OVERVIEW
Anomalous origin of the left or right coronary artery from either two or a single coronary artery in a non-corresponding aortic sinus, i.e., the left coronary artery originating in the right sinus of the aorta and the right coronary artery originating in the left sinus, with 1/3 to 1/2 of cases forming a tangent line or sharp angle with the aortic wall in its proximal segment and traveling between the aorta and the pulmonary arteries, can produce symptoms of myocardial ischemia and sudden death, which requires surgical treatment.
Etiology
The pathogenesis of this malformation is unknown and is likely due to the connection of the left or right coronary plexus to an incompatible aortic sinus. The left coronary artery plexus connects to the right aortic sinus bud to produce a left coronary artery originating abnormally from the right sinus of the aorta; the right coronary artery plexus connects to the left aortic sinus bud to form a right coronary artery originating from the left sinus of the aorta.
Symptoms
Some patients, especially older children and young adults, have symptoms of angina pectoris, syncope, and coma; but others have no clinical symptoms and die suddenly after strenuous exercise. There are usually no abnormal physical signs.
Examination
Coronary angiography may show the location and direct route of the anomalous origin of the coronary artery from the aorta.
Diagnosis
In a small number of patients, the diagnosis is made by echocardiography or electron beam tomography. The most reliable diagnostic method is selective coronary angiography, which shows the location of the anomalous origin of the coronary artery in the aorta, as well as the course of the anomalous coronary artery and whether or not it travels between two major arteries.
Complications
Myocardial ischemia, myocardial infarction, and sudden unexplained death may occur.
Treatment
1. Indications for surgery
(1) The patient has chest pain and palpitation during or after exercise, and the examination proves that this deformity produces myocardial ischemia.
(2) Patients with a history of syncope and coma, who have experienced temporary ventricular tachycardia.
2. Preoperative preparation
Observe the coronary angiogram to determine the surgical approach. For those with heart failure, apply digitalis and diuretics.
3. Surgical method
(1) Abnormal coronary artery opening remodeling.
(2) Coronary artery bypass grafting. In some cases, if abnormal opening remodeling cannot be applied, internal mammary artery or saphenous vein coronary artery bypass grafting can be used.
Prognosis
The incidence of this malformation is low, and the number of cases that can be selected for surgery is small. In the past, only a few cases have been reported to be treated surgically, and the recent results of the surgery are satisfactory.
Prevention
1. Primary prevention
Congenital heart disease is caused by environmental factors, genetic factors and their interaction. For the prevention of genetic factors, it is important to pay attention to pre-marital examination, avoid consanguineous marriage, and accept genetic counseling. More importantly, we should try to detect, avoid and prevent environmental factors that may cause unfavorable changes in genetic predisposition during pregnancy, such as viral infection drugs, ethanol and maternal diseases. Breaking the link between environmental factors and genetic factors is the key to primary prevention.
2. Secondary prevention
(1) Early diagnosis The early diagnosis of CHD can be divided into two steps. ① Fetal diagnosis: in the 16-20 weeks of pregnancy, the use of pregnant women’s abdominal puncture of the amniotic membrane, amniotic fluid, amniotic fluid cell culture, chromosome analysis, gene diagnosis and enzyme activity, amniotic fluid metabolites, special proteins and enzyme activity, etc. can also be used in the 8-12 weeks of pregnancy through the vagina of the woman sucked chorionic villi for the above tests, for those caused by single gene mutations and chromosomal aberrations of congenital heart diseases. The test is of great value for congenital heart disease caused by single gene mutations and chromosomal aberrations. (2) Diagnosis in infancy: A thorough physical examination of the infant should be performed, especially a careful auscultation of the cardiovascular system, and those found to be suspicious should be further examined by echocardiography.
(2) Early treatment Once it is clear that the fetus has congenital cardiovascular anomalies during the fetal period, the pregnancy should be terminated promptly. For certain hereditary enzyme or metabolic defects, early replacement therapy should be carried out after birth.
3.Tertiary prevention
Once congenital heart disease is clearly diagnosed, the fundamental method of treatment is to perform surgery to completely correct the cardiovascular malformation, thus eliminating the pathophysiological changes caused by the malformation. Without surgery or temporarily inoperable, it is advisable to avoid overwork according to the condition, so as not to cause heart failure, if the occurrence of heart failure to anti-heart failure treatment. Prevention and treatment of complications, where patients with pre-coronary heart disease in the implementation of invasive examination or treatment, including cardiac catheterization, tooth extraction, tonsillectomy, etc., should routinely apply antibiotics in order to prevent infective endocarditis.