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slit-like ostium&#44; acute angle take-off&#44; intramural course&#44; elliptical vessel course&#44; and proximal vessel narrowing of the anomalous vessel&#46; Patients with these features may be more prone to sudden cardiac death &#40;SCD&#41; or even myocardial infarction &#40;MI&#41; as a direct consequence of scissor-like shearing&#44; kinking or lateral dynamic compression of the vessel due to increased pressure in both the aorta and the pulmonary artery during strenuous physical exercise&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;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&#44; palpitations&#44; MI&#44; heart failure&#44; syncope&#44; and SCD&#46; This issue is of great importance in younger and active patients&#44; 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&#46; Basso et al&#46; reviewed two large registries&#44; assembled consecutively in the US and Italy&#44; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> They found that warning cardiac symptoms were not uncommon shortly before SCD &#40;typically associated with a anomalous left main coronary artery&#41;&#44; suggesting that a history of exertional syncope or chest pain requires exclusion of this anomaly&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Diagnostic workup is usually guided by the suspicion of coronary artery disease&#44; so ischemia-driven testing is frequently the initial approach&#44; followed by coronary imaging &#40;coronary angiography&#44; coronary computed tomography angiography &#91;CCTA&#93;&#44; or magnetic resonance imaging&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Recently CCTA has been used more widely&#44; which will probably lead to further increases in incidental diagnosis of ACAOS&#46; The question of appropriate management for such cases will therefore arise more frequently&#46;</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&#46; Nevertheless&#44; the type of lesion and the course of the coronary artery should also be taken into account&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> However&#44; in asymptomatic patients the decision whether to operate should be made on an individual basis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Sousa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> describe their experience in surgically managing seven patients with this anomaly&#44; reporting no mortality and good medium-term survival&#46; Based on their results&#44; they advise surgery in symptomatic patients suggestive of myocardial ischemia&#44; asymptomatic patients with a left coronary artery arising from the right sinus of Valsalva&#44; and some patients with an anomalous right coronary artery from the left sinus&#44; when the expected surgical risks are minimal&#44; particularly when they are young and engaged in physically strenuous jobs or hobbies&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A recent study by Grani et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> suggests a more benign course in middle-aged patients with ACAOS&#44; since medium-term outcomes &#40;major adverse cardiac events&#41; were favorable and not statistically different from a matched control cohort without coronary artery anomalies&#44; regardless of whether there was an interarterial course&#46; These findings are only applicable in this setting&#59; in a pediatric population or even in young adults the results could be different&#46; In this context&#44; Sousa et al&#46;&#8217;s study is important&#44; since they have demonstrated that it is possible to perform anatomical correction&#44; avoiding coronary artery bypass grafting&#44; in the majority of cases with excellent perioperative results&#46; We therefore believe that the age factor should also be considered when dealing with asymptomatic patients with ACAOS and an interarterial course&#44; and that surgical intervention should be reserved for younger patients&#44; under 35-40 years of age&#46;</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&#46;</p></span></span>"
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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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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The reported incidence of anomalous origin of the coronary arteries is 0&#46;1&#37; to 1&#46;3&#37; in the general population&#46; Anomalous coronary arteries arising from the opposite sinus of Valsalva &#40;ACAOS&#41; are the most frequently found of such anomalies and are associated with adverse cardiac events&#44; particularly in the young&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;3</span></a> The left circumflex artery originating from the right sinus is the most common ACAOS&#44; with an incidence of 0&#46;4&#37;&#46; The right coronary artery arising from the left sinus or the left main coronary artery arising from the right sinus are less common&#44; with a prevalence in the general population between 0&#46;1&#37; and 0&#46;3&#37;&#46;</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&#44; slit-like ostium&#44; acute angle take-off&#44; intramural course&#44; elliptical vessel course&#44; and proximal vessel narrowing of the anomalous vessel&#46; Patients with these features may be more prone to sudden cardiac death &#40;SCD&#41; or even myocardial infarction &#40;MI&#41; as a direct consequence of scissor-like shearing&#44; kinking or lateral dynamic compression of the vessel due to increased pressure in both the aorta and the pulmonary artery during strenuous physical exercise&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;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&#44; palpitations&#44; MI&#44; heart failure&#44; syncope&#44; and SCD&#46; This issue is of great importance in younger and active patients&#44; 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&#46; Basso et al&#46; reviewed two large registries&#44; assembled consecutively in the US and Italy&#44; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> They found that warning cardiac symptoms were not uncommon shortly before SCD &#40;typically associated with a anomalous left main coronary artery&#41;&#44; suggesting that a history of exertional syncope or chest pain requires exclusion of this anomaly&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Diagnostic workup is usually guided by the suspicion of coronary artery disease&#44; so ischemia-driven testing is frequently the initial approach&#44; followed by coronary imaging &#40;coronary angiography&#44; coronary computed tomography angiography &#91;CCTA&#93;&#44; or magnetic resonance imaging&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Recently CCTA has been used more widely&#44; which will probably lead to further increases in incidental diagnosis of ACAOS&#46; The question of appropriate management for such cases will therefore arise more frequently&#46;</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&#46; Nevertheless&#44; the type of lesion and the course of the coronary artery should also be taken into account&#46; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> However&#44; in asymptomatic patients the decision whether to operate should be made on an individual basis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>&#44; Sousa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> describe their experience in surgically managing seven patients with this anomaly&#44; reporting no mortality and good medium-term survival&#46; Based on their results&#44; they advise surgery in symptomatic patients suggestive of myocardial ischemia&#44; asymptomatic patients with a left coronary artery arising from the right sinus of Valsalva&#44; and some patients with an anomalous right coronary artery from the left sinus&#44; when the expected surgical risks are minimal&#44; particularly when they are young and engaged in physically strenuous jobs or hobbies&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A recent study by Grani et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> suggests a more benign course in middle-aged patients with ACAOS&#44; since medium-term outcomes &#40;major adverse cardiac events&#41; were favorable and not statistically different from a matched control cohort without coronary artery anomalies&#44; regardless of whether there was an interarterial course&#46; These findings are only applicable in this setting&#59; in a pediatric population or even in young adults the results could be different&#46; In this context&#44; Sousa et al&#46;&#8217;s study is important&#44; since they have demonstrated that it is possible to perform anatomical correction&#44; avoiding coronary artery bypass grafting&#44; in the majority of cases with excellent perioperative results&#46; We therefore believe that the age factor should also be considered when dealing with asymptomatic patients with ACAOS and an interarterial course&#44; and that surgical intervention should be reserved for younger patients&#44; under 35-40 years of age&#46;</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&#46;</p></span></span>"
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Informação do artigo
ISSN: 08702551
Idioma original: Inglês
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Ano/Mês Html Pdf Total
2024 Novembro 6 6 12
2024 Outubro 37 31 68
2024 Setembro 58 24 82
2024 Agosto 48 28 76
2024 Julho 37 37 74
2024 Junho 44 34 78
2024 Maio 37 19 56
2024 Abril 47 31 78
2024 Maro 38 21 59
2024 Fevereiro 33 21 54
2024 Janeiro 30 24 54
2023 Dezembro 34 21 55
2023 Novembro 34 26 60
2023 Outubro 24 18 42
2023 Setembro 23 23 46
2023 Agosto 31 15 46
2023 Julho 18 6 24
2023 Junho 25 16 41
2023 Maio 48 28 76
2023 Abril 17 1 18
2023 Maro 37 33 70
2023 Fevereiro 24 21 45
2023 Janeiro 17 14 31
2022 Dezembro 26 21 47
2022 Novembro 39 37 76
2022 Outubro 26 18 44
2022 Setembro 23 28 51
2022 Agosto 32 40 72
2022 Julho 23 39 62
2022 Junho 23 38 61
2022 Maio 21 33 54
2022 Abril 26 29 55
2022 Maro 27 44 71
2022 Fevereiro 28 32 60
2022 Janeiro 22 25 47
2021 Dezembro 23 25 48
2021 Novembro 30 44 74
2021 Outubro 39 33 72
2021 Setembro 23 32 55
2021 Agosto 29 31 60
2021 Julho 15 23 38
2021 Junho 20 21 41
2021 Maio 23 30 53
2021 Abril 54 47 101
2021 Maro 70 34 104
2021 Fevereiro 74 25 99
2021 Janeiro 32 16 48
2020 Dezembro 33 22 55
2020 Novembro 21 14 35
2020 Outubro 25 17 42
2020 Setembro 35 13 48
2020 Agosto 28 9 37
2020 Julho 35 16 51
2020 Junho 43 10 53
2020 Maio 25 9 34
2020 Abril 29 15 44
2020 Maro 29 7 36
2020 Fevereiro 56 23 79
2020 Janeiro 52 6 58
2019 Dezembro 24 15 39
2019 Novembro 25 16 41
2019 Outubro 46 8 54
2019 Setembro 24 5 29
2019 Agosto 27 10 37
2019 Julho 24 12 36
2019 Junho 29 23 52
2019 Maio 52 9 61
2019 Abril 31 15 46
2019 Maro 107 15 122
2019 Fevereiro 111 8 119
2019 Janeiro 161 6 167
2018 Dezembro 87 16 103
2018 Novembro 36 15 51
2018 Outubro 76 18 94
2018 Setembro 33 19 52
2018 Agosto 32 13 45
2018 Julho 69 14 83
2018 Junho 26 10 36
2018 Maio 36 15 51
2018 Abril 45 44 89
2018 Maro 0 16 16
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