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Thromboaspiration was attempted but it was impossible to advance the aspiration catheter due to the diffuse disease of the vessel&#46; Simple angioplasty with a semicompliant balloon &#40;2 mm&#215;15 mm&#41; was therefore performed&#44; with recovery of TIMI 3 distal flow &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C&#59; arrow&#41;&#46; We decided not to implant a stent because of diffuse disease and the small diameter of the vessel&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient evolved well and was promptly extubated&#46; In order to confirm the origin and course of the SCA&#44; multislice computed tomography &#40;MSCT&#41; was performed&#46; It confirmed the existence of an SCA originating from the right sinus&#46; Immediately after the origin of this main trunk&#44; it gave off a small vessel that reached the anterior interventricular sulcus anteriorly to the aorta and pulmonary artery &#40;proximal LAD territory&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D&#41;&#46; The single common trunk&#44; 7 mm in diameter at its proximal segment&#44; had numerous calcified plaques along its route without significant stenosis&#46; A large left posterolateral branch followed the left atrioventricular groove supplying the nominal CX territory &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>E&#41;&#46; Finally&#44; the SCA gave rise to a distal branch on the distal anterior wall of the left ventricle&#44; completing the irrigation of the LAD territory&#46; Given these findings&#44; the SCA was classified as RII-A subtype according to Lipton&#39;s classification&#46; Due to the non-malignant course of the SCA&#44; the patient was discharged under medical therapy consisting of dual antiplatelet therapy &#40;aspirin and clopidogrel&#41; for 12 months&#44; atorvastatin&#44; metoprolol and enalapril&#46; After one year of clinical follow-up&#44; he remains asymptomatic&#44; with no further adverse events&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">An SCA&#44; defined as an artery that arises from an arterial trunk of a coronary sinus and irrigates the entire myocardium&#44; is one of the most rarely seen coronary artery anomalies &#40;CAA&#41;&#44; with an incidence of 0&#46;05&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a> The prognosis of patients with SCA varies according to its anatomic distribution and associated coronary atherosclerosis&#46; The majority of these anomalies are diagnosed as incidental findings on coronary angiography&#46; However&#44; 20&#37; of cases are associated with life-threatening symptoms&#44; such as arrhythmias&#44; syncope&#44; myocardial infarction&#44; or sudden death &#40;SD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> SCAs were classified by Lipton et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> according to the site of origin &#40;right or left coronary sinus of Valsalva&#41;&#44; the anatomical distribution on the ventricular surface&#44; and the relationship with the ascending aorta and the pulmonary artery&#46; In patients with an SCA and an intra-arterial course&#44; SD may occur when the SCA is compressed between the aorta and pulmonary artery during vigorous exercise&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Coronary angiography is the gold standard for the evaluation of coronary artery disease&#46; However&#44; in the case of CAA&#44; further evaluation by MSCT is recommended to determine the course of the anomaly and prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">To the best of our knowledge this case is the first reported in the literature describing a patient with an RII-A subtype SCA presenting with ST-segment elevation myocardial infarction and cardiac arrest&#46; It should be borne in mind that coronary atherosclerosis is common in CAA&#44; and that its clinical presentation can be as stable coronary artery disease or acute coronary syndromes &#40;ACS&#41;&#46; Even after a malignant interarterial course of the SCA is excluded&#44; cardiac arrest is a possible clinical presentation produced by myocardial ischemia in the context of an ACS and should be managed according to clinical practice guidelines&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Case report
Single coronary artery presenting as acute myocardial infarction
Artéria coronária única associada a um enfarte agudo do miocárdio
Alfonso Jurado-Román
Autor para correspondência
alfonsojuradoroman@gmail.com

Corresponding author.
, Ignacio Sánchez-Pérez, Fernando Lozano-Ruíz-Poveda, Natalia Pinilla-Echeverri, María T. López-Lluva, Andrea Moreno-Arciniegas, Manuel Marina-Breysse, Jesús Piqueras-Flores
Interventional Cardiology Department, University General Hospital of Ciudad Real, Ciudad Real, Spain
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Suddenly&#44; four hours after admission&#44; the patient experienced cardiac arrest in ventricular fibrillation&#46; Advanced cardiopulmonary resuscitation was performed and after five defibrillations&#44; he recovered sinus rhythm with inferior ST elevation&#46; The patient was transferred to our center for primary percutaneous coronary intervention&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">On coronary angiography&#44; a single coronary artery &#40;SCA&#41; originating from the right coronary sinus was observed&#44; which also supplied the territory of the left anterior descending &#40;LAD&#41; and circumflex &#40;CX&#41; arteries &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and B&#59; <a class="elsevierStyleCrossRef" href="#sec0045">videos 1 and 2</a>&#41;&#46; An acute marginal branch had a thrombotic occlusion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#59; arrow&#41;&#46; The acute occlusion was easily crossed with a Runthrough NS<span class="elsevierStyleSup">&#174;</span> floppy guidewire&#46; Thromboaspiration was attempted but it was impossible to advance the aspiration catheter due to the diffuse disease of the vessel&#46; Simple angioplasty with a semicompliant balloon &#40;2 mm&#215;15 mm&#41; was therefore performed&#44; with recovery of TIMI 3 distal flow &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C&#59; arrow&#41;&#46; We decided not to implant a stent because of diffuse disease and the small diameter of the vessel&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The patient evolved well and was promptly extubated&#46; In order to confirm the origin and course of the SCA&#44; multislice computed tomography &#40;MSCT&#41; was performed&#46; It confirmed the existence of an SCA originating from the right sinus&#46; Immediately after the origin of this main trunk&#44; it gave off a small vessel that reached the anterior interventricular sulcus anteriorly to the aorta and pulmonary artery &#40;proximal LAD territory&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D&#41;&#46; The single common trunk&#44; 7 mm in diameter at its proximal segment&#44; had numerous calcified plaques along its route without significant stenosis&#46; A large left posterolateral branch followed the left atrioventricular groove supplying the nominal CX territory &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>E&#41;&#46; Finally&#44; the SCA gave rise to a distal branch on the distal anterior wall of the left ventricle&#44; completing the irrigation of the LAD territory&#46; Given these findings&#44; the SCA was classified as RII-A subtype according to Lipton&#39;s classification&#46; Due to the non-malignant course of the SCA&#44; the patient was discharged under medical therapy consisting of dual antiplatelet therapy &#40;aspirin and clopidogrel&#41; for 12 months&#44; atorvastatin&#44; metoprolol and enalapril&#46; After one year of clinical follow-up&#44; he remains asymptomatic&#44; with no further adverse events&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">An SCA&#44; defined as an artery that arises from an arterial trunk of a coronary sinus and irrigates the entire myocardium&#44; is one of the most rarely seen coronary artery anomalies &#40;CAA&#41;&#44; with an incidence of 0&#46;05&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a> The prognosis of patients with SCA varies according to its anatomic distribution and associated coronary atherosclerosis&#46; The majority of these anomalies are diagnosed as incidental findings on coronary angiography&#46; However&#44; 20&#37; of cases are associated with life-threatening symptoms&#44; such as arrhythmias&#44; syncope&#44; myocardial infarction&#44; or sudden death &#40;SD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> SCAs were classified by Lipton et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> according to the site of origin &#40;right or left coronary sinus of Valsalva&#41;&#44; the anatomical distribution on the ventricular surface&#44; and the relationship with the ascending aorta and the pulmonary artery&#46; In patients with an SCA and an intra-arterial course&#44; SD may occur when the SCA is compressed between the aorta and pulmonary artery during vigorous exercise&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Coronary angiography is the gold standard for the evaluation of coronary artery disease&#46; However&#44; in the case of CAA&#44; further evaluation by MSCT is recommended to determine the course of the anomaly and prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">To the best of our knowledge this case is the first reported in the literature describing a patient with an RII-A subtype SCA presenting with ST-segment elevation myocardial infarction and cardiac arrest&#46; It should be borne in mind that coronary atherosclerosis is common in CAA&#44; and that its clinical presentation can be as stable coronary artery disease or acute coronary syndromes &#40;ACS&#41;&#46; Even after a malignant interarterial course of the SCA is excluded&#44; cardiac arrest is a possible clinical presentation produced by myocardial ischemia in the context of an ACS and should be managed according to clinical practice guidelines&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            0 => "Single coronary artery"
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            2 => "Cardiac arrest"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A single coronary artery is one of the most rarely seen coronary artery anomalies&#46; In addition&#44; the specific subtype &#40;Lipton RII-A&#41; that our patient presented is one of the least common&#44; and its clinical presentation as myocardial infarction and cardiac arrest has not been described in the literature&#46; The case shows that although it is essential to exclude a malignant interarterial course of the vessel&#44; cardiac arrest is a possible clinical presentation produced by myocardial ischemia in the context of acute myocardial infarction and should be managed according to clinical practice guidelines&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Uma art&#233;ria coron&#225;ria &#250;nica &#233; uma das anomalias mais raras das art&#233;rias coron&#225;rias&#46; Al&#233;m disso&#44; o subtipo espec&#237;fico &#40;Lipton R-IIA&#41; presente no nosso doente &#233; um dos menos frequentes e a sua apresenta&#231;&#227;o cl&#237;nica como enfarte do mioc&#225;rdio e como paragem card&#237;aca n&#227;o foi ainda descrita na literatura&#46; O caso mostra que&#44; embora o descarte de um percurso interarterial maligno do vaso seja essencial&#44; a paragem card&#237;aca &#233; uma apresenta&#231;&#227;o cl&#237;nica poss&#237;vel causada por isquemia do mioc&#225;rdio no cen&#225;rio de um enfarte agudo do mioc&#225;rdio&#44; que dever&#225; ser tratada de acordo com as recomenda&#231;&#245;es pr&#225;ticas cl&#237;nicas&#46;</p></span>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">&#40;A and B&#41; Coronary angiography showing a single coronary artery &#40;SCA&#41; originating from the right coronary sinus&#44; also supplying the territory of the left anterior descending &#40;LAD&#41; and circumflex &#40;CX&#41; arteries&#44; and thrombotic occlusion of an acute marginal branch &#40;A&#44; arrow&#41;&#59; &#40;C&#41; primary percutaneous coronary intervention recovering distal TIMI 3 flow in the culprit vessel &#40;arrow&#41;&#59; &#40;D and E&#41; multislice computed tomography reconstruction&#46; After its origin&#44; the main trunk of the SCA crosses the base of the heart to supply the contralateral coronary artery&#46; Immediately after the origin of this main trunk&#44; it also gives off a small vessel that reaches the anterior interventricular sulcus anteriorly to the aorta &#40;AO&#41; and pulmonary artery &#40;PA&#41; to supply the proximal LAD territory&#46;</p>"
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                      "titulo" => "Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology&#46; 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation&#58; Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology &#40;ESC&#41;"
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                      "titulo" => "Isolated single coronary artery &#40;RII-B type&#41; presenting as an inferior wall myocardial infarction&#58; a rare clinical entity"
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