Clinical case of Surgical Treatment of Coronary Heart Disease in an Adult Patient with the Anterior Descending Artery Originating from the Right Sinus of Valsalva

Dovgan O. M., Fedorchuk A. P., Varbanets S. V., Chernetsky Y. O.

Ukrainian Children’s Cardiac Center, Kyiv, Ukraine

Abstract. Аbnormal coronary artery origins can occur both in isolation and in combination with congenital heart defects. In the vast majority of cases, such anomalies can affect the deterioration of coronary blood flow with ischemic manifestations. The report describes effort angina in an adult patient who in the childhood underwent operation for the congenital heart defect because of inter-arterial compression of the left anterior descending artery originating with a separate mouth from the right sinus of Valsalva.

The purpose of this study is to evaluate the outcome of surgical treatment of coronary heart disease in a patient with abnormal origin of the left anterior descending artery, bicuspid aortic valve and aortic root dilatation.

Materials and methods. The paper presents the result of surgical treatment of a patient with abnormal origin of the left anterior descending artery, bicuspid aortic valve and aortic root dilatation, surgical myocardial revascularization in coronary heart disease. It describes the results of instrumental methods, the choice of treatment and control remote results of the operation.

Results and discussion. A 43-year-old patient with complaints of angina pectoris underwent instrumental studies such as coronary angiography, bicycle ergometry, computer coronary angiography with comparison of their results. A surgical way of correction of impaired coronary blood flow on the left anterior descending artery was chosen by performing mammary coronary bypass surgery on a beating heart. During the re-examination after 3 months, the patient had no complaints of chest pain, and repeated bicycle ergometry revealed no data on myocardial ischemia.

Conclusion. Thus, this clinical case clearly demonstrates the necessity of understanding congenital heart defects, their pathological anatomy and comparison with findings of all clinical and instrumental examinations in the diagnosis and treatment of coronary heart disease in patients with congenital heart defects and abnormal coronary artery origin. Only a comprehensive approach to such patients will provide an opportunity for rapid and correct diagnosis, accordingly, for the choice of adequate treatment.

Keywords: coronary artery anomalies, coronary heart disease, coronary angiography, mammary coronary bypass surgery.

Abnormal coronary artery origins can occur both in isolation and in combination with congenital heart defects. In the vast majority of cases, such anomalies can affect the deterioration of coronary blood flow with ischemic manifestations. The report describes effort angina in an adult patient who in the childhood underwent operation for the congenital heart defect because of inter-arterial compression of the left anterior descending artery originating with a separate mouth from the right sinus of Valsalva.

Congenital abnormal coronary artery origins are rare and occur in the range of 0.3% to 1.6% of cases [1]. Despite its low frequency, such pathology can cause worsening of the coronary blood flow, resulting in symptoms of angina, congestive heart failure, and possible sudden coronary death.

There are several variants of abnormal coronary artery origins: a) left or right coronary artery from the pulmonary trunk; b) coronary artery stenosis; c) absence of one of the coronary arteries; d) coronary heart fistulae; e) abnormal coronary artery origins from the aorta. The latter account for 1/3 of the number of all congenital abnormal coronary artery origins [1, 2].

The purpose of this study is to analyse the rare case of abnormal origin of the anterior interventricular branch of the left coronary artery in a patient with a bicuspid aortic valve, aortic root dilatation, and manifestations of typical anginal pain in the heart, resistant to drug treatment.

Materials and methods. Patient G., 43 years old, referred to our institution for retrosternal anginal pain attacks with low physical or psycho-emotional activity that emerged and progressed over the last two years. The past history shows that the patient was operated twice for congenital heart defects. At the age of eight, he underwent surgical closure of patent ductus arteriosus, and at the age of 17, the perimembranous ventricular septal defect was closed in the setting of artificial circulation.

Results and discussion. In the outpatient setting, the patient underwent instrumental examinations, which diagnosed coronary heart disease. Stable angina pectoris, III FC. Congenital heart disease. Bicuspid aortic valve. Combined aortic defect with predominant moderate insufficiency and with minimal stenosis. Aneurysmal aortic root dilatation at the level of the sinuses of Valsalva and the ascending aorta. Mild sub-aortic stenosis in the form of fibro-muscular diaphragm. Mild to moderate tricuspid failure. Mild hypertension in the pulmonary artery. Condition after closure of patent ductus arteriosus and interventricular septal defect repair: no data for re-shunting of interventricular septal defect and recanalization of patent ductus arteriosus were detected. HF I with good left ventricular systolic function (EF 56%), NYHA II.

The patient was hospitalized and underwent a thorough examination. Echocardiography detected that the aortic valve defect was moderate (moderate reversal flow on the aortic valve and small systolic pressure gradient between the left ventricle and the aorta, which was 19 mmHg). The size of the heart cavities is not increased. The aortic diameter at the level of sinuses of Valsalva was 44 mm and that of the ascending aorta was 41 mm. Left ventricular systolic function was good (EF = 56%). Attention was drawn to the areas of impaired segmental myocardial contractility in the form of hypokinesis of all departments of the interventricular septum and the anterior wall of the left ventricle. Given the fact that the patient had all the clinical manifestations of angina, as well as impaired segmental myocardial contractility, he underwent bicycle ergometry, which registered ST-segment depression up to 3 mm in V2-V4 leads at the load of 50 W on the ECG. Coronary angiography was performed in a routine manner, which did not detect hemodynamically significant lesions or systolic compression of the coronary arteries, but diagnosed that both coronary arteries originated from the right coronary sinus.

As the load test detected signs of ischemia and the coronarography diagnosed abnormal coronary artery origin, CT scan of coronary arteries was performed to detail the anatomy of the patient’s heart vessels. The following peculiarities of the coronary artery anatomy were detected: right dominant type of blood supply, the anterior descending interventricular artery originates with a separate ostium from the right coronary sinus (inter-arterial/ intramural course) with signs of systolic compression of 25-50% in the middle and distal thirds without signs of severe stenosis and atherosclerotic plaques. Other coronary arteries were without signs of stenosis and atherosclerotic lesions. The dimensions of the aortic root corresponded to the data obtained by echocardiography.

Based on the clinical manifestations, objective and instrumental examination findings, it was decided to perform off-pump mammary coronary artery bypass grafting with an anastomosis between the left internal thoracic artery and left anterior descending artery, without the use of artificial blood circulation. As the aortic defect was moderate, it was decided not to eliminate it. The course of the postoperative period was without peculiarities and complications. On Day 8 after surgery, the patient was discharged from the hospital in a satisfactory condition without signs of angina.

3 months after surgery, the patient was examined in an outpatient setting. No clinical signs of angina were detected. Heart ultrasound showed good contractility of the left ventricular myocardium (EF 60%) without zones of segmental contractility disorders. Control ergometry was performed which detected no data for ischemic heart disease.

From the foregoing, it can be stated that the manifestations of myocardial ischemia were caused by systolic compression of the anterior descending interventricular artery, which originated from the right coronary sinus and passed between the ascending aorta and the pulmonary trunk. The mechanism of compression of this coronary artery is explained by the fact that the aortic root and pulmonary trunk expand during physical exertion, and thus change the initial angle of the coronary artery passing between them. In addition, the left coronary artery can be constricted by the intercoronary commissure, especially in the diastole phase when the aortic valve closes. In this case, the situation was aggravated by the existing aortic root dilatation. The effect of aortic root dilatation on coronary artery compression is evidenced by the fact that clinical manifestations of angina pectoris appeared only in the last two years before surgery.

Conclusions. Thus, this clinical case clearly demonstrates the necessity of understanding congenital heart defects, their pathological anatomy and comparison with findings of all clinical and instrumental examinations in the diagnosis and treatment of coronary heart disease in patients with congenital heart defects and abnormal coronary artery origin. Only a comprehensive approach to such patients will provide an opportunity for rapid and correct diagnosis, accordingly, for the choice of adequate treatment.

References

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2. Anish H, Arun M, Madhu R. Anomalous origin of left main coronary artery from the right sinus of Valsalva presenting as non ST elevation acute coronary syndrome: A case report. The Egyptian Heart Journal. 2017; 215–18.

3. Marler AT, Malik JA, Slim AM. Anomalous Left Main Coronary Artery: Case Series of Different Courses and Literature Review. Case Reports in Vascular Medicine. 2013;2013:380952. https://doi.org/10.1155/2013/380952

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Published: March 2019