Anomalous Coronary Arteries from the Opposite Coronary Sinus: Similar Long-term Outcomes from Medical or Surgical Treatment
Abstract & Commentary
By Andrew J. Boyle, MBBS, PhD
Source: Krasuski RA, et al. Long-term outcome and impact of surgery on adults with coronary arteries originating from the opposite coronary cusp. Circulation. 2011;123:154-162.
Coronary artery anomalies are being recognized with increasing frequency due to the increased usage of computed tomography (CT) and magnetic resonance imaging (MRI) scans in patients with chest pain syndromes. Anomalous coronary arteries that arise from the opposite sinus (ACAOS), particularly those with an inter-arterial course (IAC) between the aorta and the pulmonary artery, have been associated with sudden cardiac death (SCD) in children, adolescents, and competitive athletes. Whether this association is also true in the general adult population is not known. Furthermore, the treatment of ACAOS with IAC has increasingly become surgical, yet the benefit of surgery in adult patients is not known. Thus, Krasuski and colleagues retrospectively evaluated over 200,000 cardiac catheterizations from the Cleveland Clinic between 1966 and 2007. They identified 301 adult patients with ACAOS, of whom 54 had IAC. They stratified the cohort on the basis of medical vs. surgical treatment, and on whether or not they had IAC. Long-term mortality was confirmed with the Social Security Death Index.
Results: The number of referrals for ACAOS is increasing exponentially. The rates of surgery for ACAOS are also increasing exponentially. Patients with ACAOS that had an IAC, compared to those who did not have an IAC, were younger (52 ± 13 vs. 59 ± 13 years; p = 0.001), presented with chest pain more commonly (82% vs. 62%; p = 0.01), had less extensive atherosclerosis (p = 0.01) despite similar coronary risk factors profiles, and were significantly more likely to undergo surgical intervention (52% versus 27%; p < 0.001). However, there was no difference in survival between those with and those without an IAC (median 9.2 vs. 9.3 years; p = 0.45).
Of the 54 patients with ACAOS and IAC, just over 50% (n = 28) underwent a surgical intervention. The surgical intervention included bypass of the anomalous vessel with the use of an arterial graft in 10 patients (with concurrent ligation of the native vessel in 1 case), bypass with the use of a saphenous venous graft in 10 patients (with concurrent ligation of the native vessel in 1 case), reimplantation in five patients, and surgical unroofing in three patients. There were no peri-operative deaths. Compared to medically managed patients, surgically managed patients had more extensive coronary atherosclerosis (p = 0.03) but were less likely to have diabetes mellitus (0% vs. 23%; p = 0.01) and were more likely to have had an abnormal stress test (94% vs. 46%; p = 0.002). Survival did not appear to differ after 10 years between patients treated surgically and those treated medically (92.9% vs. 92.3%; p = 0.65). The authors conclude that in patients with an anomalous coronary artery from the opposite sinus of Valsalva, surgical management appears to have been favored recently. Despite no peri-operative mortality, a positive impact on long-term survival was not observed. The impact of surgery in older adults with anomalous coronary arteries arising from the opposite coronary sinus with IAC deserves further study.
The management of patients with ACAOS has been problematic because of the paucity of data in this area. The studies linking ACAOS with sudden cardiac death were small and usually involved younger competitive athletes. This interesting study utilizes a large dataset of adult patients undergoing cardiac catheterization and casts doubt on the need for surgery for ACAOS. The study has significant inclusion bias, because the patients were referred for coronary angiography and thus were likely to have been symptomatic, at least to some degree. This is especially true in the earlier decades of the study. Whether these results can be generalized to the asymptomatic patient who is diagnosed incidentally by non-invasive imaging for some other reason remains unknown. Although the median survival was short (around nine years) and there was low surgical mortality, surgery resulted in no demonstrable mortality benefit at 10 years. Further prospective studies are needed to confirm the most appropriate management strategy.