Sağ koroner arterin karşı taraftan anormal çıkışı: 17 vakalık seri

Öz

Amaç: Sağ koroner arterin sol sinüs Valsalva'dan anormal çıkışı, aort ve pulmoner arter arasında seyretmesi, ateroskleroz olmaksızın göğüs ağrısına, akut miyokard enfarktüsüne ve hatta ani ölüme sebep olabilir. Özellikle genç hastalar ciddi klinik olaylar açsından risk altında olsa da, orta-ileri yaştaki hastalarda da farklı klinik seyirler gözlenebilir. Bu çalışmada, orta-ileri yaştaki hastalarda sol sinüsten Valsalva'dan çıkan sağ koroner arterin anjiyografik varyasyonları, klinik bulguları ve uzun dönem bulguları incelenmiştir. Gereç ve Yöntemler: 1999-2005 yılları arasında farklı merkezlerde koroner anjiyografi yapılan 70.850 hastanın kayıtları en az iki girişimsel kardiyolog tarafından incelendi. Sağ koroner arterin ayrıntılı değerlendirilmesi gerektiğinde, çok kesitli bilgisayarlı tomografi de kullanıldı. Tüm hastalar ortalama 50 ay takip edildi. Bulgular: Toplam 17 hastada (%0.024) karşı taraftan çıkan sağ koroner arter tespit edildi. Bu hastaların 12 (%71) sinde sağ koroner arter sol sinüs Valsalva'dan, 5 (%29) inde çıkan aortada sol sinüs Valsalva üzerinden çıkmaktaydı. Sağ koroner arterin başlangıç kısmının retro-aortik seyri 2 (%12) hastada gözlenirken, 15 (%88) inde inter-arteryel seyretmekteydi. Hastaların 9 (%53) unda aterosklerotik tutulum gözlenmedi. 3 (%18) hastaya, bunlardan birisinin aterosklerotik tutulumu yoktu, anormal sağ koronere bağlı koroner bypass yapıldı. Hastalardan birisine de anormal sağ koroner arter nedeniyle stent takıldı. Takip süresince 3 hasta kalp dışı nedenlere bağlı olarak kaybedildi. Diğer 14 hasta olaysız olarak takip edildi. Sonuç: Sol sinüs Valsalva kaynaklı sağ koroner arter saptanan orta-ileri yaştaki hastalarda, akut koroner sendrom ya da istirahat EKG'sinde iskemi olmaksızın, tıbbi tedavi uygun bir seçenektir. 

Anahtar Kelimeler

• Ani Ölüm,Koroner Arter Anomalileri,Miyokardiyal İskemi

Anomalous origin of the right coronary artery from contralateral side: a series of 17 cases

Öz

Objective: Anomalous origin of the right coronary artery (RCA) from left sinus of Valsalva (LSV), coursing between the aorta and pulmonary artery can lead to angina pectoris, acute myocardial infarction or even sudden death in the absence of atherosclerosis. Especially young patients have the risk of serious clinical events, but middle-aged-to elderly patients have variable clinical courses. In this study, we presented angiographic variations, clinical findings and long term follow-up data of RCA originating from left side in middle-aged-to elderly patients Material and Methods: We reviewed the records of 70,850 patients undergoing coronary angiography between 1999-2005 years. At least two invasive cardiologists examined the angiogram of each patient. If necessary, multislice computerized tomography was used for detailed investigation of the RCA. All patients were followed up for approximately 50 months. Results: Seventeen patients (0,024%) were found to have anomalous origin of RCAfrom contralateral side. The anomalous RCAoriginated within the LSVin 12 (71%) patient, from ascending aorta above the LSVin 5 (29%) patients. The retroaortic course of the initial RCAwas seen in 2 (12%) patients while 15 (88%) patients showed interarterial course. No atherosclerotic involvement was seen in 9 (53%) patients. Three patients (18%), one of them had no atherosclerotic lesion, underwent CABG due to anomalous RCA. One patient was also treated by stent implantation to the anomalous RCA. Three patients died during the follow up period due to noncardiac causes. Other 14 patients have been followed up uneventfully. Conclusion: Medical treatment is a plausible choice of treatment in anomalous RCA originating from LSV in middle–aged-to elderly patients in the absence of ischemia on 12-lead resting ECG and/or acute coronary syndrome.

Anahtar Kelimeler

• Angiography,Coronary vessel anomalies,Myocardial ischemia,Sudden death

Kaynakça

1. 1) White NK, Edwards JE. Anomalies of the coronary arteries; report of four cases. Arch Pathol 1948;45(6):766-71. 2) Cheitlin MD, De Castro CM, McAllister HA. Sudden death as a complication of anomalous left coronary origin from the anterior sinus of Valsalva, A not-sominor congenital anomaly. Circulation 1974;50(4):780- 7. 3) Roberts WC, Siegel RJ, Zipes DP. Origin of the right coronary artery from the left sinus of Valsalva and its functional consequences: analyses of 10 necropsy patients. Am J Cardiol 1982;49(4):863-8. 4) Tuncer C, Batyraliev T, Yilmaz R, et al. Origin and distribution anomalies of the left anterior descending artery in 70,850 adult patients: multicenter data collection. Catheter Cardiovasc Interv 2006;68(4):574- 85. 5) Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardovasc Diagn 1990;21(1):28-40. 6) Gol MK, Ozatik MA, Kunt A, et al. Coronary artery anomalies in adult patients. Med Sci Monit 2002;8(9):636-41. 7) Alexander RW, Griffith GC. Anomalies of the coronary arteries and their significance. Circulation 1956;14(5):800-5. 8) Wilkins CE, Betancourt B, Mathur VS, et al. Coronary artery anomalies: a review of more than 10,000 patients from the Clayton Cardiovascular Laboratories. Tex Heart Inst J 1988;15(3):166-73. 9) Vlodaver Z, Neufeld HN, Edwards JE. Coronary arterial variations in the normal heart and in congenital heart disease. New York: Academic Press; 1975.p.171. 10) Jim MH, Siu CW, Ho HH, et al. Anomalous origin of right coronary artery from the left coronary sinus: incidence, characteristics, and a systematic approach for rapid diagnosis. J interv Cardiol 2005;18(2):101-6. 11) Ceyhan C, Tekten T, Onbasili AO. Primary percutanous coronary intervention of anomalous origin of right coronary artery above the left sinus of Valsalva in a case with acute myocardial infarction. Coronary anomalies and myocardial infarction. Int J Cardiovasc Imaging 2004;20(4):293-7. 12) Maki F, Ohtsuka T, Suzuki M, et al. Myocardial ischemia induced by anomalous aortic origin of the right coronary artery in a patient with atrial septal defect. Jpn Heart J 2001;42(3):371-6. 13) Taylor AJ, Byers JP, Cheitlin MD, et al. Anomalous right or left coronary artery from the contralateral coronary sinus: “high risk” abnormalities in the initial coronary artery course and heterogenous clinical outcomes. Am Heart J 1997;133(4):428-35. 14) Thomas D, Salloum J, Montalescot G, et al. Anomalous coronary arteries coursing between the aorta and pulmonary trunk: clinical indications for coronary artery bypass. Eur Heart J 1991;12(7):832-4. 15)Angelini P. Coronary artery anomalies. an entity in search of an identity. Circulation 2007;115(10):1296- 305. 16) Taylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with isolated congenital coronary anomalies. J Am Coll Cardiol 1992;20(3):640-7. 17) Kaku B, Kanaya H, Ikeda M, et al. Acute inferior myocardial infarction and coronary spasm in a patient with an anomalous origin of the right coronary artery from the left sinus of Valsalva. Jpn Circ J 2000;64(8):641-3. 18) Basso C, Maron BJ, Corrado D, et al. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. J Am Coll Cardiol 2000;35(6):1493- 501. 19) Mirchandani S, Phoon CK. Management of anomalous coronary arteries from the contralateral sinus. Int J Cardiol 2005;102(3):383-9. 20) Pelliccia A. Congenital coronary artery anomalies in young patients. new perspectives for timely identification. J Am Coll Cardiol 2001;37(2):598-600. 21) Kaku B, Shimizu M, Yoshio H, et al. Clinical features on prognosis of Japanese patients with anomalous origin of the coronary artery. Jpn Circ J 1996;60(10):731-41. 22) Ghosh PK, Agarwal SK, Kumar R, et al. Anomalous origin of right coronary from left aortic sinus. J Cardivasc Surg 1994;35(1):65-70. 23) Barriales Villa R, Moris C, Lopez Muniz A, et al. Adult congenital anomalies of the coronary arteries described over 31 years of angiographic studies in the Asturias Principality: main angiographic and clinical characteristics. Rev Esp Cardiol 2001;54(3):269-81.