Fiechter, Michael

Ghadri, Jelena R.

Kaufmann, Philipp A.

Landmesser, Ulf

Lüscher, Thomas F.

Templin, Christian

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Squibb, sanofi-aventis, Eli Lilly and Co., Daiichi Sankyo, Inc., TheMedicines Company, Portola, Novartis, Medicure, Accumetrics,Arena Pharmaceuticals, and Astra Zeneca; and research grantsfrom Bristol Myers Squibb, sanofi-aventis, GlaxoSmithKline,Otsuka, Eli Lilly and Co., Daiichi Sankyo, Inc., The MedicinesCompany, Portola, Accumetrics, Schering-Plough, Astra Zeneca,Eisai, and Johnson and Johnson A.P. K. reports a research grantBoston Scientific.ReferencesThe list of references is available in the online version of this paper.CARDIOVASCULAR FLASHLIGHT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .doi:10.1093/eurheartj/ehr273Online publish-ahead-of-print 6 August 2011Cardiac hybrid imaging in a patient with a single coronary arteryoriginating from the right sinus of ValsalvaJelena R. Ghadri1, Michael Fiechter1,3, Christian Templin2, Thomas F. Lu¨scher2,3, Philipp A. Kaufmann1,2,3, andUlf Landmesser2,3*1Cardiac Imaging, University Hospital Zurich, Zurich, Switzerland; 2Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland; and3Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Ramistrasse 100, CH-8091 Zurich, Switzerland* Corresponding author. Tel: +41 44 255 95 95, Fax: +41 44 255 44 01, Email: ulf.landmesser@usz.chA 59-year-old female patient presented to theemergency department of the University Hospitalof Zurich with an acute onset of severe chest painduring the last 2 h. After sublingual nitroglycerinadministration, the chest pain largely resolved.The electrocardiogram showed no ischaemicST-segment or T-wave changes. Laboratoryexamination revealed an elevated troponin T(0.019 mg/L).The clinical presentation was suggestive of anon-ST elevation acute coronary syndrome andthe patient underwent coronary angiography reveal-ing a single coronary artery originating from the rightsinus ofValsalva, a rare coronary anomaly, combinedwith coronary artery disease,with two subtotal stenoses of the dominant right coronaryartery (RCA; Figure 1A). The left anterior descending (LAD) and circumflex (LCX) artery derived from a short left main equivalent andcoursed aberrantly to the left side (Figure 1A). The LCX equivalent had a small lumen diameter in the whole proximal segment, wherethe artery showed an irregular contour, suggestive of a long atherosclerotic lesion (Figure 1A). Coronary stent implantation in the RCAwas performed immediately due to severe angina pectoris symptoms in the cath lab (Figure 1B), after which the patient was free ofangina. Afterwards, the patient was examined by cardiac hybrid imaging (combining coronary CT and 99mTc-tetrofosmin SPECTmyocardialperfusion imaging; Figures 1C–H) to determine the course of the coronary arteries and potential related myocardial ischeamia. The LADequivalent coursed anterior to the right ventricle and the LCX equivalent coursed prepulmonary (Figures 1G andH ), indicating a particularlyrare coronary anomaly. Cardiac hybrid imaging revealed a small myocardial ischaemia in the lateral territory supplied by the LCX equivalent(Figure 1D) that was treated medically using a b-blocker. In the follow-up, the patient was free of angina pectoris or dyspnoea.Here,wedescribe to thebest of our knowledge the first caseof cardiac hybrid imaging evaluation in a patientwith a single coronary artery. Adiagnostic challenge in these patients is to determine whether cardiac ischaemia is related to coronary atherosclerotic lesions or to the con-genital abnormality thatmay cause cardiac ischaemia by several mechanisms. In the present case, the extent of cardiac ischaemiawas small andrelated to the territory supplied by the LCX equivalent, suggesting that it was not resulting from the course of the left main equivalent.Surgical correction in patientswith isolated coronary artery anomalies is in particular considered in patientswho have coronary arteriescoursing between the aorta and pulmonary artery, since this abnormality has been observed to be related to sudden cardiac death, typi-cally but not exclusively at a young age (,30 years) and in patients where a large cardiac territory is at risk for ischaemia.In summary, in our patient, coronary artery disease was present in the setting of a rare coronary congenital abnormality. Cardiachybrid imaging suggested that cardiac ischaemia was not related to the course of the left main equivalent, since ischaemia was clearlylimited to the territory supplied by the LCX equivalent, and was most likely due to a long atherosclerotic lesion observed in the prox-imal segment of this artery. Given that the patient was free of symptoms in the follow-up, had a small extent of ischaemia, and a pre-served LV function, an optimal medical therapy rather than a further interventional or surgical treatment was recommended.Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2011. For permissions please email: journals.permissions@oup.comCoronary revascularization in diabetic patients 2757

Cardiac hybrid imaging in a patient with a single coronary artery originating from the right sinus of Valsalva

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