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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Coronary artery anomalies &#40;CAAs&#41; are a diverse group of congenital disorders with highly variable manifestations and pathophysiological mechanisms&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The wide spectrum of CAAs has been comprehensively organized by Paolo Angelini&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">2</span></a> who divided them into anomalies of origin and course&#59; anomalies of intrinsic coronary arterial anatomy&#59; anomalies of coronary termination&#59; and anomalous anastomotic vessels&#46; The terms &#8216;anomalous&#8217; or &#8216;abnormal&#8217; are generally used to define any variant form of coronary arterial anatomy&#59; variant forms are observed in less than 1&#37; of the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">3</span></a> Isolated CAAs have been described in 0&#46;5&#37; of patients undergoing coronary angiography&#44;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">4&#44;5</span></a> 0&#46;3&#37; of individuals at autopsy<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">6</span></a> and 0&#46;17&#37; in a prospective echocardiographic series&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">7</span></a> An anomalous coronary artery arising from the opposite sinus of Valsalva &#40;ACAOS&#41; is the subgroup of coronary anomalies with the most potential for clinical repercussions in adults&#44; especially sudden cardiac death &#40;SCD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A systematic review of the diagnostic databases of the cardiology and cardiothoracic surgery departments of Centro Hospitalar S&#46; Jo&#227;o retrieved a total of nine adult patients with ACAOS between 2007 and 2016&#46; Although the first paper published in Portugal reporting the surgical repair of an ACAOS dates from 2006&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">8</span></a> this is the first surgical series so far reported in this country&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This retrospective study was performed by reviewing the clinical records of all patients at our institution&#44; including coronary angiograms&#44; computed tomography &#40;CT&#41; coronary angiograms and follow-up consultations&#46; Patients with CAAs other than ACAOS were excluded&#46; Individual reports were categorized by demographics&#44; clinical presentation&#44; method of diagnosis&#44; type and course of coronary anomaly&#44; type of surgery&#44; time of cardiopulmonary bypass and aortic clamping&#44; length of hospital stay and postoperative complications &#40;<a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Outcomes were assessed clinically for angina&#44; myocardial infarction&#44; death and cause&#44; and results of postoperative examinations &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Survival&#44; follow-up time and freedom from cardiac events were calculated &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Statistical analysis was performed with IBM SPSS Statistics 24&#46;0&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">9</span></a> Sample statistics are presented as mean and standard deviation or median and interquartile range&#44; according to distribution&#46; Survival data were computed by the Kaplan-Meier method&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A literature review of observational studies was performed on PubMed&#44; using the search term &#8220;coronary anomalies&#8221; in the Title&#47;Abstract&#44; limited to papers published between January 2000 and June 2016&#46; Exclusion criteria were the reporting of coronary anomalies other than origin from the opposite sinus and language other than English&#44; Portuguese or Spanish&#46; Four additional papers published before 2000 were included by cross-reference&#46; One additional paper&#44; published in March 2017&#44; was included after editorial review&#46; Significant publications with special emphasis on clinical presentation&#44; diagnosis&#44; surgical indications and operative results were read and major contributions referenced in the discussion&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">Nine adult patients comprised this study group&#44; as no children were identified in the databases with this diagnosis&#46; Four of them had the left coronary artery &#40;LCA&#41; originating from the right sinus of Valsalva&#44; and in the other five the right coronary artery &#40;RCA&#41; originated from the left sinus&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Seven of these patients were proposed and accepted for surgery and operated with success by the same surgeon &#40;JC&#41;&#46; Three patients had an LCA from the right sinus and the other four had an RCA from the left sinus&#46; In one&#44; the coronary course was extramural and intramyocardial&#44; and in the other six it was intramural&#46; Mean age at surgery was 57&#46;1&#177;8&#46;9 years&#59; two patients were male and five female&#46; Four had hypertension and dyslipidemia and none had diabetes&#46; A 75-year-old woman&#44; diagnosed in 2008 with an LCA from the right sinus&#44; symptoms of heart failure and severe respiratory insufficiency&#44; was not referred for surgery and died suddenly six months after diagnosis&#46; An asymptomatic female patient&#44; 22 years old and a firefighter&#44; performed several stress tests without evidence of ischemia and has been followed medically&#44; but had to quit her job&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Surgical revascularization techniques commonly used to address ACAOS include&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Ostial reimplantation&#44; involving detachment of the coronary button and attachment in the correct sinus &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#44; which was performed in case 6&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">In case 3&#44; the course of the coronary was extramural and intramyocardial&#44; hence reimplantation would be our first choice&#46; However&#44; this technique could have jeopardized a large right infundibular branch and a lateral anastomosis was created in the right sinus&#44; thereby creating a coronary artery with two ostia<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">10</span></a>&#59;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Coronary artery bypass grafting &#40;CABG&#41;&#44; with an arterial graft performed in our oldest patient &#40;case 2&#41;&#44; taking the precaution of creating a proximal stenosis in the anomalous RCA and thus avoiding competitive flow and occlusion of the graft &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#59;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Unroofing&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">11</span></a> which is suitable for anomalous coronaries with long intramural segments&#44; in which incision of the common wall of the aorta and anomalous coronary opens their intramural segment to the aortic lumen &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; undertaken in cases 5 and 7&#59; and</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Neo-ostium creation&#44; adopted when there is a long intramural segment of the anomalous coronary that crosses a commissure of the aortic valve&#44; in which case unroofing would necessitate detaching the commissure&#44; increasing the risk of later aortic regurgitation&#46; In this case&#44; instead of a complete unroofing procedure&#44; only a partial incision is made in the common wall in the correct sinus&#44; thus creating a coronary with two ostial openings &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41;&#59; this was performed in patients 4 and 9&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">All operated patients recovered without major complications&#46; Median length of stay was 7 &#40;5-21&#41; days&#46; Minor complications consisted of persistent atrial fibrillation and fever without focus in two patients&#46; There was no in-hospital mortality&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Mean follow-up time is 90&#46;3&#177;19&#46;7 months&#46; One patient died 22 months after surgery&#44; from a gall bladder carcinoma&#44; resulting in a cumulative survival of 75&#177;21&#37; at 113 months after surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The other six are alive&#44; asymptomatic in cardiac terms&#44; and follow-up stress tests revealed no evidence of residual myocardial ischemia &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Most cases of sudden death in adults are caused by atherosclerotic ischemic heart disease&#46; However&#44; reports in young adults identify CAAs as the leading<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">12</span></a> or second leading cause of SCD in the latter&#44; after hypertrophic cardiomyopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">13</span></a> ACAOS is a rare clinical entity&#44; with a reported incidence of 0&#46;06&#37; to 0&#46;9&#37; for anomalous RCA and 0&#46;025&#37; and 0&#46;15&#37; for anomalous LCA in a cross-sectional imaging series&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">14</span></a> and 0&#46;7&#37; in an MRI-based screening series&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">15</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In Portugal&#44; three previous imaging studies documented incidences of coronary anomalies of 0&#46;54&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">4</span></a> 0&#46;68&#37;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">5</span></a> and 2&#46;69&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">16</span></a> The latter&#44; based on a consecutive series of 360 patients undergoing cardiac CT angiography&#44; unlike the first two which were based on coronary angiography&#44; included only symptomatic patients with a higher pretest probability of coronary disease&#44; which may explain the higher incidence of coronary anomalies found&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The most serious anomaly is anomalous origin of the LCA from the pulmonary artery &#40;also known as Bland-White-Garland syndrome&#41;&#46; It is rare in adults&#44; usually manifesting in infancy or early childhood&#44; and without surgery about 90&#37; of these children die within the first year of life&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">17</span></a> The principal CAA associated with SCD in young adults is ACAOS with an interarterial course&#44;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">13</span></a> within the myocardial sulcus between the great arteries &#40;intramyocardial&#41; or within the anterior wall of the aorta between the great arteries &#40;intramural&#41;&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">It is of major clinical importance which course is taken&#46; Although retroaortic&#44; prepulmonic and septal &#40;subpulmonic&#41; courses appear to be benign&#44; an interarterial course carries a high risk for SCD and is often referred as a malignant course&#44; most commonly an LCA arising from the right sinus of Valsalva &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">13&#44;18&#44;19</span></a> An LCA arising from the right sinus of Valsalva&#44; although relatively rare &#40;0&#46;03&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">20</span></a> is an important associated finding in patients with SCD&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">12</span></a> On the other hand&#44; although less frequently associated with SCD&#44; an RCA from the left sinus is more prevalent &#40;0&#46;1&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">20</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Figure 7</a>&#41;&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><elsevierMultimedia ident="fig0035"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Clinical manifestations range from asymptomatic to angina&#44; myocardial infarction&#44; heart failure&#44; syncope&#44; arrhythmias and sudden death&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">21</span></a> Myocardial ischemia in association with this anomaly can create an electrically unstable myocardial substrate predisposing to lethal ventricular tachyarrhythmias&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">22</span></a> Several potential mechanisms have been proposed to explain myocardial ischemia in patients with ACAOS&#58; compression of the coronary artery between the aorta and pulmonary artery&#44; particularly during exercise&#59; an acute angle of coronary origin with a slit-like lumen and&#47;or an ostial ridge as it arises from the aorta&#59; spasm of the anomalous coronary artery&#44; possibly as a result of endothelial injury&#59; or a hypoplastic intramural coronary arterial course&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">13&#44;22&#44;23</span></a> Extrinsic compression of the left main coronary artery can occur in patients with severe pulmonary hypertension and enlarged pulmonary artery trunk&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">21</span></a> Accelerated development of atherosclerotic coronary disease has also been documented in some of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">24</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Timely diagnosis remains a major clinical challenge&#44; because of insufficient clinical suspicion&#44; as well as the difficulties implicit in routine screening examinations or clinical testing for these malformations&#44; which can be relatively difficult to diagnose since patients are often asymptomatic&#46; Vague cardiovascular symptoms occur in 18-30&#37; of them and SCD may be the first or only manifestation of underlying heart disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">5&#44;22&#44;25</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Even in symptomatic patients&#44; a correct diagnosis requires a very high index of clinical suspicion&#59; 55&#37;-93&#37; of patients who die suddenly with a coronary anomaly have no forewarning&#44; although about 10&#37; are known to have had a pre-mortem cardiological evaluation for symptoms related to the anomaly&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">1</span></a> Echocardiography is a low-cost non-invasive method and has been effectively used to identify CAAs&#44; but its sensitivity and specificity decrease considerably with increasing patient age&#44; due to difficulties with the ultrasound window&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">26</span></a> The resting electrocardiogram &#40;ECG&#41; is a relatively effective screening test for cardiomyopathies such as hypertrophic cardiomyopathy&#44; but it is almost always normal in the presence of congenital CAAs except with anomalous origin of the LCA from the pulmonary artery&#44; and so the ECG provides little benefit in coronary anomaly screening&#44; because the ischemia is transient&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">13&#44;27</span></a> Other tests such as transesophageal echocardiography&#44; cardiac magnetic resonance imaging and CT angiography are expensive and carry additional risks&#44; but further assessment by the latter two techniques is recommended to determine the course of the anomaly and risk stratification&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">28</span></a> Multislice CT allows three-dimensional visualization of the coronary arteries with high spatial resolution&#44; and may be the most promising imaging modality for diagnosing these anomalies&#46; It has been reported that this technique may be superior to conventional angiography in defining ostial origin&#44; proximal path of anomalous coronary branches and the presence of intramural hypoplasia&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">18&#44;21</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The decision whether to intervene can be difficult and is dependent on the type of lesion&#44; the course of the coronary artery&#44; its known association with SCD and any symptoms present at the time of diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">20</span></a> For patients with obvious symptoms such as syncope or chest pain with exercise&#44; documented exercise-induced ischemia or a documented episode of SCD&#44; the decision regarding intervention is clear&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">It is for the asymptomatic patient who has been diagnosed for other reasons that the decision is more difficult&#46; For asymptomatic patients with an LCA arising from the right sinus with an interarterial course&#44; the decision to intervene is more consensual<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a> on the basis of the large amount of myocardium at risk&#46; However&#44; for patients with an RCA from the left sinus the decision is not so clear&#46; If it has an interarterial course and there is evidence of myocardial ischemia on a stress test&#44; it should be corrected<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">29</span></a> but&#44; if the patient is asymptomatic and there is no evidence of ischemia&#44; current guidelines accept clinical follow-up and avoidance of strenuous activity&#44; as in our case 8&#44; the young female former fire-fighter&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">However&#44; in the last 20 years&#44; there have been at least 15 published reports of unexpected sudden death in previously asymptomatic patients with an anomalous RCA from the left sinus&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">30</span></a> not only during exercise<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">31&#8211;33</span></a> but also at rest&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">34</span></a> Some of these patients had undergone previously normal cardiovascular examinations including ECGs&#44; and in one case&#44; despite a precise pre-mortem diagnosis&#44; physical activity was not prohibited and the patient died during a soccer game&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">33</span></a> Furthermore&#44; there are sufficient data suggesting a high risk of sudden death from exercise burden in young patients diagnosed with ACAOS with an interarterial course&#44; whether the origin is right or left&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">33&#44;35&#44;36</span></a> In spite of this&#44; controversially&#44; other studies limited to middle-aged or older adults with ACAOS have reported a more benign clinical picture&#44;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">37</span></a> with no deaths or similar major cardiovascular events in a matched cohort of patients without coronary anomalies&#46;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">37&#44;38</span></a> Major limitations of these studies are the presence of a majority of patients with RCA arising from the left sinus&#44; a short follow-up time&#44; and a possible selection bias toward low-risk patients who have survived their younger years&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Again&#44; the absence of reported deaths in a large cohort of military recruits<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">12</span></a> and only one sudden death in a review of two large prospective registries of young athletes in Italy and the USA<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">22</span></a> suggest a more benign clinical picture&#46; These deceptively contradictory data are well explained by the sample &#8211; the former report the risk of death of those living with ACAOS as opposed to the prevalence of ACAOS in patients who have already died&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">39</span></a> Whatever the real or theoretical risk&#44; all the authors agreed that patients with an asymptomatic anomalous RCA should be prohibited from competitive sports&#44; strenuous recreational activities or jobs imposing a high level of physical endeavor&#46; While old or sedentary patients can more easily accept these restrictions&#44; young or middle-aged adults might find them harder to follow&#44; especially blue-collar or rural workers trying to find new employment&#46; In these cases&#44; we and others<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">29&#44;39</span></a> consider that surgery is justifiable and that the low surgical risk of the intervention outweighs the risk of sudden death&#44; even if minimal&#44; and its ominous consequences&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Intravascular ultrasound &#40;IVUS&#41; can support the indication for intervention by diagnosing the acute take-off of the anomalous coronary artery&#44; initial segments of hypoplasia and lateral compression of the coronary wall by the aorta&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">39</span></a> With IVUS it is possible to quantify the coronary hypoplasia index &#40;the ratio between the circumference of the smaller intramural intussuscepted segment and that of the more distal extramural vessel&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">2</span></a> Moreover&#44; the lateral compression of the intramural segment&#44; which results in a smaller area&#44; particularly during systole&#44; can be quantified by the ratio of the smallest to the largest diameter in an IVUS cross-section&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">2&#44;39</span></a> A further workup should include nuclear stress testing&#44; which is an important method to assess effort-induced ischemia and scars&#46; It can also be used to establish the follow-up assessment after an intervention&#46; Selective coronary angiography is indicated in situations when there is a need to exclude obstructive coronary disease and to assess the severity of congenital obstruction&#46; Angelini and his group have proposed that IVUS should be used to establish acceptable selection criteria for interventional treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">2</span></a> Unfortunately this diagnostic tool is not available in our institution&#44; so the take-off of the coronaries is assessed by CT angiography&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Surgical techniques that have been used to repair this anomaly include&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">Ostial reimplantation is the preferred technique when the intramural segment crosses the aortic valve below the level of the commissures&#46; Here&#44; the proximal segment of the anomalous coronary artery is sectioned at the point where it exits from the aorta and is reimplanted in the appropriate sinus&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">14</span></a> It is also frequently used despite the concerns of some authors&#44; who point out that the risk of coronary manipulation may theoretically exceed the natural risk of the lesion itself&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">40</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">CABG has been disapproved&#44; especially in young patients&#44; because of the limited life-span of venous grafts and competitive flow in arterial grafts&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">41</span></a> However&#44; CABG could play an important role in the management of older<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">42</span></a> or high-risk patients&#44; above all if performed off-pump&#44; thus avoiding cardiopulmonary bypass&#44; overcoming concerns about competitive flow by the creation of a proximal stenosis in the anomalous coronary&#44; with intraoperative flow measurement of the arterial graft&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">Unroofing&#44; the most commonly used technique&#44; which consists of fenestration of the intramural portion of the anomalous artery&#44; releasing the lumen of the coronary into the aorta&#46; It is important to consider the relationship between the intramural coronary and the aortic valve commissures&#44; because when the intramural segment travels below the level of the aortic commissures&#44; unroofing of the intramural segment can damage the aortic valve and will increase the risk of aortic regurgitation months later&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">14&#44;43&#44;44</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">Neo-ostium creation is performed when a long intramural segment of the anomalous coronary artery crosses an aortic valve commissure before exiting the wall&#46; In this technique a new ostium is created in the exit sinus by unroofing the anomalous coronary at this level&#44; avoiding manipulation of the aortic valve and reducing the risk of aortic regurgitation&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">14</span></a></p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Pulmonary translocation&#44;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">45</span></a> described in a few cases&#44; is a complex operation consisting of enlarging the slit-like ostium and the proximal coronary&#44; followed by lateral displacement of the pulmonary trunk and anastomosis to the left pulmonary artery&#44; to prevent compression of the anomalous coronary between the great vessels&#46; This has been specifically used in cases where there is a single coronary ostium and no intramural segment&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">14</span></a></p></li></ul></p><p id="par0180" class="elsevierStylePara elsevierViewall">Percutaneous stent implantation from the origin and covering the full extension of compression of the anomalous coronary artery&#44; although technically challenging and carrying the problem of life-long antiplatelet therapy&#44; has also been described&#44; in both right<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">46</span></a> and left<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">47</span></a> ACAOS in older adults&#44; although it is still the subject of debate&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">44</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusion</span><p id="par0185" class="elsevierStylePara elsevierViewall">ACAOS with a course between the great vessels is a rare condition and most patients are asymptomatic&#46; Surgery should be considered to prevent sudden death in patients with ACAOS plus symptoms suggestive of myocardial ischemia and also in asymptomatic patients&#44; especially those with an LCA arising from the right sinus of Valsalva&#46; The most controversial is the asymptomatic patient with an anomalous RCA from the left sinus&#46; This is the more common lesion and although associated with SCD&#44; it is unclear which subset of patients is at risk&#46; Some authors postulate that a conservative approach&#44; with beta-blockers and lifestyle measures in order to avoid strenuous exercise&#44; may be adopted in the absence of symptoms or myocardial ischemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">20&#44;26</span></a> Treatment should be individualized and the risk&#47;benefit ratio should be assessed for every patient&#44; but since the risks of surgery are minimal and the results are excellent&#44;<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">39&#8211;41&#44;43&#8211;45</span></a> we agree that some of these patients should undergo surgical correction&#44; whether or not symptoms are present&#44; if they are young and engaged in physically strenuous jobs or hobbies&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            1 => "ACAOS"
            2 => "CAA"
            3 => "CABG"
            4 => "CT"
            5 => "ECG"
            6 => "IVUS"
            7 => "LAD"
            8 => "LCA"
            9 => "RCA"
            10 => "SCD"
            11 => "STEMI"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec973779"
          "palabras" => array:4 [
            0 => "Origem a&#243;rtica an&#243;mala da art&#233;ria coron&#225;ria"
            1 => "Seio de Valsalva"
            2 => "Trajeto interarterial"
            3 => "Cirurgia card&#237;aca"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patients with anomalous coronary arteries arising from the opposite sinus of Valsalva &#40;ACAOS&#41;&#44; the left coronary artery &#40;LCA&#41; arising from the right sinus or the right coronary artery &#40;RCA&#41; from the left sinus with an interarterial course&#44; may present from complete absence of symptoms to sudden cardiac death&#46; Although there are guidelines on indications for surgery&#44; controversy remains&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective review was performed of all adult patients diagnosed with ACAOS in our hospital between 2007 and 2016&#46; Demographic&#44; clinical&#44; perioperative and follow-up data were collected from clinical records and summarized&#46; A review of the published literature was performed with special emphasis on clinical presentation&#44; surgical indications and results&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Seven symptomatic patients underwent surgery &#40;mean age 57&#46;1&#177;8&#46;9 years&#44; two male&#44; five female&#41;&#59; they recovered without complications and to date have had no recurrence of myocardial ischemia&#46; One asymptomatic patient with an anomalous RCA has been medically followed without evidence of myocardial ischemia&#46; A 75-year-old woman&#44; diagnosed in 2008 with an anomalous LCA&#44; was not referred for surgery and died suddenly six months after diagnosis&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Surgery for coronary abnormalities is performed with low risk and all published series report full operative survival&#46; The indications for surgery are well established for patients with interarterial anomalous LCA and symptomatic patients with interarterial anomalous RCA&#46; However&#44; there is some uncertainty concerning asymptomatic patients&#44; particularly those with an anomalous interarterial RCA&#44; for whom we propose a more assertive approach&#44; if young or engaged in strenuous activities&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Doentes com origem an&#243;mala de uma art&#233;ria coron&#225;ria no seio coron&#225;rio oposto &#40;OAAC &#8211; art&#233;ria coron&#225;ria esquerda&#44; ACE&#44; proveniente do seio direito ou art&#233;ria coron&#225;ria direita&#44; ACD&#44; origin&#225;ria do seio esquerdo&#41; com um percurso interarterial podem apresentar desde aus&#234;ncia de sintomas at&#233; morte s&#250;bita&#46; Apesar da exist&#234;ncia de <span class="elsevierStyleItalic">guidelines</span> para orienta&#231;&#227;o cir&#250;rgica&#44; controv&#233;rsias persistem&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foi feito um estudo retrospetivo de todos os doentes adultos diagnosticados com OAAC no Hospital de S&#46; Jo&#227;o&#44; entre 2007 e 2016&#46; Foram recolhidos dados demogr&#225;ficos&#44; cl&#237;nicos&#44; perioperat&#243;rios e do seguimento&#46; Uma revis&#227;o da literatura foi feita&#44; enfatizou a apresenta&#231;&#227;o cl&#237;nica&#44; as indica&#231;&#245;es e os resultados cir&#250;rgicos&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Sete doentes sintom&#225;ticos foram submetidos a cirurgia &#40;a m&#233;dia de idade foi de 57&#44;1 &#177; 8&#44;9 anos&#59; dois homens&#44; cinco mulheres&#41;&#44; recuperaram sem complica&#231;&#245;es e sem recorr&#234;ncia de isquemia do mioc&#225;rdio&#46; Uma doente jovem assintom&#225;tica&#44; com uma ACD an&#243;mala&#44; mant&#233;m-se em seguimento&#44; sem interven&#231;&#227;o e sem evid&#234;ncia de isquemia&#46; O primeiro doente da s&#233;rie&#44; sexo feminino&#44; 75 anos&#44; foi diagnosticada em 2008 com ACE an&#243;mala&#44; n&#227;o foi proposta para cirurgia e morreu subitamente seis meses ap&#243;s o diagn&#243;stico&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A cirurgia das anomalias coron&#225;rias &#233; feita com risco baixo e sem mortalidade operat&#243;ria em todas as s&#233;ries publicadas&#46; As indica&#231;&#245;es para cirurgia est&#227;o bem estabelecidas para doentes com ACE an&#243;mala e trajeto interarterial e em doentes sintom&#225;ticos com ACD an&#243;mala&#46; Contudo&#44; permanecem incertezas em doentes assintom&#225;ticos&#44; particularmente naqueles que apresentam uma ACD an&#243;mala com trajeto interarterial&#44; para os quais propomos uma abordagem mais interventiva&#44; se jovens ou sujeitos a atividades vigorosas&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introdu&#231;&#227;o e objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#245;es"
          ]
        ]
      ]
    ]
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Survival after surgery&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Reimplantation of anomalous right coronary artery in the anterior sinus&#46;</p>"
        ]
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        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Patent right internal thoracic artery-right coronary artery &#40;RCA&#41; graft &#40;large arrow&#41; and anomalous RCA from the left sinus&#44; with a surgically created proximal stenosis &#40;thin arrow&#41;&#46;</p>"
        ]
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      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Unroofing&#46; Arrow indicates the already detached common wall between the intramural coronary and the aortic lumen&#46;</p>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Fenestration of the anomalous left coronary artery &#40;LCA&#41;&#44; with creation of a neo-ostium &#40;blue star&#41;&#46; Note the small&#44; slit-like anomalous opening of the LCA in the right sinus &#40;black arrow&#41;&#46;</p>"
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          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Anomalous origin of the left coronary artery in the right sinus&#46; Course variations&#58; &#40;1&#41; normal coronary anatomy&#59; &#40;2&#41; interarterial course&#59; &#40;3&#41; prepulmonary course&#59; &#40;4&#41; retroaortic course&#59; &#40;5&#41; subpulmonic course&#46; L&#58; left coronary sinus&#59; LAD&#58; left anterior descending artery&#59; LCx&#58; left circumflex artery&#59; LMCA&#58; left main coronary artery&#59; NC&#58; non-coronary sinus&#59; R&#58; right coronary sinus&#59; RCA&#58; right coronary artery&#46; Adapted from Bienert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">26</span></a>&#46;</p>"
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        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Anomalous origin of the right coronary artery in the left sinus&#46; &#40;1&#41; Normal coronary anatomy&#59; &#40;2&#41; right coronary artery originating from the left sinus&#46; L&#58; left coronary sinus&#59; LAD&#58; left anterior descending artery&#59; LCx&#58; left circumflex artery&#59; LMCA&#58; left main coronary artery&#59; NC&#58; non-coronary sinus&#59; R&#58; right coronary sinus&#59; RCA&#58; right coronary artery&#46; Adapted from Bienert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">26</span></a>&#46;</p>"
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">ACS&#58; acute coronary syndrome&#59; Age&#58; age at diagnosis in years&#59; CA&#58; coronary angiography&#59; CHF&#58; congestive heart failure&#59; CT&#58; computed tomography coronary angiography&#59; LCA&#58; left coronary artery&#59; NSTEMI&#58; non-ST-elevation myocardial infarction&#59; NYHA&#58; New York Association functional class&#59; RCA&#58; right coronary artery&#59; RITA&#58; right internal thoracic artery&#59; STEMI&#58; ST-elevation myocardial infarction&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anatomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Course&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Associated lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Operation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ACS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LCA from right sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intramural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Angina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCA from left sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intramural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bypass RITA to RCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ACS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCA from left sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intramyocardial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anastomosis RCA-aorta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">57&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inferior STEMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LCA from right sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intramural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Occlusion of posterior RCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LCA fenestration &#8211; neo-ostium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHF &#40;NYHA III&#41;&#59; no angina&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCA from left sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intramural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Rheumatic triple valve disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unroofing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NSTEMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCA from left sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Short&#44; intramural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCA reimplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiac arrest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LCA from right sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intramural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Unroofing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Atypical chest pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCA from left sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intramural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chest pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LCA from right sinus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Intramural&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LCA fenestration &#8211; neo-ostium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">CA&#58; coronary angiography&#59; CT&#58; computed tomography coronary angiography&#59; Echo&#58; echocardiography&#59; FUP&#58; follow-up time in months&#59; LCA&#58; left coronary artery&#59; LoS&#58; length of stay in days&#59; RCA&#58; right coronary artery&#59; RITA&#58; right internal thoracic artery&#59; TVS&#58; triple valve surgery&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case</th><th class="td" title="table-head  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery</th><th class="td" title="table-head  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">LoS</th><th class="td" title="table-head  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical status</th><th class="td" title="table-head  " colspan="3" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Postoperative exams</th><th class="td" title="table-head  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FUP</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Echo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Stress test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Imaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Sudden death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Off-pump RITA-RCA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asymptomatic<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCA-RITA graft patent&#59; RCA proximal 90&#37; stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">113&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anastomosis RCA-aorta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anastomosis open on CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LCA neo-ostium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inferior akinesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild inferior defect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TVS&#59; RCA unroofing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Dead &#40;cancer&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RCA reimplantation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal CA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LCA unroofing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anastomosis open on CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">LCA neo-ostium&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Asymptomatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">-&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
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            0 => array:3 [
              "identificador" => "bib0240"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Coronary artery anomalies - current clinical issues&#58; definitions&#44; classification&#44; incidence&#44; clinical relevance&#44; and treatment guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P&#46; Angelini"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Texas Hear Inst J&#46;"
                        "fecha" => "2002"
                        "volumen" => "29"
                        "paginaInicial" => "271"
                        "paginaFinal" => "278"
                      ]
                    ]
                  ]
                ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Coronary artery anomalies&#58; An entity in search of an identity"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "P&#46; Angelini"
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.106.618082"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation&#46;"
                        "fecha" => "2007"
                        "volumen" => "115"
                        "paginaInicial" => "1296"
                        "paginaFinal" => "1305"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17353457"
                            "web" => "Medline"
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              "identificador" => "bib0250"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Coronary artery anomalies"
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                          "autores" => array:2 [
                            0 => "A&#46;E&#46; Becker"
                            1 => "R&#46;H&#46; Anderson"
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                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Pathology of Congenital Heart Disease&#46;"
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                        "serieFecha" => "1981"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Preval&#234;ncia de anomalias na origem e trajecto das art&#233;rias coron&#225;rias em popula&#231;&#227;o portuguesa n&#227;o selecionada&#58; estudo retrospectivo"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "E&#46; Correia"
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                            2 => "B&#46; Rodrigues"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Port Cardiol&#46;"
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                0 => array:2 [
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                      "titulo" => "Percentagem de anomalias coron&#225;rias numa popula&#231;&#227;o de doentes submetidos a angiografia &#8211; estudo retrospectivo"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;J&#46; Correia"
                            1 => "J&#46;L&#46; Faria"
                            2 => "P&#46;P&#46; Cardoso"
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        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0195" class="elsevierStylePara elsevierViewall">We are grateful to the Department of Cardiothoracic Surgery of Centro Hospitalar S&#46; Jo&#227;o for assistance in retrieving the data and for the clinical care of the patients&#59; to Dr&#46; Adelino Leite Moreira&#44; for reading the paper&#59; and to Dr&#46; Jorge Almeida&#44; for reading the paper and preoperative assessment of the patients&#46;</p>"
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