Surgical Correction of Coronary Arteriovenous Fistula in the Newborn Period / 日本心臓血管外科学会雑誌

Coronary arteriovenous fistula (CAVF) is defined as an abnormal communication between the coronary artery and a cardiac cavity or a major blood vessel. It is the most common congenital anomaly of the coronary arteries, but it is relatively rare, accounting for only approximately 0.4% of all congenital heart diseases. Most cases of CAVF are clinically asymptomatic in young patients, but with increasing age, symptoms begin to appear and surgical treatment is required. In rare cases of CAVF, however, symptoms may appear in the neonatal period and early surgery may be required. In this article, we report the case of a 12-day-old patient diagnosed after birth with CAVF between the aneurysmatic left anterior descending artery and the right ventricle. This patient required early surgical intervention due to concerns about worsening heart failure and developing coronary artery ischemia. Although various surgical options were considered, we opted for an arteriotomy of the left anterior descending artery and closed the fistula with two autologous pericardial patches. There has been no signs of postoperative ischemic changes or enlargement of the coronary aneurysm during the 4 years of follow up, and careful monitoring will continue.

Aorto-Left Ventricular Tunnel : a Surgical Intervention at 2 Hours after Birth / 日本心臓血管外科学会雑誌

A male infant was diagnosed with aorto-left ventricular tunnel (ALVT) because of advanced left ventricular hypertrophy and massive reflux from the aorta to the left ventricle during the fetal period. Aorto-left ventricular tunnel closure was emergently performed 2 h after birth in cooperation with the hospital where he was born. The aortic end of the ALVT was located above the right-left coronary commissure, and the measured diameter was 8 mm. The aortic valve was tricuspid, but it was thickened and the opening was limited ; it was further complicated by a right coronary artery anomaly. Taking the valve distortion and surgical invasion into consideration, only the aortic end was closed using an autologous pericardial patch. Although mild aortic valve stenosis and regurgitation remained after surgery, the postoperative course was uneventful, and the left ventricular hypertrophy and cardiac function were improved.

A study of simple congenital coronary artery anomalies based on a large-sample coronary CT angiography / 中华放射学杂志

Objective:To investigate the classification and prevalence of simple congenital coronary artery anomalies (CCAA) in Chinese in a large samples of coronary CT angiography (CCTA), and briefly summarize the CT characteristics of "malignant" anomalies.Methods:The data of patients who had undergone CCTA from July 2009 to January 2017 and were diagnosed as simple CCAA were analyzed retrospectively. CCAA were classified according to the origination, number of orifices and termination, and the prevalence of various CCAA was statistically analyzed. Anomalous origin of coronary artery included the origin of coronary artery from the opposite coronary sinus, the non-coronary sinus, the aorta or around the primary sinus, the pulmonary artery, and left circumflex artery originated from the diagonal branch. Abnormal number of orifices included single coronary artery (SCA), right coronary artery and conus branch arising separately, and left anterior descending branch and circumflex branch arising separately. Abnormal termination was coronary artery fistula (CAF). Anomalous origin of coronary artery from the opposite sinus, anomalous origin of the coronary artery from the pulmonary artery, SCA, and multiple or large CAFs were defined as"malignant"anomalies.Results:Among 165 133 patients, 2 148(1.301%) had coronary anomalies, including 1 302 (0.789%) of origin anomalies, 298 (0.181%) of abnormal number of orifices and 548 (0.332%) of abnormal termination. There were 700 cases (0.424%) with coronary artery rising from the opposite sinus, 179 of which had opening or proximal lumen stenosis due to compression, 7 of which had subendocardial myocardial ischemia or infarction on CCTA without coronary artery disease (CAD). The coronary arteries originated from posterior sinus, the aorta or around the primary sinus were found in 48 cases (0.029%), 531 cases(0.322%), respectively. Coronary artery originating from pulmonary artery was detected in 20 cases (0.012%), all of which were left main trunk originating from pulmonary artery, showed tortuous dilation of coronary arteries. Five cases showed obvious subendocardial myocardial ischemia or infarction without CAD. SCA, right coronary artery and conus branch arising separately, left anterior descending branch and circumflex artery arising separately were detected in 102 (0.062%), 53 (0.032%) and 143 (0.087%) cases respectively. Only 1 of 102 cases with SCA showed myocardial ischemia without CAD. A total of 548 cases (0.332%) were diagnosed as CAF, of which the coronary-pulmonary fistula was most common with a highest prevalence of 0.277% (458 cases). Coronary artery-atrial fistula and coronary artery-ventricular fistula were detected in 22 (0.013%) and 60 (0.036%) cases. There were 6 cases (0.004%) of coronary artery-coronary venous fistula and 2 cases (0.001%) of coronary artery-superior vena cava fistula.Conclusions:The occurrence of CCAA is not uncommon, among which anomalous origin of coronary artery is the most common, and special attention should be paid to "malignant"anomalies.

Coronary-to-Pulmonary Artery Fistula in Adults: Natural History and Management Strategies

OBJECTIVE: To evaluate the natural course of coronary-to-pulmonary artery fistula (CPAF) detected on coronary computed tomography angiography (CCTA) and to propose potential treatment strategies. MATERIALS AND METHODS: In this retrospective multicenter study, we assessed the CCTA reports of 188 CPAF patients evaluated between March 2009 and June 2016. Fifty-seven patients were excluded because their follow-up (FU) periods were less than 2 years. Information regarding demographic characteristics, past history, treatment method, and the occurrence of major adverse cardiac events (MACE) during the FU period was collected. We analyzed the morphologic features of CPAF and the various factors associated with surgical treatment. Patients who had undergone FU CCTA after being diagnosed with CPAF were assessed for the presence of morphological changes on FU imaging. RESULTS: The median age of the study population was 63.0 years (range, 57.0–72.0 years), and the median FU period was 5.72 years (range, 4.08–6.96 years). The most common origin of the CPAF was both coronary arteries in 76 (58.0%) cases. An aneurysm or aneurysms was/were present in 41 (31.3%) cases. Fifty-four (41.2%) fistulas were less than 2 mm in size. Eight patients underwent surgery, and 123 (93.9%) patients received optimal medical treatment (OMT). The fistula size was significantly different between the two treatment groups (p = 0.013) and was the only factor associated with surgical treatment (odds ratio = 1.14, p = 0.021). Only one patient in the OMT group reported MACE during the FU period due to preexisting coronary artery disease. Twenty-nine patients (22.1%) underwent FU CCTA after CPAF diagnosis, with a median FU period of 3.81 years. None of the patients in the OMT group demonstrated morphological changes in the CPAF on FU imaging. CONCLUSION: Most CPAFs identified on CCTA have a favorable prognosis. Observation with OMT is usually an appropriate strategy. Fistula size is a possible determinant for surgical treatment.

Type 4 dual left anterior descending coronary artery

No abstract available.

Funtional significance of the intermediate lesion in a single coronary artery assessed by fractional flow reserve

No abstract available.

Neo-ostium Formation in Anomalous Origin of the Left Coronary Artery

Anomalous origin of a coronary aortic artery is a rare cardiac anomaly. Although it can cause angina, syncope, and palpitations, most patients are asymptomatic. This anomaly requires surgical treatment or intervention because it is associated with sudden death. Several surgical techniques, such as coronary reimplantation, coronary artery bypass grafting (CABG), unroofing, and neo-ostium formation, have been proposed as treatments. We report a case surgically treated with neo-ostium formation in anomalous origin of the left coronary artery from the right coronary sinus.

Coronary Blood Flow Disturbance of a Single Coronary Artery in a Patient Undergoing Aortic Valve Replacement: A case report / 대한흉부외과학회지

A 57-year-old man with dyspnea was transferred to our institution. Echocardiography demonstrated grade III aortic valve regurgitation with a bicuspid aortic valve. The preoperative coronary angiography showed a left single coronary artery. Replacement of the aortic valve was performed. Ventricular fibrillation developed during weaning the patient of cardiopulmonary bypass after aortotomy repair. An anomalous origin of the coronary arteries is usually an incidental finding. However, in patients who are undergoing aortic valve replacement, a single coronary artery can significantly complicate the procedure. If this is present, then it is imperative that the precise anatomy be clearly identified and the required procedure should be modified to avoid injury to these vessels.

Extended Unroofing Procedure for Creation of a New Ostium for an Anomalous Right Coronary Artery Originating from the Left Coronary Sinus: A case report / 대한흉부외과학회지

An anomalous origin of the coronary artery with subsequent coursing between the great vessels is a rare congenital heart defect that may cause myocardial ischemia and sudden death. Several surgical techniques have been described to address this defect. An extended unroofing procedure to create an alternative ostium for the right coronary artery was successfully carried out in a patient having an anomalous origin of the right coronary artery. The newly constructed orifice was widely patent 3 months later, without any episodes of myocardial ischemia or aortic regurgitation.

Coronary Artery Bypass Grafting in Patients with Acute Myocardial Infarction with an Abnormal Origin of the Right Coronary Artery / 대한흉부외과학회지

An abnormal origin of the right coronary artery can be responsible for sudden death, myocardial ischemia, arrhythmia and syncope, and it may be associated with the accelerated development of atherosclerotic disease. The mechanisms of ischemia in the case of an abnormal origin of the right coronary artery are currently unclear and several surgical methods have been proposed to treat this malady. Multidetector Computed Tomography shows the course of the abnormal coronary artery, it helps to clarify the mechanism of the ischemia and it aids in choosing the best surgical approach. We report here on a case of acute myocardial infarction with an abnormal origin of the right coronary artery. Coronary artery bypass grafting was subsequently carried out to treat this patient.

Three cases of right coronary anomaly confirmed by multi-detector computed tomography / 대한내과학회지

Congenital anomaly of the right coronary artery is a very rare disease. It can cause syncope, angina pectoris, acute myocardial infarction, ventricular fibrillation and sudden cardiac death during exercise in the young population. The dominancy of the coronary artery, and the site, shape and pathway of the right coronary artery seems to play a key role in developing those above mentioned events. Especially, it has been known that the right coronary artery that courses between the aorta and pulmonary trunk increases the risk of sudden death. Therefore, precise evaluation is needed to diagnose the presence and type of coronary artery anomaly. Nowadays, multi-detector computed tomography is used to diagnose coronary anomalies and this provides clear images of coronary anomaly in a safe and noninvasive way. We report here on three cases of right coronary anomaly that coursed between the aorta and pulmonic trunk, and this was confirmed by multi-detector computed tomography.

Early Result of Surgical Management of the Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery / 대한흉부외과학회지

BACKGROUND: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly, but is one of the most common causes of myocardial ischemia which would result in high mortality within the first year of life. This is our early result of the surgical management for these patients. MATERIAL AND METHOD: From June 1989 to July 2003, 6 patients with ALCAPA and one patient with ARCAPA (Anomalous origin of the Right coronary artery from the pulmonary artery) underwent surgical repair. We have reviewed the all medical records, electrocardiogram, chest X-ray and echocardiography retrospectively. RESULT: Three of the patients were boys and four were girls. The median age at the operation was 5.4 months (Range: 3~33 months). The average body weight of at the operation was 6.7 kg (Range: 3.7~11.3 kg). A mean follow up period was 18 months. Only 3 patients were initially diagnosed as ALCAPA. And 3 patients had moderate mitral regurgitation. Immediate coronary artery reimplantation on diagnosis with the aim of restoring a two-coronary system circulation was done. The average bypass time was 114+/-37 minutes, and the average aortic cross clamping time was 55+/-22 minutes. The average stay of intensive care unit was 5+/-3 days, the mean mechanical ventilator time was 38+/-45 hours and the hospital stay after operation was 12+/-5 days. There were significant improvements in electrocardiogram and chest X-ray of the all patients except one late death patient. The ventricular function showed almost normal recovery after operation; the EF (Ejection Fraction) increased from 41.2+/-10.3% to 60.5+/-15.8% within 1 month and to 59.8+/-13.9% within 1 year after operation, the SF (Shortening Fraction) increased from 23.6+/-4.7% to 38.6+/-8.4% within 1 month and to 37.4+/-7.9% within 1 year after operation, LVEDDI (Left Ventricular End-diastolic Dimension Index) decreased from 100.8+/-25.6 mm/m2 to 90.3+/-19.2 mm/m2 within 1 month and to 79.3+/-15.8 mm/m2 within 1 year after operation. Concomitant mitral repair was done in two patients with anterior mitral leaflet prolapse. In every patient, mitral valve showed less than mild regurgitation during follow up. One late death occurred in which patient Dor procedure was applied 10 months after initial operation due to the dilated cardiomyopathy. CONCLUSION: In the management of this rare and could be fatal Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), early suspicion and correct diagnosis is of most important.But, after diagnosis, immediate restoration of 2 coronary systems could result in good outcome.

Congenital Left Main Coronary Artery Atresia / 대한흉부외과학회지

Left main coronary artery atresia is a very rare congenital coronary anomaly with blind end of left main trunk. The clinical symptoms as syncope, failure to thrive, and myocardial infarction are presented and surgical treatments are required in most cases. We report a case of a 14-months-old girl with left main coronary artery atresia and excellent surgical result of 1 year follow-up after coronary artery bypass with left internal thoracic artery.

Coronary Artery Bypass Graft (CABG) for Intracavitary Coronary Artery Disease: A case report / 대한흉부외과학회지

Intracavitary coronary artery is variant anomalous entrance to right ventricular cavity of left anterior descending artery. Since the disease is extremely rare, there has not been any report of it in Korea and is only found in 0.2 ~0.3% of all CABG patients. It is very difficult to be diagnosed by preoperative coronary arteriography (CAG) and secure suture is needed for right ventriculotomy after CABG due to bleeding from right ventricle. Horizontal mattress suture with pledget has been recommended but, it could compress the myocardium surrounding ventriculotomy and result in disturbed flow of left anterior descending artery branch and perforating artery. So we used simple interrupted suture and the patient was recovered as other CABG patients without complications.

Long-Term Results for Repair of Pulmonary Atresia with Intact Ventricular Septum / 대한흉부외과학회지

BACKGROUND: Pulmonary atresia with intact ventricular septum is morphologically heterogeneous, and the surgical outcome remains suboptimal compared to other complex congenital heart defects. We evaluated the long-term results for repair of pulmonary atresia with intact ventricular septum. MATERIAL NAD METHOD: Between January 1992 and June 2004, 38 patients underwent repair of pulmonary atresia with intact ventricular septum. The average age was 18 days (2~382 days). The average Z-value of the tricuspid annulus diameter was -3.1 (-5.6~0.8). Thirteen (36%) patients had right ventricle-to-coronary artery fistulas, and 4 (11%) patients had right ventricle-dependent coronary circulation. Average follow-up was 55 months (3 months~12.2 years). RESULT: Twenty-four patients underwent initial right ventricle (RV) decompression and 14 patients underwent systemic-to-pulmonary arterial shunt only. The average size of the tricuspid annulus of the patients who underwent RV decompression was significantly larger than that of the patients who underwent systemic-to-pulmonary arterial shunt only (Z-value -2.2 vs. -4.8, p= 0.000). There were 5 (13%) early and 1 late deaths. Early deaths occurred in 3 patients who had undergone RV decompression, and in 2 patients who had undergone systemic-to-pulmonary arterial shunt only (p=1.0). Biventricular repair was achieved in 12 (32%) patients, single ventricular repair in 8 (21%), and one and a half ventricular repair in 4 (11%) patients. Nine (24%) patients are waiting for the definitive repair. Kaplan-Meier survival at 5 and 8 years was 83.2%, respectively. CONCLUSION: Most of the deaths occurred after the initial palliation. Overall long- term survival was satisfactory. Early mortality should be reduced with careful preoperative evaluation and proper surgical strategy.

Unroofing Procedure in the Treatment of Anomalous Origin of Right Coronary Artery from Left Sinus of Valsalva between Aorta and Pulmonary Trunk / 대한흉부외과학회지

Anomalous origin of right coronary artery from left sinus of valsalva is associated with sudden unexpected death, syncope, arrhythmia and myocardial ischemia. The mechanism that explains the restriction of coronary flow in the anomalous coronary artery is unclear but several surgical methods have been proposed, such as coronary artery bypass graft, coronary reimplantation, translocation of pulmonary artery, and unroofing procedure. We reported the surgical correction of the anomalous origin of right coronary artery from left sinus of valsalva between the aorta and pulmonary trunk using the unroofing procedure.

Surgical Treatment of Anomalous Origin of Coronary Artery from the Pulmonary Artery: Postoperative Changes of Ventricular Dimensions and Mitral Regurgitation / 대한흉부외과학회지

BACKGROUND: The aims of this study are to verify the result of the surgical treatment of ALCAPA and to identify the postoperative changes of left ventricular dimensions and mitral regurgitation (MR). MATERIAL AND METHOD: Fifteen patients operated on since 1985 were included in the study. The patients operated on before 1998 (n=9) showed heterogeneous properties with various surgical strategies and cardiopulmonary bypass techniques. However, six patients were operated on with the established surgical strategy since 1998; 1) Dual perfusion and dual cardioplegic solution delivery through ascending aorta and main pulmonary artery, 2) Coronary transfer by rolled-conduit made of pulmonary artery wall flap, and 3) Additional mitral valvular procedure was not performed. RESULT: Median age of the study group was 6 months (1 month to 34 years). The operative methods were left subclavian artery to left coronary artery anastomosis in 1, simple ligation in 2, Takeuchi operation in 2, and coronary reimplantation in 10 pateints. The mean follow up period was 5.5<5.8 years (2 months 14 years). There were one early death (6.7%) and one late death. Overall 5-year survival rate was 85.6+/-9.6%. The Z-value of left ventricular end-diastolic and end-systolic dimensions were 6.4+/-3.0 and 5.1+/-3.6 preoperatively, and decreased to 1.7+/-1.9 and 0.8+/-1.6 in 3 months (p<0.05). Significant preoperative MR was identified in 6 patients (40%) and all the patients showed immediate improvement of MR within 1 month postoperatively. There were 3 cases of reoperation due to coronary anastomosis site stenosis and recurrence of MR. However, there was no mortality nor late reoperation in the patients operated on after 1998. CONCLUSION: The surgical treatment of ALCAPA showed favorable survival and early recovery of ventricular dimensions and mitral valvular function. Although long-term reintervention was required in some cases of earlier period, all the cases after 1998 showed excellent surgical outcome without long-term problem.

Coronary artery anomalies: prevalence and clinical profile in elderly patients / 老年心脏病学杂志（英文版）

Objective Although congenital heart diseases are uncommon in the elderly, coronary artery anomalies may be incidentally discovered in old age. We sought to determine the incidence and clinical features of coronary artery anomalies (CAAs) in patients over 65 years of age. Patients and methods Medical records of patients undergoing coronary artery angiography in the years 1997-2002 at the Legnago General Hospital were retrospectively reviewed, The clinical profiles of all patients with CAAs and CAA subtypes were noted. Comparison between patients under and over 65 was performed. Data are given as mean standard deviation and as percentages. Results Sixtysix patients (1.21%, Female/Male 22/44, mean age 65.3 ± 10.6 years) out of the 5450 who underwent coronary angiography in the years 1997-2002 had CAAs. In mast cases (63%, 41/66 patients), the patients were over 65.CAAs were discovered incidentally in these elderly patients while undergoing coronary artery angiography for dilated cardiomyopathy, ischemic heart disease, and valvular heart disease in 75% of the cases (30/41 patients). Patients over 65 had more cardiac comorbidities and .a higher incidence of coronary atherosclerosis. Conclusions The angiographic incidence of CAAs in elderly patients is increasing as the population ages and this occurrence calls for a wider knowledge of the anatomy and pathophysiology of CAAs among geriatric cardiologists. Elderly patients seem to present with lower risk coronary anomalies (separated origin of left anterior descending coronary artery and circanfflex artery, origin of circumflex artery from the right sinus or the right coronary artery, double coronary artery)but have a higher risk profile compared to younger patients due to the frequency of cardiac comorbidities and superimposed coronary artery atherosclerosis.

Coronary Artery Transfer for Anomalous Origin of Left Coronary Artery from Right Coronary Sinus / 대한흉부외과학회지

Anomalous aortic origin of left coronary artery is a rare congenital coronary anomaly that can cause clinical manifestations such as ischemic chest pain, arrhythmic syncope or even sudden cardiac death. We describe a case of anomalous aortic origin of left main coronary artery presented as a cardiogenic shock which was successfully treated by coronary artery transfer.

Anomalous Origin of The Left Circumflex Coronary Artery from The Left Pulmonary Artery / 대한흉부외과학회지

Anomalous origin of the coronary artery in children is a rare disease. Especially anomalous origin of the left coronary artery from pulmonary artery(ALCAPA) is a fatal condition in neonates with myocardial failure. Among the ALCAPA, origin of the circumflex coronary artery from the pulmonary artery is an extremely rare congenital coronary anomaly. We report a case of reimplantation of the left circumflex coronary artery from the left pulmonary artery to the ascending aorta in a 4-year-old girl.