Letter to the Editor
Anomalous aortic origin of a coronary artery and sudden cardiac death
Origen aórtico anómalo de las arterias coronarias y muerte súbita cardiaca
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artery and sudden cardiac death" "tieneTextoCompleto" => true "saludo" => "<span class="elsevierStyleItalic">Dear Editor</span>," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "40" "paginaFinal" => "41" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Antonio Padilla-Serrano, José Antonio Fernández-Sánchez, Rafael De la Chica Ruíz-Ruano" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Antonio" "apellidos" => "Padilla-Serrano" "email" => array:1 [ 0 => "antoniopadillaserrano@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "José Antonio" "apellidos" => "Fernández-Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Rafael" "apellidos" => "De la Chica Ruíz-Ruano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos Cardiovasculares, Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Universitario Virgen de las Nieves, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Origen aórtico anómalo de las arterias coronarias y muerte súbita cardiaca" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 721 "Ancho" => 1865 "Tamanyo" => 133809 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0060" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">A</span>) Right coronary angiography image showing the right coronary artery and an anomalous origin of the circumflex coronary artery. <span class="elsevierStyleItalic">B</span>) Left coronary angiography image showing the anterior descending coronary artery and the diagonal coronary artery. <span class="elsevierStyleItalic">C</span>) Coronary artery computed tomography angiography reconstruction image showing an anomalous origin of the circumflex coronary artery with an outflow from the right coronary artery and a retroaortic course.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ao: aorta; RC: right coronary artery; Cx: circumflex coronary artery; DA: anterior descending coronary artery; Dg: diagonal coronary artery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The incidence of sudden cardiac death (SCD) in athletes increases with age. Among the structural causes, an anomalous origin of the coronary arteries ranks second. However, coronary artery disease is the most common cause in middle age and older individuals. An anomalous origin of the right coronary artery is more prevalent, but among athletes who have experienced SCD, an anomalous origin of the left coronary artery is much more common.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 52-year-old man with no cardiovascular risk factors or substance abuse, a high-profile sportsman who, at the end of a training session, presented with an episode of out-of-hospital cardiorespiratory arrest and who, after the administration of defibrillation with an automatic external cardioverter-defibrillator, recovered his pulse and level of consciousness. Subsequent electrocardiogram showed ST-segment depression in leads II, III and aVF and ST-segment elevation in leads I, aVL and V4 to V6. Urgent coronary angiography showed no significant angiographic lesions in the coronary arteries but did show an anomaly of the origin of the circumflex artery (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Anomalous aortic origin of the left coronary artery (AAOLCA) is rare. It may arise from the right sinus of Valsalva, above the sinus of Valsalva or rarely from the non-coronary sinus. Depending on the course of the vessel, we distinguish 5 subtypes: interarterial (between the aorta and the pulmonary artery), subpulmonic (intraconal or intraseptal), prepulmonic, retroaortic or retrocardiac.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Currently, computed tomography angiography (CT angiography) of the coronary arteries and magnetic resonance angiography (MR angiography) of the heart are the only Class I tests indicated for imaging the AAOLCA and its course. Coronary angiography offers high spatial resolution but cannot distinguish the type of vessel course. However, in combination with IVUS <span class="elsevierStyleItalic">(intravascular ultrasound)</span>, it allows the identification of coronary flow obstruction.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The risk of SCD is difficult to assess in these patients, as is the role of AAOLCA in ischaemia or symptoms because the available data do not adequately reflect the clinical spectrum of these abnormalities. The risk of SCD is higher in young individuals during or after a period of strenuous exertion, when the vessel orifice has a fishmouth shape, an acute angle, an intramural or interarterial course and in the case of hypoplasia of the proximal portion of the coronary artery.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> A significant portion of patients (38%–66%) had no symptoms prior to sudden death.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Non-invasive functional tests can be performed, however, the absence of ischaemia in these tests cannot be considered conclusive, especially when potentially high-risk anatomical variants are present.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Revascularisation is recommended for patients with an interarterial course, regardless of whether they have ischaemia or symptoms and in patients with vascular wall hypoplasia or coronary flow obstruction, even in the absence of ischaemia. When revascularisation is indicated, surgical correction is the treatment of choice.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In athletes with an AAOLCA, especially in the interarterial subtype, restriction of all competitive sports while awaiting surgical repair is recommended. At 3 months after surgery, intensive activities can be considered if the patient remains asymptomatic and an exercise stress test shows no evidence of ischaemia or cardiac arrhythmias.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In our patient, CT angiography of the coronary arteries showed an anomalous origin of the circumflex artery with exit from the proximal segment of the right coronary artery, with an angle of 45° and a retroaortic course, not intramural, between the aortic root and the left atrium (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C). The vasospasm test and the ischaemia induction test were negative. Cardiac MRI angiography showed pathological mesocardial gadolinium uptake at the basal-mid inferolateral level on late enhancement sequences suggestive of myocardial ischaemia. This finding corresponded to an area of chronic poor perfusion secondary to both myocardial hypertrophy due to high-intensity sport and the fact that, when correlating the cardiac MRI angiography images and the coronary artery course of the CT angiography, this area had no main vessel supply and therefore had to be supplied by microcirculation. Finally, as the cause of the SCD could not be clarified conclusively, it was decided to implant a subcutaneous ICD (implantable cardioverter defibrillator) and to cease high-intensity sporting activity.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion, AAOLCA is a rare entity that is sometimes associated with SCD. There is a lack of data demonstrating that any particular management strategy prevents SCD, therefore, decisions on whether surgery is necessary or whether exercise restriction or medical treatment would be beneficial are based on the synthesis of limited data.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0045" class="elsevierStylePara elsevierViewall">Instructions to authors and ethical responsibilities have been taken into account. In addition, the hospital's protocols and procedures related to the publication of patient data, as well as the privacy of the subject, have been observed.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have not received any financial support.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors' contribution</span><p id="par0055" class="elsevierStylePara elsevierViewall">All authors have contributed equally to the conception, drafting and final approval of the scientific paper.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Authors' contribution" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 721 "Ancho" => 1865 "Tamanyo" => 133809 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0060" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">A</span>) Right coronary angiography image showing the right coronary artery and an anomalous origin of the circumflex coronary artery. <span class="elsevierStyleItalic">B</span>) Left coronary angiography image showing the anterior descending coronary artery and the diagonal coronary artery. <span class="elsevierStyleItalic">C</span>) Coronary artery computed tomography angiography reconstruction image showing an anomalous origin of the circumflex coronary artery with an outflow from the right coronary artery and a retroaortic course.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ao: aorta; RC: right coronary artery; Cx: circumflex coronary artery; DA: anterior descending coronary artery; Dg: diagonal coronary artery.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.F. Van Hare" 1 => "M.J. Ackerman" 2 => "J.K. Evangelista" 3 => "R.J. Kovacs" 4 => "R.J. Myerburg" 5 => "K.M. Shafer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2015.09.036" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2015" "volumen" => "66" "paginaInicial" => "2372" "paginaFinal" => "2384" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26542660" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Anomalous origin of the coronary artery arising from the opposite sinus: prevalence and outcomes in patients undergoing coronary CTA" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.K. Cheezum" 1 => "B. Ghoshhajra" 2 => "M.S. Bittencourt" 3 => "E.A. Hulten" 4 => "A. Bhatt" 5 => "N. 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