysm formation Intimal ulceration Medial degeneration Intimal rupture Atherosclerotic deposition Calcification Side branch (nutrient) obstruction Mural thrombosis Coronary rupture

32. SURGERY Surgical fistula closure can be successful if CAVF is well defined and clear surgical access is believed to be technically achievable. Recurrence may be a problem if anatomic definition is suboptimal, and surgery may be difficult to perform owing to poorly visualized, typically distal fistulous connections. Surgical closure of audible CAVF with appropriate anatomy is recommended in all large CAVFs and in small to moderate CAVFs in the presence of symptoms of myocardial ischemia, threatening arrhythmia, unexplained ventricular dysfunction, or left atrial hypertension

33. Catheterization-Based Intervention Numerous reports of transcatheter closure with coils or detachable devices describe near or complete CAVF occlusion in attempted closure procedures . Criteria for transcatheter closure of CAVF are similar to those used for surgical closure of CAVF. Transcatheter closure of CAVF should be performed only in centers with particular expertise in such intervention.

34. 2018 AHA/ACC Guideline for evaluation of anomalous coronary artery

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