An unusual case of a 53-year-old male with a right coronary artery originating from the left sinus of Valsalva is presented. Despite acute myocardial infarction due to occlusion of the aberrant right coronary artery (RCA), PTCA was not immediately performed. After 81 mg/day of aspirin had been administered for 1 month, PTCA to the subtotal stenosis of the RCA resulted in failure due to poor deployment of the guiding catheters complicated by withdrawal and uncrossing of a guiding wire. However, complete recanalization occurred after giving the patient 162 mg/day of aspirin for 8 months. Low dose aspirin was effective in recanalizing the subtotal stenosis after failed PTCA

Fujiwara Hideki

Ikeda Satoshi

Iwanaga Seima

Kohno Shigeru

Kose Noriyuki

Miyahara Yoshiyuki

Yoshida Shigeo

Nagasaki University's Academic Output SITE: NAOSITE

Acta Med. Nagasaki 44 : 61-65A Case of Anomalous Origin of the Right Coronary Artery from the Left Sinus of Valsalva- Special Reference to PTCA Procedures and Aspirin Effect to Failed PTCA of the   Anomalous Coronary Artery -Noriyuki KOSE 1), Hideki FUJIWARA 1), Seima IWANAGA 1), Shigeo YOSHIDA 2), Satoshi IKEDA 3), Yoshiyuki MIYAHARA 3), Shigeru KOHNO 3),1) Cardiology Division of the Department of Internal Medicine, Ebisumachi Hospital 2) Division of Internal Medicine, Showakai Hospital 3) Second Department of Internal Medicine, Nagasaki University School of Medicine An unusual case of a 53-year-old male with a right coro-nary artery originating from the left sinus of Valsalva is presented. Despite acute myocardial infarction due to occlu-sion of the aberrant right coronary artery (RCA), PTCA was not immediately performed. After 81 mg/day of aspirin had been administered for 1 month, PTCA to the subtotal stenosis of the RCA resulted in failure due to poor deploy-ment of the guiding catheters complicated by withdrawal and uncrossing of a guiding wire. However, complete reca-nalization occurred after giving the patient 162 mg/day of aspirin for 8 months. Low dose aspirin was effective in recanalizing the subtotal stenosis after failed PTCA.nary angioplasty (PTCA) 6,". Currently, ticlopidine and /or aspirin is frequently used for cases that underwent PTCA or stenting for antiplatelet and antithrombin ef-fects. Reportedly, higher daily doses (900-1500 mg) of aspirin are not more effective than lower doses (75-325 mg) for patients undergoing angioplasty, and aspi-rin alone, or in combination with dipyridamole, pre-vents early and late occlusion of the aortocoronary veingraft8. We herein report a rare case of anomalous origin of the right coronary artery from the left sinus of Valsalva. Following an unsuccessful PTCA, late recanalization occurred after administering low dose aspirin alone. The PTCA procedure and approach are discussed, as well as the effect of aspirin.Key words: aberrant right coronary artery ; PTCA ; subtotal           stenosis ; aspirin ; recanalizationCase ReportIntroduction Anomalous origin of the right coronary artery from the left sinus of Valsalva is an uncommon congenital condition and its incidence is 0.07-0.19% angiographi-cally14 > and 0.004% at autopsy". However, with the re-cent increased use of coronary angiography, more pa-tients with this anomaly have been detected, some of whom have undergone percutaneous transluminal coro-Address Correspondence : Noriyuki Kose, M.D., The Cardiology Division of the Department of Internal Medicine, Ebisumachi Hospital, 3-4 Ebisumachi, Nagasaki 850-0056, Japan TEL: +81-95-824-9131 FAX: +81-95-824-9651 A 58-year-old male with obesity, hypertension, hyper-lipidemia and a long smoking history was admitted to our hospital with dyspnea and substernal chest pain, revealing 0.1 mV of ST depression in leads I, aVi_, and V4 - V6, and a rS pattern in leads III and aVF on elec-trocardiography (ECG) (Fig. 1). No serum biochemical abnormality. was evident. The patient received 1.5 mg /hr of isosorbide dinitrate (ISDN) and 500 IU/hr of heparin sodium intravenously without emergency coro-nary angiography.  The next day, the white blood cell count was 9100 / u e , GOT 57 IU/ £ , LDH 342 IU/ ~, CPK 491 IU/ P , and ECG showed QS in lead aVF (Fig. 1). Coronary angiography 19 hours after admission showed no sig-nificant stenosis of the left anterior descending coro-nary artery (LAD). After failing to detect RCA in theright sinus of the Valsalva with a Judkins-type right-6F-4cm (JR6F-4) catheter via the right femoral artery, it was demonstrated with a Judkins-type left-6F-4cm (JL6F-4) catheter and left ventriculography (LVG), re-vealing its orifice anteriorly above the LCA orifice in the left sinus of Valsalva (Fig. 2-A,B). This case was diagnosed as acute myocardial infarction due to occlu-sion of the proximal RCA, which originated anomalously from the left sinus of Valsalva. Intravenous infusions of ISDN and heparin sodium were continued for an ad-ditional 24 hours without intracoronary thrombolysis (ICT) or PTCA.  After orally administering 81 mg/day of aspirin and 40 mg/day of ISDN for 1 month, coronary angiogra-phy demonstrated thrombolysis in myocardial infarc-tion (TIMI) grade 0 flow of the RCA with reduced in-ferior wall motion (Fig. 3-A). One week later, informed consent was obtained, and we proceeded with PTCA to the TIMI grade 1 flow of the mid-RCA (Fig. 3-B), viathe right femoral artery with a JL7F-4 guiding cathe-ter (Vista britetip, Cordis, U.S.A.) and a 0.014" wire (Hi-Torque Floppy, ACS, U.S.A ). Despite several bal-looning attempts with a 1.5-mm x 20-mm and a 4.0-mm x 20-mm balloon catheter (Trackstar, Cordis, U.S. A.), the lesion did not sufficiently dilate (Fig. 3-C). We changed the guiding catheter to an AL7F-1 and an AL7F-1.5 (Wiseguide, Scimed Life System Inc., U.S.A.) because of poor engagement. The inadvertently with-drawn guiding wire could not cross the lesion, result-ing in failed PTCA (Fig. 4-A, B). The patient was placed on 162 mg/day of aspirin and 40 mg/day of ISDN indefinitely.  Eight months after the failed PTCA, coronary angi-ography revealed TIMI grade 3, and excellent RCA recanalization with normal inferior wall motion (Fig. 4-C). The patient has shown an uneventful course for 3 years.On admission Next day On admisssion Next dayFig. 1 Electrocardiography on admission and the next day.A) The RCA shows complete occlusion associated with throm-bus.A) The RCA originating from the left sinus of Valsalva shows complete occlusion and the LCA is faintly demon-strated.B) One week later, TIMI grade 1 flow is evident.B) LVG shows high anterior takeoff RCA above the orifice of LCA.The solid arrow demonstrates the RCA and the open ar-row demonstrates the LCA. LCA : left coronary artery LVG : left ventriculography RCA : right coronary arteryFig. 2 Coronary angiography 1 day after admission.C) PTCA is performed.Fig. 3 Coronary angiography 1 month after AMLA) Guiding wire cannot cross the occluded lesion while changing guiding catheters.B) PTCA results in failure without sufficient recanalization.C) Complete recanalization of RCA occurs 8 months after failed PTCA.Fig. 4 Late recanalization after failed PTCA.Discussion Although the origin of the RCA from the left sinus of Valsalva has been considered a minor congenital anomaly of no clinical significance'), current studies in-dicate that myocardial infarction, angina pectoris, syn-cope, ventricular tachycardia/ fibrillation, and sudden death can be attributed to this aberrant anatomical con-dition"". The possible causes of the above dysfunctions include distal kinking5> or compression of the ectopic artery between the aorta and the pulmonary trunk dur-ing exercise"'), diminished flow into the RCA due to its upright slit-like ostium9> and an acute angle origin"). Although PTCA to this anomaly is technically diffi-cult due to its abnormal anatomy"), it has been re-ported in patients with angina') and acute myocardial infarction'). Its success depends on the appropriate choice of balloon and a Judkins-type left or an Amplatz-type left guiding catheter in a stable position'"). However, PTCA to the chronic subtotal stenosis with this anom-aly is very rare. Rather than via the femoral approach, the right brachial artery approach should have been attempted in our case, because it has a good back-up due to improved angulation between the guiding cathe-ter and the coronary ostium'>.  The possible reasons why recanalization occurredafter failed PTCA are as follows : (1) the occluded le-sion comprised thrombus alone without complete or-ganization, calcification, tortuosity and significant ste-nosis ; (2) the duration of total occlusion was less than 35 days, and (3) oral administration of low dose aspi-rin in combination with ISDN may have been effective. We could not identify the exact date of recanalization because neither a 3 nor a 6-month follow-up angiogra-phy was performed. Since TIMI grade 0 improved to grade 1 flow within a week, recanalization possibly oc-curred within three months of the initial PTCA.  Although ticlopidine and aspirin have shown a syn-ergistic effect in reducing platelet deposition') and thrombin generation after PTCA15', we gave low dose aspirin alone because its best risk-to-benefit and cost-to-benefit ratios were better than alternatives such as ticlopidine or warfarin, both of which reveal various side effects. Oral and intravenous administration of as-pirin over 325 mg/day may reduce platelet aggrega-tion and thrombosis formation more effectively than a lower dose16-'7. In contrast, our case showed that low dose aspirin (162 mg/day) recanalized the chronic sub-total stenosis naturally without any bleeding complica-tions. This was supported by Winter et al. who re-ported 150 mg/day of oral aspirin or an intravenous dose of 100 mg/day can completely inhibit platelet aggregation and vasoconstriction, and a daily mainte-nance dose of 75mg is sufficient to effectively inhibit thromboxane A2 synthesis in long-term treatment's).  In conclusion, this case showed that making an ac-curate diagnosis and therapeutic strategy for the aber-rant coronary artery requires careful angiographic and left ventriculographic or aortographic observations with an appropriate approach and guiding catheter. Further-more, low dose aspirin was effective to recanalize the chronic subtotal stenosis.   arising from a separate ostium in the left sinus of valsalva : a case    report. Angiology 46 : 629-632, 1995 7) Azuma T, Maeda K, Sakaguchi H, Miyaoka H, Akagi H, Yamamoto    T. Two cases of PTCA for acute myocardial infarction with    anomalous origin of the right coronary artery from the left sinus    of valsalva. Jpn J Interv Cardiol 9 : 85-90, 1994 8) Magnani B, Semprini F. Low-dose aspirin in the long-term treat-   ment of the patient with ischemic heart disease. Cardiologia 39    15-21, 1994 9) Roberts WC, Siegel RJ, Zipes DP. Origin of the right coronary ar-   tery from the left sinus of valsalva and its functional conse-   quences : Analysis of 10 necropsy patients. Am J Cardiol 49 : 863-   868, 1982 10) Mahowald JM, Blieden LC, Coe JI, Edwards JE. Ectopic origin of    a coronary artery from the aorta : Sudden death in 3 of 23 pa-   tients. 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Circulation 90 : I-   552, 1994 17) Dabaghi SF, Damat S, Hendricks 0, Payne J, Kleiman NS. Low    dose aspirin inhibits in vitro platelet aggregation within minutes    after ingestion. Circulation 86 : 1-261, 1992 18) Winter K, Husted SE, Vissinger H. Low dose acetylsalicylic acid in    the anti-thrombotic treatment of patients with stable angina pecto-   ris and acute coronary syndromes (unstable angina pectoris and    acute myocardial infarction). Pharmacol Toxicol 74 : 141-147, 1994References1) Engel HJ, Torres C, Page HL. Major variations in anatomical origin    of the coronary arteries, angiographic observations in 4,250 pa-   tients without associated congenital heart disease. Cathet. Cardi-   ovasc. Diag I : 157-169, 1975 2) Chaitman BR, Lesperance J, Saltiel J, Bourassa MG. Clinical,    angiographic, and hemodynamic findings in patients with anoma-   lous origin of the coronary arteries. Circulation 53 : 122-131, 1976 3) Kimbiris D, Iskandrian AS, Segal BL, Bemis CE. 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A Case of Anomalous Origin of the Right Coronary Artery from the Left Sinus of Valsalva - Special Reference to PTCA Procedures and Aspirin Effect to Failed PTCA of the Anomalous Coronary Artery -

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A Case of Anomalous Origin of the Right Coronary Artery from the Left Sinus of Valsalva - Special Reference to PTCA Procedures and Aspirin Effect to Failed PTCA of the Anomalous Coronary Artery -

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