Surgical Treatment for Occlusion of Left Coronary Artery Ostium by an Aortic Valve Cusp / 日本心臓血管外科学会雑誌

The patient was a 4-year-old boy, with no indication of heart disease at birth. When he was 4 years and 3 months old, he underwent surgery for cryptorchidism, and persistent changes after crying, consisting of ST-segment depression, were noted on the ECG. Therefore, it was decided that a detailed examination would be carried out. Aortography revealed that a small left coronary cusp had formed a pouch and that there was a delayed washout of the contrast material in the left coronary artery compared with the right coronary artery. Right coronary angiography showed retrograde flow to the left coronary artery. There was no significant aortic regurgitation, and no stenosis in the left coronary artery. Intraoperative findings demonstrated that the hypoplastic left coronary cusp had adhered to the aortic wall and covered the left sinus of Valsalva. Enlargement of the Valsalva was performed by placing a patch from the aortic transection site to an area directly above the coronary artery ostium. Postoperatively, the patient recovered satisfactorily and was discharged on the eleventh postoperative day. Cardiac catheterization performed 6 months after surgery showed no aortic regurgitation, no significant stenosis in the left coronary artery, and no retrograde flow from the right coronary artery. We report our experience with the rare case described above.

Aortic Stenosis and Regurgitation with Aortic Subannular Left Ventricular Diverticulum and Occlusion of the Right Coronary Ostium by the Bicuspid Aortic Valve / 日本心臓血管外科学会雑誌

A 63-year old man was referred to our hospital with dyspnea on exertion and palpitation. An echocardiogram disclosed aortic stenosis and regurgitation, mitral regurgitation and tricuspid regurgitation. During cardiac catheterization, the right coronary ostium could not be cannulated, by coincidence, showed ventricular outpouching. Preoperative contrast-enhanced CT showed the partition wall isolating the right coronary ostium and the left ventricular outpouching in the subaortic valve area. The patient underwent aortic valve replacement after resection of the rudimentary right coronary cusp, and we resected the outpouching and closed the orifice with mattress sutures from the inside of the LV and the outside. Histopathology demonstrated that the resected outpouching was congenital fibrous left ventricular diverticulum.

Quadricuspid aortic valve: A rare intraoperative diagnosis by transesophageal echocardiography

Quadricuspid aortic valve (QAV) is a rare congenital anomaly frequently associated with other anomalies particularly coronary anomalies. It may be detected on transthoracic or transesophageal echocardiography. We present here a case report of a 27-year-old male patient with a QAV, the valve being regurgitant and requiring aortic valve replacement. It has been reported as isolated case reports in the literature and various theories exist to the development of QAV. The diagnosis requires a high degree of suspicion and a detailed assessment, and if asymptomatic, then patients need to be carefully followed up for the development of aortic regurgitation.

Occlusion of Left Coronary Ostium by Fusion of a Rudimentary Aortic Cusp to the Aortic Wall / 日本心臓血管外科学会雑誌

A 65-year old man with a diagnosis of aortic regurgitation from childhood referred to our hospital due to palpitations and dyspnea on exertion. Transthoracic echocardiography showed severe aortic regurgitation, but the form of left coronary aortic cusp was not detected clearly. Trans esophageal echocardiography revealed small left coronary aortic sinus covered with a rudimentary left coronary cusp. Right coronary angiography showed retrograde flow to left coronary artery, and pooling of contrast material in the aortic cusp. Cannulation into the left coronary ostium could not be performed, aortography revealed no antegrade left coronary blood flow. The patient underwent aortic valve replacement with mechanical valve after resection of the rudimentary left coronary cusp, and ascending aorta replacement using selective cerebral perfusion. The post operative course was uneventful. We report on a rare case of occlusion of left coronary ostium with a rudimentary aortic cusp.

Morphological Study of Coronary Sinus in Human Cadaveric Hearts.

Background: The coronary sinus is a dilated venous channel opening into the right atrium of the heart. The coronary venous system has gained importance in recent years for electrophysiological procedures like arrhythmia ablation, biventricular pacing and implantation of cardiac pacemakers. The present study aims to study the formation and tributaries of coronary sinus and also the morphology of thebesian valve. Materials and Methods: 30 formalin fixed cadaveric hearts available in the department of Anatomy, Dhanalakshmi Srinivasan Medical College and Hospital, Perambalur, Tamil nadu, was used for the study. The formation and tributaries of coronary sinus were noted. The length of coronary sinus in millimeters was measured from the union of great cardiac vein and left marginal vein upto the opening of the coronary sinus in the right atrium with vernier calipers. The width of the coronary ostium in the right atrium was measured in millimeters with vernier calipers. Results: In 93.33% specimens the coronary sinus was formed by the union of great cardiac vein and left marginal vein. In 3.33% specimens it was formed by the union of great cardiac vein and posterior vein of left ventricle, and in 3.33% specimens it was formed by the union of great cardiac vein and oblique vein of left atrium. The left marginal vein was absent in 2 specimens and small cardiac vein was absent in 1 specimen. The mean length of coronary sinus was 54.98 + 12.2mm. The mean width of coronary sinus ostium was 9.35 + 3.24mm. The Thebesian valve was present in 93.33% specimens and it was semilunar in shape. Conclusion: The knowledge of coronary sinus anatomy will be helpful during electrophysiological procedures. KEY WORDS: Coronary Sinus, Cardiac Veins, Thebesian Valve, Coronary Ostium, Electrophysiological Procedures.

Origins of the coronary arteries and their significance

Objective: To describe the normal and variant anatomy of the coronary artery ostia in Indian subjects. Introduction: Anomalous coronary origins may cause potentially dangerous symptoms, and even sudden death during strenuous activity. A cadaveric study in an unsuspected population provides a basis for understanding the normal variants, which may facilitate determination of the prevalence of anomalies and evaluation of the value of screening for such anomalies. Methods: One hundred and five heart specimens were dissected. The number of ostia and their positions within the respective sinuses were observed. Vertical and circumferential deviations of the ostia were observed. The heights of the cusps and the ostia from the bottom of the sinus were measured. Results: No openings were present in the pulmonary artery or the non-coronary sinus. The number of openings in the aortic sinuses varied from 2-5 in the present series; multiple ostia were mostly seen in the anterior sinus. The majority of the ostia lay below the sinutubular ridge (89 percent) and at or above the level of the upper margin of the cusps (84 percent). Left ostial openings were mainly centrally located (80 percent), whereas the right coronary ostia were often shifted towards the right posterior aortic sinus (59 percent). Discussion: The preferential location of the ostia was within the sinus and above the cusps, but below the sinutubular ridge. On occasion, normal variants like multiple ostia, vertical or circumferential shift in the position, and slit-like ostia may create confusion in interpreting the images and pose a difficulty during procedures like angiography, angioplasty, and coronary artery bypass grafting.

A Case of Congential Atresia of Left Main Coronary Ostium

Congenital atresia of left main coronary ostium is a rare congenital coronary anomaly. This anomaly was detected during elective coronary angiogram in a 40 year-old female patient with chest pain and exertional dyspnea. Treadmill exercise test demonstrated 2 mm upslope depression of ST segment at stage I and the test was terminated due to chest pain. Myocardial stress SPECT using 201 Tl-dipyridamole showed reversible perfusion defects at anterior, apex and lateral wall. It was impossible to select left coronary artery ostium and right coronary angiogram revealed 30% eccentric stenosis at proximal right coronary artery with grade 3 collateral flow to left anterior descending and circumflex arteries. Operative finding revealed totally occluded left coronary ostium with membrane-like, non-atheromatous tissue similar to aortic wall. The patient was successfully treated with coronary artery bypass grafts (CABG) using left internal mammary artery and great saphenous vein. She underwent follow-up coronary angiogram, which revealed patent grafts, at one year after CABG and no cardiovascular event was observed on 5-year clinical follow-up.