Editorial comment
Anomalous coronary arteries arising from the opposite aortic sinus: When to intervene?
Anomalias nas artérias coronárias com origem no seio aórtico oposto: quando intervir?
Gonçalo Freitas Coutinho
Serviço de Cirurgia Cardiotorácica do Centro Universitário e Hospitalar de Coimbra, Coimbra, Portugal
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arteries arising from the opposite aortic sinus: When to intervene?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "237" "paginaFinal" => "238" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Gonçalo Freitas Coutinho" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Gonçalo Freitas" "apellidos" => "Coutinho" "email" => array:1 [ 0 => "goncalofcoutinho@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cirurgia Cardiotorácica do Centro Universitário e Hospitalar de Coimbra, Coimbra, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Anomalias nas artérias coronárias com origem no seio aórtico oposto: quando intervir?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The reported incidence of anomalous origin of the coronary arteries is 0.1% to 1.3% in the general population. Anomalous coronary arteries arising from the opposite sinus of Valsalva (ACAOS) are the most frequently found of such anomalies and are associated with adverse cardiac events, particularly in the young.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1–3</span></a> The left circumflex artery originating from the right sinus is the most common ACAOS, with an incidence of 0.4%. The right coronary artery arising from the left sinus or the left main coronary artery arising from the right sinus are less common, with a prevalence in the general population between 0.1% and 0.3%.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The clinical relevance of this rare entity is thought to be related directly to the hemodynamic significance of particular anatomic features such as an interarterial course, slit-like ostium, acute angle take-off, intramural course, elliptical vessel course, and proximal vessel narrowing of the anomalous vessel. Patients with these features may be more prone to sudden cardiac death (SCD) or even myocardial infarction (MI) as a direct consequence of scissor-like shearing, kinking or lateral dynamic compression of the vessel due to increased pressure in both the aorta and the pulmonary artery during strenuous physical exercise.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Timely diagnosis can be challenging because clinical presentation may range from complete absence of symptoms to angina, palpitations, MI, heart failure, syncope, and SCD. This issue is of great importance in younger and active patients, because in most instances they are asymptomatic and standard electrocardiographic testing under resting or exercise conditions is unlikely to provide clinical evidence of myocardial ischemia and would not be reliable as a screening test in large populations. Basso et al. reviewed two large registries, assembled consecutively in the US and Italy, of young competitive athletes who died suddenly in order to characterize their clinical profile and to identify clinical markers that would enable ACAOS to be detected during life in young competitive athletes.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> They found that warning cardiac symptoms were not uncommon shortly before SCD (typically associated with a anomalous left main coronary artery), suggesting that a history of exertional syncope or chest pain requires exclusion of this anomaly.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Diagnostic workup is usually guided by the suspicion of coronary artery disease, so ischemia-driven testing is frequently the initial approach, followed by coronary imaging (coronary angiography, coronary computed tomography angiography [CCTA], or magnetic resonance imaging).<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Recently CCTA has been used more widely, which will probably lead to further increases in incidental diagnosis of ACAOS. The question of appropriate management for such cases will therefore arise more frequently.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The indication for surgical intervention is straightforward when there are symptoms or myocardial ischemia related to the coronary anomaly. Nevertheless, the type of lesion and the course of the coronary artery should also be taken into account. Intravascular ultrasound has been demonstrated to be a valuable tool in assessing the origin and proximal segment of the anomalous vessel and lateral compression of the coronary wall by the aorta when present.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> However, in asymptomatic patients the decision whether to operate should be made on an individual basis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>, Sousa et al.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> describe their experience in surgically managing seven patients with this anomaly, reporting no mortality and good medium-term survival. Based on their results, they advise surgery in symptomatic patients suggestive of myocardial ischemia, asymptomatic patients with a left coronary artery arising from the right sinus of Valsalva, and some patients with an anomalous right coronary artery from the left sinus, when the expected surgical risks are minimal, particularly when they are young and engaged in physically strenuous jobs or hobbies.</p><p id="par0035" class="elsevierStylePara elsevierViewall">A recent study by Grani et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> suggests a more benign course in middle-aged patients with ACAOS, since medium-term outcomes (major adverse cardiac events) were favorable and not statistically different from a matched control cohort without coronary artery anomalies, regardless of whether there was an interarterial course. These findings are only applicable in this setting; in a pediatric population or even in young adults the results could be different. In this context, Sousa et al.’s study is important, since they have demonstrated that it is possible to perform anatomical correction, avoiding coronary artery bypass grafting, in the majority of cases with excellent perioperative results. We therefore believe that the age factor should also be considered when dealing with asymptomatic patients with ACAOS and an interarterial course, and that surgical intervention should be reserved for younger patients, under 35-40 years of age.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coronary artery abnormalities and sudden cardiac death" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 7 | 13 |
| 2024 October | 37 | 37 | 74 |
| 2024 September | 40 | 22 | 62 |
| 2024 August | 40 | 39 | 79 |
| 2024 July | 31 | 27 | 58 |
| 2024 June | 31 | 21 | 52 |
| 2024 May | 38 | 24 | 62 |
| 2024 April | 31 | 24 | 55 |
| 2024 March | 52 | 25 | 77 |
| 2024 February | 58 | 25 | 83 |
| 2024 January | 18 | 24 | 42 |
| 2023 December | 22 | 28 | 50 |
| 2023 November | 29 | 22 | 51 |
| 2023 October | 21 | 31 | 52 |
| 2023 September | 16 | 28 | 44 |
| 2023 August | 20 | 14 | 34 |
| 2023 July | 27 | 10 | 37 |
| 2023 June | 19 | 9 | 28 |
| 2023 May | 38 | 18 | 56 |
| 2023 April | 17 | 6 | 23 |
| 2023 March | 40 | 27 | 67 |
| 2023 February | 30 | 21 | 51 |
| 2023 January | 23 | 17 | 40 |
| 2022 December | 32 | 32 | 64 |
| 2022 November | 36 | 35 | 71 |
| 2022 October | 34 | 29 | 63 |
| 2022 September | 26 | 29 | 55 |
| 2022 August | 20 | 30 | 50 |
| 2022 July | 33 | 37 | 70 |
| 2022 June | 25 | 26 | 51 |
| 2022 May | 19 | 21 | 40 |
| 2022 April | 28 | 45 | 73 |
| 2022 March | 28 | 39 | 67 |
| 2022 February | 25 | 29 | 54 |
| 2022 January | 31 | 22 | 53 |
| 2021 December | 19 | 21 | 40 |
| 2021 November | 30 | 37 | 67 |
| 2021 October | 27 | 34 | 61 |
| 2021 September | 20 | 23 | 43 |
| 2021 August | 28 | 34 | 62 |
| 2021 July | 16 | 14 | 30 |
| 2021 June | 13 | 28 | 41 |
| 2021 May | 30 | 45 | 75 |
| 2021 April | 57 | 47 | 104 |
| 2021 March | 65 | 28 | 93 |
| 2021 February | 47 | 18 | 65 |
| 2021 January | 29 | 16 | 45 |
| 2020 December | 28 | 12 | 40 |
| 2020 November | 22 | 16 | 38 |
| 2020 October | 14 | 20 | 34 |
| 2020 September | 44 | 6 | 50 |
| 2020 August | 17 | 6 | 23 |
| 2020 July | 34 | 21 | 55 |
| 2020 June | 33 | 8 | 41 |
| 2020 May | 26 | 7 | 33 |
| 2020 April | 23 | 3 | 26 |
| 2020 March | 39 | 6 | 45 |
| 2020 February | 32 | 14 | 46 |
| 2020 January | 26 | 9 | 35 |
| 2019 December | 22 | 6 | 28 |
| 2019 November | 36 | 11 | 47 |
| 2019 October | 9 | 3 | 12 |
| 2019 September | 10 | 8 | 18 |
| 2019 August | 36 | 7 | 43 |
| 2019 July | 29 | 6 | 35 |
| 2019 June | 25 | 17 | 42 |
| 2019 May | 27 | 12 | 39 |
| 2019 April | 17 | 20 | 37 |
| 2019 March | 85 | 23 | 108 |
| 2019 February | 59 | 5 | 64 |
| 2019 January | 74 | 8 | 82 |
| 2018 December | 72 | 10 | 82 |
| 2018 November | 35 | 14 | 49 |
| 2018 October | 49 | 11 | 60 |
| 2018 September | 16 | 11 | 27 |
| 2018 August | 22 | 4 | 26 |
| 2018 July | 14 | 1 | 15 |
| 2018 June | 16 | 4 | 20 |
| 2018 May | 25 | 6 | 31 |
| 2018 April | 10 | 5 | 15 |
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