Coronary artery anomalies

# Overview
The coronary arteries are usually perpendicular to the aortic wall and they are radially arranged relative to the center of the aorta. The ostia may be rounding, oval, or elliptical, and the position of the ostium does not appear to affect the flow through it.

# Classification

## Anomalous Pulmonary Origin of the Coronary Arteries
Anomalous Pulmonary Origin of the Coronary Arteries (APOCA) is characterized by the origin of a coronary artery from the pulmonary artery.  Left coronary artery is the most common anomaly seen arising from pulmonary artery (ALCAPA), in which angiography shows the absence of left coronary ostium normal flow from the left aortic sinus.  Other anomalies of the coronary arteries origin include:
- Left circumflex artery (Cx) arising from pulmonary artery posterior facing sinus
- Left anterior descending artery (LAD) arising from pulmonary artery posterior facing sinus
- Right coronary artery (RCA) arising from pulmonary artery anterior right facing sinus (ARCAPA):
- Symptoms of myocardial ischemia
- Syncope
- Cardiomyopathy
- Coronary artery arising from other locations outside pulmonary facing sinuses e.g. anterior left sinus, pulmonary trunk, or pulmonary branch
Mortality rate in the first year of life has been reported to be 95% in untreated cases with poor collateral network.
Courtesy of Professor Peter Anderson DVM PhD

## Anomalous Coronary Artery From the Opposite Sinus
It is an improper site of coronary origin, in some cases in involve the origin of two coronaries from the same ostium.  The anomalous coronary origin leads to different anomalous course for the coronary arteries, which can be detected by angiography and they are as follow:
LCA runs in a different courses when arise from right sinus of valsalva, and it includes a septal, anterior,
interarterial, and posterior course.  The anomalous courses can be more specified as follow:
- Posterior atrioventricular groove
- Retroaortic
- Between aorta and pulmonary artery
- Intraseptal
- Anterior to pulmonary artery
- Posteroanterior interventricular groove
Courtesy of Professor Peter Anderson DVM PhD
When LAD arises from the right anterior sinus, it may run in a similar course as LCA which include:
- Between aorta and pulmonary artery
- Intraseptal
- Anterior to pulmonary artery
- Posteroanterior interventricular groove
LCx artery when arise from right sinus of valsalva, it may run in the posterior atrioventricular groove, or follow a retroaortic course.
When RCA arise from the left sinus, it follows the same anomalous courses as the LAD when arise from the the right sinus of Valsalva, with the most common course is the interarterial.

## Coronary Artery Fistulas
Coronary artery fistulas are rare findings, defines as any abnormal communication through which coronary artery blood is shunted into:
- Any of the cardiac chambers
- The besian veins that empty into the cardiac chambers
- The coronary sinus
- The SVC
- The pulmonary veins
- The mediastinal vessels
It is identified in 10 (0.05%) of 18,272 diagnostic cardiac catheterizations.  The number, origin, and course of the coronary arteries is otherwise normal.

## Congenital Coronary Stenosis or Atresia
Congenital coronary stenosis can be associated with other congenital diseases (e.g. supravalvular aortic stenosis, calcific coronary sclerosis, or rubella syndrome), or one of the intrinsic coronary arterial anatomy anomalies, which may involve left coronary artery, left anterior descending artery, right coronary artery, and left circumflex artery.
Other intrinsic coronary arterial anatomy anomalies include:
- Coronary ostial dimple
- Coronary ectasia or aneurysm
- Absent coronary artery
- Coronary hypoplasia
- Intramural coronary artery (muscular bridge)
- Subendocardial coronary course
- Coronary crossing
- Anomalous origination of posterior descending artery from the anterior descending branch or a septal penetrating branch
- Split RCA
- Split LAD
- Ectopic origination of first septal branch

## Myocardial Bridging
Myocardial bridge is defined as a segment of a major coronary epicardial artery that "tunnels" or passes intramurally through the myocardium beneath the muscle bridge during systole. Myocardial bridges are generally located in the distribution of the left anterior descending artery (LAD) and its diagonal branches.  It has been associated with angina, arrhythmia, depressed left ventricular function, myocardial stunning, early death after cardiac transplantation, and sudden death.
On angiography, the bridged segment appears of normal caliber during diastole, and abruptly narrows with systole.  Shown below is an animated image depicting myocardial bridge, and two static images of the same case depicting myocardial bridge.  Outlined with yellow in the image on the left is the part of the coronary artery during diastole.  This same part of the coronary artery is outlined in yellow in the image on the right during systole; note that this outlined part is narrowed compared to its shape during diastole.

## High Anterior Origin of the Right Coronary Artery
A superior origin of the RCA above the sinotubular ridge, although it is found commonly, it has no hemodynamic significance. This case is suspected during catheterization when it fails to engage the ostium of the RCA, and injection of contrast medium into the right sinus of Valsalva may reveal the anomalous origin.

# 2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)

## Evaluation and Surgical Intervention (DO NOT EDIT)

## Coronary Anomalies Associated With Supravalvular Aortic Stenosis (DO NOT EDIT)

## Coronary Anomalies Associated With Tetralogy of Fallot (DO NOT EDIT)

## Coronary Anomalies Associated With Dextro-Transposition of the Great Arteries After Arterial Switch Operation (DO NOT EDIT)

## Congenital Coronary Anomalies of Ectopic Arterial Origin (DO NOT EDIT)

## Anomalous Left Coronary Artery From the Pulmonary Artery (DO NOT EDIT)

## Coronary Arteriovenous Fistula (DO NOT EDIT)

## Management Strategies for CAVF(DO NOT EDIT)