Surgical revascularization of a rare type IV dual left anterior descending artery—a case report

Background Type IV dual left anterior descending artery (LAD) is a rare congenital coronary anomaly. Though benign with most of the patients being asymptomatic, knowledge of its existence and identification during coronary angiography is important during coronary interventions and surgical revascularization. Case presentation We present a rare case of type IV dual left anterior descending artery (LAD) with anomalous origin of one of the two vessels from the right coronary sinus. A 49-year-old female presented with inferior wall infarction and she underwent coronary angiography. Coronary angiogram showed triple vessel coronary artery disease. This rare variant of dual LAD was identified and was confirmed intra-operatively. The patient underwent coronary revascularization with grafts to both the LAD systems. Conclusions Proper assessment of the angiogram and knowledge of the coronary anomalies is required during surgical revascularization and percutaneous coronary interventions. This rare anomaly can be missed due to the anomalous origin of the LAD from the right coronary sinus. The identification of the dual LAD and grafting of both the LAD systems is required to achieve complete revascularization.

Unique Association of Aortopulmonary Window With Anomalous Origin of Left Coronary Artery From Pulmonary Artery in an Infant: A Blessing in Disguise?

Aortopulmonary window (APW) seen in association with anomalous origin of left coronary artery from pulmonary artery (ALCAPA) is extremely uncommon. When faced with this combination, ALCAPA usually goes undetected since most of the clinical and echocardiographic features of ALCAPA, including ventricular dysfunction are absent due to co-existent pulmonary hypertension. Herein we report a 5-month-old child with a large APW in whom a preoperative computed tomography angiogram facilitated the diagnosis of ALCAPA. The case is described for its rarity and the challenges faced during management. Also, it is extremely crucial that this coronary anomaly is identified and corrected during surgery, since failure to do so results in unforeseen postoperative ventricular dysfunction.

The vertebral Artery Anomalous, Stenosis vs Hypoplasia as the leading cause of Stroke. An anatomical cross-Sectional Study of VA anomalies in Neck three-Dimensional computed Tomography Angiography

Introduction: A thorough understanding of the vertebral artery (VA) variations and course of the artery and its related branches could significantly enhance the efficacy and safety of interventions involving the neck and spine. Here, we aimed to investigate the incidence of various VA variations in individuals presenting with signs and symptoms of stroke with our neurology team. Material and Method: In this retrospective study we investigate CTA images of patients with signs and symptom of stroke who referred to specialized medical imaging centre. An experienced board-certified radiologist evaluated the CTA images, recording the characteristics of VA, regarding dominance and any possible anomalies. These included anomalous origin, anomalous route, anomalous branching, stenosis, hypoplasia, atresia, thrombosis, and dissection. All data were analyzed using SPSS version24 and Pearson Chi-Square and Fishers test used for anomaly and gender correlation. Results: A total of 125 patients (53.6% females; mean age, 60.7 (11-87)) were included. In the case of VA dominance, 66.4% of cases were co-dominant while 16.0% were right, and 12.8% were left dominant. Overall, males had more VA anomalies than females, 24.8% and 17.6%, respectively (in general, 42.4% of all participants) (p = 0.020). Among patients, 4.0% (n = 5) had an anomalous origin and anomalous branching was reported in 5 patients (4.0%). Among the variations, significant stenosis (18.4%) and hypoplasia (17.6%) were the most prevalent anomalies with the earliest one having the higher rate. While anomalous branching was reported in 5 patients (4.0%). Conclusions: VA variations are relatively common and should be addressed during procedures involving the neck region and would allow surgeons to avoid life threatening injury.

462 Accidental detection of an anomalous origin of the coronary arteries in a patient with STEMI: a case report

Coronary artery anomalies and variants are relatively uncommon congenital disorders of the coronary artery anatomy and constitute the second most common cause of sudden cardiac death in young competitive athletes. Normally there are two main coronary arteries, which stem from the sinuses of Valsalva and descend towards the cardiac apex. The most frequent anomalous origin of the coronary arteries associated with sudden cardiac death is the anomalous origin of a coronary artery from the contralateral sinus, particularly if the anomalous coronary artery has a course between the aorta and the pulmonary artery. The diagnosis of a coronary artery anomaly is insidious since patients are usually asymptomatic. Indeed, in most of the cases, coronary anomalies are discovered incidentally during coronary angiography or on autopsy following sudden cardiac death. However, in some cases, symptoms like angina, syncope, heart failure, and myocardial infarction may occur. We want to describe the case of a 54 years old man who went to another hospital of our district with chest pain. The EKG showed an infero-lateral STEMI. The patient underwent systemic thrombolysis complicated by arrhythmic storm, treated with effective DC shock, then he was urgently transferred to our Hospital to perform a PCI rescue. The coronary angiography showed a critical stenosis of the right coronary artery, treated with the implantation of a zotarolimus-eluting coronary stent system. Surprisingly, an abnormal origin of the anterior interventricular artery and circumflex artery from seperated hosts in the right coronary sinus was detected. A computed tomography showed the separated origin of the right coronary artery and the left main from the right coronary sinus; moreover, the left main presented a retroaortic course between the bulb and the left atrium; the left anterior intraventricular artery run anterior to the aortic root. During hospitalization, a diagnosis of diabetes was made with consequent setting of adequate hypoglycemic therapy. Serial echocardiograms showed an improval in the ejection fraction (from 35–40% to 50%). The patient was discharged in well clinical conditions and 1 month later at the follow-up, during an outpatient visit, he was fully asymptomatic. The dynamic EKG according to Holter showed rare isolated ventricular beats; laboratory tests were normal. The anomalous origin of a coronary ostium from the contralateral sinus is the most frequently anomaly which is associated with sudden cardiac death, in particular when the left coronary artery origins from the right sinus. The rapid advancement of the imaging techniques, including CT, CMR, intravascular ultrasound, and optical coherence tomography, have provided us with a wealth of new information on this subject. Coronary artery CT offers the best performance in terms of spatial resolution, acquisition time, and image contrast but the use is limited due the dose of ionizing radiation and the use of contrast agents, in particular taking into account that most patients are young. CMR is capable of visualizing the origin of the coronary arteries non-invasively, without use of ionizing radiation and contrast agents. Currently however, due to spatial resolution, the capability of CMR to visualize smaller coronary branches is still a limiting factor preventing full assessment of coronary arteries using this modality. Developments and more widespread access to advanced cardiac imaging will undoubtedly lead to earlier diagnoses. The taxonomies of the anomalous origin of coronary arteries are inconsistent and complex and so we want to make our contribution to the register of cases of abnormal origin of coronary arteries for the risk of sudden cardiac death and ischaemic events related to.

770 Small heart and single coronary artery in a young patient with chronic fatigue syndrome: a case report

Aims Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a clinically defined condition reported mostly in adults, characterized by fatigue and unexplained aspecifical symptoms. Patients with CFS/ME frequently have reduced stroke volume with an inverse relation between cardiac output and post-exertional malaise severity. We describe a rare case of a young man affected by CFS/ME, small heart, and anomalous anatomy of left main coronary artery (LMCA). Methods and results A 19-year-old Caucasian male referred to our clinic complaining weakness, lack of concentration, and sleepiness. He suffered by CFS/ME, D hypovitaminosis, inflammatory bowel disease, and exocrine pancreas insufficiency. Blood tests revealed no pathological findings. Faecal exams documented intestinal dysbiosis and low pancreatic elastase. He was treated with oxygen-ozone rectal insufflations and probiotics. Physical examination was unremarkable. Electrocardiogram showed normal sinus rhythm. Echocardiogram revealed reduced diameters of the left ventricle (LV), normal aortic root dimensions and, in a five-chamber apical view, a binary structure that seemed to cross the aorta perpendicularly. Cardiac magnetic resonance (CMR) found reduced LV stroke volume (34 ml/m2) and end-diastolic volume (57 ml/m2) together with reduced end-diastolic wall mass (51 g/m2). Right ventricle volumes were reduced too. In addition, the exam confirmed the anomalous origin of LMCA stemming from the proximal segment of right coronary artery and following a retro-aortic course. Mechanism of CFS/ME remains unknown, although various factors have been implicated, including immune activation, chronic viral infection, and emotional disorders. A considerable number of patients affected by CFS has an anatomically small heart. Small heart syndrome, in fact, may contribute to the onset of CFS/ME. Previous studies hypothesized that clinical manifestations of CMS/ME were caused by reduced venous return, cardiac output, and heart mass, together with decreased arterial oxygen saturation. Single coronary artery is an uncommon congenital anatomic abnormality identified by a single coronary ostium giving rise to all arteries supplying the heart. Thus, we reported a rare case of a very young man affected by chronic fatigue syndrome and small heart, investigated not only with echocardiogram but also with CMR, not often used in this clinical setting. More, we found an anomalous origin of LMCA. From literature, it’s not reported any cases of a patient including these three rare conditions (CFS/ME, small heart, and single coronary artery). Conclusions This case highlights that CFS/ME together with small heart is a condition possible also in young people. More studies and reports could be necessary to better define the association between cardiac congenital anomalies and CFS/ME. 770 Figure