Case Report | Open Access
Sri Harsha Patlolla, Saraschandra Vallabhajosyula, Malcolm R. Bell, "Incidental Anomalous Left Coronary Artery in a Transplanted Heart", Case Reports in Cardiology, vol. 2019, Article ID 2715896, 3 pages, 2019. https://doi.org/10.1155/2019/2715896
Incidental Anomalous Left Coronary Artery in a Transplanted Heart
Anomalous coronary artery is an uncommon congenital cardiac anomaly that is often detected incidentally on coronary angiography. It has rarely been reported in the donor heart of patients who have undergone cardiac transplantation. Here, we report a case of a 72-year-old patient who received a second heart transplant and has been identified to have an anomalous left main coronary artery originating from the right coronary sinus on postoperative coronary angiography.
Anomalous coronary artery arising from the opposite sinus has been reported in less than 2% of the population , and the reported frequency of a left main coronary artery arising from the right coronary sinus is less than 0.2% [2, 3]. The anomalous origin of coronary arteries has been infrequently noted in patients with prior cardiac transplantation. Herein, we report a case of an anomalous left coronary artery in a patient with a prior cardiac transplantation.
2. Case Report
A 72-year-old male presented to the Mayo Clinic Cardiac Catheterization Laboratory for routine posttransplant surveillance coronary angiography after undergoing a second orthotopic heart transplantation at another institution four months ago. He received his first heart transplant 30 years ago for dilated cardiomyopathy which was complicated by progressive cardiac allograft vasculopathy. In 2019, he was listed and received a second cardiac transplantation at an outside medical center. The early postoperative course was uneventful, and he was on a stable immunosuppressive regimen with prednisone, tacrolimus, and mycophenolate mofetil. A postoperative coronary angiography was attempted four weeks following the transplantation, but the left coronary artery could not be selectively engaged due to the reported inferior origin of the left main artery with likely posterior rotation. He reported being told by his physicians that they “were unable to find his heart arteries.” He subsequently transferred his posttransplant care to the Mayo Clinic. As a part of the routine postoperative surveillance, he was scheduled for a coronary angiogram, right heart catheterization, and endomyocardial biopsy.
The review of the earlier angiogram had raised the suspicion of an anomalous left coronary artery. During coronary angiography, the right coronary artery was engaged without difficulty using a 6Fr Williams right catheter and looked normal in appearance (Figure 1 and Online Video 1); the left coronary artery was also seen arising posterior-inferiorly adjacent to the right coronary ostium. Selective injection from this position using a 6Fr multipurpose catheter revealed an anomalous left coronary artery arising from the right coronary sinus (Figures 2(a), 2(b), and 3 and Online Videos 2A, 2B, and 3). The long left main artery followed a retroaortic course before bifurcating into the left anterior descending and left circumflex arteries which otherwise appeared normal in appearance. We had discussed obtaining a dedicated coronary computerized tomographic scan to delineate his coronary anatomy; however, given his advanced renal disease, this was deferred after discussion with colleagues in heart failure and cardiac transplantation. Given his asymptomatic status, he was managed conservatively with routine posttransplant surveillance.
Though coronary anomalies are mostly benign, in some cases, they are known to cause ischemic changes that can precipitate myocardial infarction or sudden cardiac death . A nationwide study reported coronary anomalies originating from the opposite sinus as the second most common cause of sudden cardiac death in young athletes . Such clinically significant events are mostly dependent on the course taken by the anomalous left coronary artery when arising from the opposite sinus . An interarterial course between the aorta and pulmonary artery is often associated with sudden cardiac death. Retroaortic, anterior, and transseptal courses of the anomalous left coronary artery have less frequently been associated with adverse events [4, 7]. Although a retroaortic course is generally considered to have a minimal risk of sudden cardiac death, there have been reports of its association with sudden death and ischemic events [2, 8, 9]. Our patient did not have any clinical symptoms necessitating intervention.
Coronary artery anomalies are a rare finding especially in heart transplant recipients and are mostly benign. They are usually identified on postoperative coronary angiograms [1, 4]. As most heart donors are young patients who are unlikely to have any preexisting indications for angiography, it is difficult to detect such anomalies prior to transplant. However, if coronary anomalies are suspected, it is important to consider the future risk of complications before rejecting the donor heart. A careful evaluation of the coronary ostia on transthoracic echocardiography should be able to identify most coronary anomalies. Computerized tomographic coronary angiography and magnetic resonance coronary angiography have been suggested as a class IIA/B recommendation for the evaluation of anomalous coronary arteries by the American Heart Association Committee on Cardiovascular Imaging . Our patient had stage III chronic kidney disease, and thus, follow-up confirmatory computerized tomographic coronary angiography was deferred. Currently, there is limited evidence on the role of cross-sectional imaging for coronary anomalies in donor hearts. Coronary anomalies in native hearts are prone to spontaneous coronary spasm in 1/3 of the cases . However, this may not be perceived in a donor heart but spasm may be considered, along with appropriate testing, if there is suspicion of angina and/or ischemia . Coronary anomalies can be managed either medically or surgically depending on the presentation. In general, an individualized approach based on the patient’s age group, clinical presentation, and consideration of the risk of sudden cardiac death is advocated [1, 13–17].
Conflicts of Interest
The authors declare that they have no conflicts of interest.
SV and MRB are responsible for the case evaluation, management, and clinical follow-up. SHP and SV are assigned to the conception and design, literature review, and draft write-up. SV and MRB are assigned to the critical revisions and mentoring. SHP, SV, and MRB approved the final manuscript.
Video 1: right coronary artery arising from the right coronary sinus. Video 2: anomalous left coronary artery arising from the right coronary sinus. Video 3: right coronary artery and anomalous left coronary artery arising from the right coronary sinus. (Supplementary Materials)
- J. C. E. Lim, A. Beale, and S. Ramcharitar, “Anomalous origination of a coronary artery from the opposite sinus,” Nature Reviews Cardiology, vol. 8, no. 12, pp. 706–719, 2011.
- N. K. Kejriwal, J. Tan, S. P. Gordon, and M. A. J. Newman, “Retroaortic course of the anomalous left main coronary artery: is it a benign anomaly?: a case report and review of literature,” Heart, Lung & Circulation, vol. 13, no. 1, pp. 97–100, 2004.
- D. Kimbiris, “Anomalous origin of the left main coronary artery from the right sinus of Valsalva,” The American Journal of Cardiology, vol. 55, no. 6, pp. 765–769, 1985.
- P. P. Agarwal, C. Dennie, E. Pena et al., “Anomalous coronary arteries that need intervention: review of pre- and postoperative imaging appearances,” Radiographics, vol. 37, no. 3, pp. 740–757, 2017.
- B. J. Maron, J. J. Doerer, T. S. Haas, D. M. Tierney, and F. O. Mueller, “Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006,” Circulation, vol. 119, no. 8, pp. 1085–1092, 2009.
- O. Yamanaka and R. E. Hobbs, “Coronary artery anomalies in 126, 595 patients undergoing coronary arteriography,” Catheterization and Cardiovascular Diagnosis, vol. 21, no. 1, pp. 28–40, 1990.
- P. Angelini, “Coronary artery anomalies--current clinical issues: definitions, classification, incidence, clinical relevance, and treatment guidelines,” Texas Heart Institute Journal, vol. 29, no. 4, pp. 271–278, 2002.
- F. K. Patterson, “Sudden death in a young adult with anomalous origin of the posterior circumflex artery,” Southern Medical Journal, vol. 75, no. 6, pp. 748-749, 1982.
- B. Madea and R. Dettmeyer, “Sudden death in cases with anomalous origin of the left coronary artery,” Forensic Science International, vol. 96, no. 2-3, pp. 91–100, 1998.
- D. A. Bluemke, S. Achenbach, M. Budoff et al., “Noninvasive coronary artery imaging: magnetic resonance angiography and multidetector computed tomography angiography: a scientific statement from the american heart association committee on cardiovascular imaging and intervention of the council on cardiovascular radiology and intervention, and the councils on clinical cardiology and cardiovascular disease in the young,” Circulation, vol. 118, no. 5, pp. 586–606, 2008.
- P. Angelini and C. Uribe, “Anatomic spectrum of left coronary artery anomalies and associated mechanisms of coronary insufficiency,” Catheterization and Cardiovascular Interventions, vol. 92, no. 2, pp. 313–321, 2018.
- R. J. Widmer, B. Samuels, H. Samady et al., “The functional assessment of patients with non-obstructive coronary artery disease: expert review from an international microcirculation working group,” EuroIntervention, vol. 14, no. 16, pp. 1694–1702, 2019.
- E. Erez, V. K. Tam, N. A. Doublin, and J. Stakes, “Anomalous coronary artery with aortic origin and course between the great arteries: improved diagnosis, anatomic findings, and surgical treatment,” The Annals of Thoracic Surgery, vol. 82, no. 3, pp. 973–977, 2006.
- S. E. Moustafa, K. Zehr, M. Mookadam, E. C. Lorenz, and F. Mookadam, “Anomalous interarterial left coronary artery: an evidence based systematic overview,” International Journal of Cardiology, vol. 126, no. 1, pp. 13–20, 2008.
- J. A. Davis, F. Cecchin, T. K. Jones, and M. A. Portman, “Major coronary artery anomalies in a pediatric population: incidence and clinical importance,” Journal of the American College of Cardiology, vol. 37, no. 2, pp. 593–597, 2001.
- J. E. Davies, H. M. Burkhart, J. A. Dearani et al., “Surgical management of anomalous aortic origin of a coronary artery,” The Annals of Thoracic Surgery, vol. 88, no. 3, pp. 844–848, 2009, discussion 847-848.
- A. J. Taylor, J. P. Byers, M. D. Cheitlin, and R. Virmani, “Anomalous right or left coronary artery from the contralateral coronary sinus: "high-risk" abnormalities in the initial coronary artery course and heterogeneous clinical outcomes,” American Heart Journal, vol. 133, no. 4, pp. 428–435, 1997.
Copyright © 2019 Sri Harsha Patlolla et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.