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J Thorac Cardiovasc Surg 1994;107:1370-1373
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Management of anomalous origin of the left coronary artery from the right sinus of Valsalva

Dietrich Bucsenez, MDa, Bruno J. Messmer, MDb, Alex Gillor, MDc, Götz von Bernuth, MDa

Klinik für Kinderkardiologiea

To the Editor:

Anomalous origin of the left coronary artery from the right anterior sinus of Valsalva is a rare coronary anomaly that may cause sudden cardiac death from myocardial infarction. We report the diagnosis of this anomaly in a young patient and its successful surgical correction by a previously undescribed technique.

Since the summer of 1990, a 13-year-old boy repeatedly had dizziness, nausea, and left precordial pain with physical exercise. In November 1990, the patient had a cardiac arrest during a basketball game. He was found to have ventricular fibrillation, was successfully resuscitated, and recovered completely after surviving a 10-day coma. Enzyme studies were indicative of myocardial infarction, which was proved by the electrocardiogram. On the basis of history and lack of evidence for other causes of myocardial infarction, a left coronary arterial anomaly was suspected. Angiography of the left ventricle showed supraapical contraction impairment, and aortic root angiography demonstrated that the left coronary artery originated from the right sinus of Valsalva and passed between the aorta and pulmonary trunk (Fig. 1). After diagnosis, the anomaly could also be seen by sector- and color-coded echocardiography (Fig. 2).



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  		Fig. 1. Aortic root angiography in 30-degree right anterior oblique (RAO) projection shows right and left coronary artery originating from the same (right) sinus of Valsalva. LCA, Left coronary artery; LAD, left anterior descending coronary artery; CX, left circumflex coronary artery; RSV, right sinus of Valsalva; RCA, right coronary artery.

 


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  		Fig. 2. Sector echocardiogram in the short left parasternal axis view shows the left coronary artery (LCA) passing abnormally between aorta (AO) and pulmonary trunk (PA). RVOT, Right ventricular outflow tract.

 
At operation performed in February 1991 (B. J. M.), the left coronary artery was found to originate from a slitlike ostium in the right anterior sinus of Valsalva, close to the ostium of the right coronary artery. The proximal course of the left coronary artery was intramural, within the aortic wall (Fig. 3, A). The left coronary artery was excised at the site of its exit from the aortic wall and the opening was closed. After careful mobilization of the free left coronary artery far beyond the bifurcation between the left anterior descending and the circumflex artery, an opening was punched into the left sinus of Valsalva and the left coronary artery was implanted with a running suture of 7-0 polydioxanone sutures (Fig. 3, B). The postoperative course was uncomplicated. The patient received low-dose aspirin for 10 months. Six months after the operation, coronary angiography demonstrated a normal origin and course for both coronary arteries (Fig. 4). Another 4 months later, the electrocardiograms at rest and during exercise were normal. One year after operation, the boy had no symptoms and was normally active.



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  		Fig. 3. A, Schematic drawing of anomalous origin of left coronary artery (LCA) from the right sinus of Valsalva (R) and of the intramural course of its proximal part within the aortic wall.CX, Left circumflex coronary artery; LAD, left anterior descending coronary artery; L, left sinus of Valsalva; N, noncoronary sinus of Valsalva; PA, pulmonary trunk; RCA, right coronary artery. B, Schematic drawing of surgical correction by reimplantation of the excised left coronary artery (LCA) into the left sinus of Valsalva (L).CXLeft circumflex coronary artery; LAD, left anterior descending coronary artery; PA, pulmonary trunk; R, right sinus of Valsalva; N, noncoronary sinus of Valsalva; RCA, right coronary artery.

 


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  		Fig. 4. Selective left coronary angiography in 30-degree right anterior oblique projection shows normal origin and course of left coronary artery after operation.

 
Anomalous origin of the left main coronary artery from the right sinus of Valsalva with its course between the aorta and pulmonary trunk is rare. It may cause sudden exercise-related cardiac death in young, otherwise healthy persons and in most cases has been diagnosed only at autopsy.Go Go 1, 2 Various mechanisms of myocardial underperfusion in this condition are discussed in the literature.Go Go 3-5 Exercise leads to increased aortic and pulmonary arterial pressures and wall tension. These increases may cause left coronary arterial insufficiency by compression of the allready slitlike ostium of the left coronary artery or by compression of its tangential course within the aortic wall. Also discussed, but rather improbable, is a direct compression of the left coronary artery during its course between the aorta and pulmonary trunk or by the left-sided aortic valve commissure.

Anomalous origin of the left coronary artery from the right sinus of Valsalva must be considered in the differential diagnosis of angina pectoris–like symptoms and exercise-related cardiac arrest or myocardial infarction in otherwise healthy-appearing young persons. The diagnosis during life is established by coronary angiography Go 6 but may be suggested by sector echocardiography, although in our case the anomaly was seen only retrospectively by this latter technique.

In only a few patients with this anomaly has it been diagnosed in time and successfully corrected. In one patient, enlargement of the left coronary arterial ostium alone was sufficient.Go Go 2, 7 In other patients, the intramural part of the left coronary artery was split, relocating the opening posteriorly into the left sinus.Go Go 4, 5 This technique, however, detaches the aortic commissure between the right and left sinuses of Valsalva, which must be resuspended secondarily. Coronary bypass with the left internal thoracic artery or a saphenous vein graft has also been described.Go Go 1, 8 In our patient, direct implantation of the left coronary artery into the left sinus of Valsalva was successfully performed. This method has the advantage of leaving the suspension of the aortic valve untouched and reestablishing the normal anatomic situation.

References

  1. Liberthson RR, Dinsmore RE, Fallon JT. Aberrant coronary artery origin from the aorta: report of 18 patients, review of literature and delineation of natural history and management. Circulation 1979;59:748-54.[Abstract/Free Full Text]
  2. Cheitlin MD, DeCastro CM, McAllister HA. Sudden death as a complication of anomalous left coronary origin from the anterior sinus of Valsalva. Circulation 1974;50:780-7.[Abstract/Free Full Text]
  3. Barth CW, Roberts WC. Left main coronary artery originating from the right sinus of Valsalva and coursing between the aorta and pulmonary trunk. J Am Coll Cardiol 1986;7:366-73.[Abstract]
  4. Donaldson RM, Raphael M, Yacoub MH, Ross DN. Hemodynamically significant anomalies of the coronary arteries: surgical aspects. Thorac Cardiovasc Surg 1982;30:7-13.[Medline]
  5. Mustafa I, Gula G, Radley-Smith R, Durrer S, Yacoub M. Anomalous origin of the left coronary artery from the anterior aortic sinus: a potential cause of sudden death. J THORAC CARDIOVASC SURG 1981;82:297-300.[Medline]
  6. Ishikawa T, Brandt PWT. Anomalous origin of the left main coronary artery from the right anterior aortic sinus: angiographic definition of anomalous course. Am J Cardiol 1985;55:770-6.[Medline]
  7. Davia JE, Green DC, Cheitlin MD, DeCastro C, Brott WH. Anomalous left coronary artery origin from the right coronary sinus. Am Heart J 1984;108:165-6.[Medline]
  8. Moodie DS, Gill C, Loop FD, Sheldon WC. Anomalous left main coronary artery originating from the right sinus of Valsalva. J THORAC CARDIOVASC SURG 1980;80:198-205.[Medline]



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