A Pelliccia

AJ Taylor

BR Chaitman

C Tedeschi

D Kimbris

D Ropers

E Cesare di

F LaBorde

J Shirani

JM Karamichalis

K Okamatsu

MJ Lipton

O Yamanaka

P Angelini

R Khouzam

R Rosa De

R Wolf

R Zanettini

RR Liberthon

T Ishikawa

T Wolf

WL Haskell

Annals of Occupational and Environmental Medicine

Roberto De Rosa

Gennaro Ratti

Donato Gerardi

Carlo Tedeschi

Monica Lamberti

Crossref

De Rosa et al. Annals of Occupational and EnvironmentalMedicine  (2015) 27:4 DOI 10.1186/s40557-015-0055-2CASE REPORT Open AccessSingle coronary artery originating from the rightsinus Valsalva and ability to workRoberto De Rosa1*, Gennaro Ratti2, Donato Gerardi3, Carlo Tedeschi4 and Monica Lamberti3AbstractWe present a case of a 56-year-old male electrician who was admitted to the hospital with atrial fibrillation, atypicalchest pain and dyspnea. He gave a history that on the morning he had working for almost 4 hours carrying outvarious activities with considerable physical effort. After cardioversion, conventional coronary angiography revealeda suspect of single coronary vessel (SCA) arising from the right sinus of Valsalva. The patient underwent multislicecomputed tomography that showed a SCA arising from the right sinus Valsalva and dividing in Right CoronaryArtery (RCA) and Left Main coronary artery (LM). The finding of posterior course of the LM without atherosclerotichas proved crucial for the expression of an opinion of working capacity even with limitation.Keywords: Single coronary artery, Multi Slices Computed Tomography, Working capacityBackgroundThe normal coronary circulation encompasses a widespectrum of normal variants, which are often detected asincidental findings during coronary angiography (CAG). Asingle coronary artery ostium is a rare finding. In thegeneral population, the incidence of single coronary ar-tery is approximately 0.024% [1,2]. Clinically it maycause recurrent ischaemia, heart failure or suddendeath. We introduce a case of an Journeyman electri-cian with average energy requirement for his workingactivity >6 Metabolic Equivalents of Task (METs), pre-senting with atrial fibrillation and chest pain after amorning of work.Case presentationA 56-year-old male electrician, with treated hypertension(reported mean values of blood pressure: 130/95 mmHg), was admitted with chest pain lasting for about60 minutes. He was journeymen electrician specializedin commercial, residential and low-voltage wiring.He gave a history that on the morning he had workingfor almost 4 hours carrying out various activities such asmanipulate cables and wires through cavities or carry* Correspondence: robertoderosa@libero.it1Department of Radiology, PSI ASL Napoli 1, (Via Ciccarelli 1), Naples (80100),ItalyFull list of author information is available at the end of the article© 2015 De Rosa et al.; licensee BioMed CentraCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.boxes of electrical equipment weighing about 20 kilos,with considerable physical effort.In his clinical history he reported to have had occa-sional atypical chest pain for which he submitted twoyears ago to exercise stress testing, which resulted max-imal for age and negative for ischaemia induced bystress. The patient on admission had tachypnoea at restwith oxygen saturation of 93%. Electrocardiogram (ECG)showed atrial fibrillation with a heart rate of 90 beats/min. Blood pressure was 175/95 mm Hg. Cardiac auscul-tation was normal but at pulmonary level bilateral basalcrackles were present. Cardiac enzymes were slightly ele-vated: Troponin T (TnT): 0,033 ng/l [norm: <0.03] andCreatine Kinase (CK): 260 U/l [norm: 47–220]. Regionalleft ventricular wall motion and ejection fraction wasnormal (Ejection Fraction EF 60%). After cardioversionwith DC shock (3 J/Kg body weight), considering TnTand CK levels [3] a CAG was performed to exclude cor-onary disease. It revealed a suspect of single coronaryvessel arising from the right sinus of Valsalva. The rightcoronary artery (RCA) showed a normal course (Figure 1:panel A). Stenoses of the coronary arteries were notpresent. In order to better define the origin and courseof the single vessel, we performed a Multi Slices ComputedTomography (MSCT) (Figure 1: panels B, C and D) usinga 64-detector-row scanner (Aquilion 64; Toshiba MedicalSystem, Tokyo, Japan).l. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Figure 1 Coronary angiography, volume rendering and curved multiplanar reconstruction from MSCT of the coronary anomalies.(Panel A) Coronary Angiography (CAG) projection showing a Single Coronary Artery (SCA) arising from right sinus of Valsalva and dividing inright coronary artery (RCA) and Left Main (LM). Volume rendering (panel B and C) and Curved Multiplanar Reconstruction (panel D) from MSCTshowed that LM turned posteriorly behind the aorta (non-malignant anomaly), reaching the atrio-ventricular groove where it divides into leftanterior descending (LAD) and left circumflex (CX) arteries.De Rosa et al. Annals of Occupational and Environmental Medicine  (2015) 27:4 Page 2 of 4MSCT showed a SCA arising from the right sinus Valsalvaand dividing in RCA and Left Main (LM) (Figure 1: panel B,C and D). The LM showed an acute take-off angle, turnedposteriorly behind the aorta, reaching the atrio-ventriculargroove where it divides into left anterior descending (LAD)and left circumflex (CX) arteries. No atherosclerotic plaquewere present. The patient was discharged with only antihy-pertensive drug therapy. After 2 month, at follow up medicalcheck, he reported no angina and no exertional dyspnea.His left ventricular ejection fraction was normal and exercisetolerance >12 METs. He returned to his full work duties, al-though we recommended him to avoiding strenuous work(under 6 METs) and work on overhead lines too.DiscussionEvaluating the capacity of a patient with coronary arteryanomalies to carry out occupational work often poses adifficult problem for the physician. The reason for thedifficulty is that many factors influence any recommen-dation regarding these patients’ return to work, and spe-cific guidelines for these condition, due to the limitednumber of affected patients in working age, have notbeen critically evaluated.In fact the overall incidence of coronary anomalies inhumans is 0.6 to 1.3% out of which the single coronaryartery originating from the right coronary sinus accountsfor 1.3% of all coronary anomalies [4-7]. Concerning thecourse of a single coronary vessel arising from the rightcoronary sinus, four anatomical variants have been de-scribed according to the crossing of the LM to the leftside of the heart: (1.) anterior: LM turns anteriorly infront of the right ventricular outflow tract; (2.) inter-arterial: LM lies between the great vessels, aorta and pul-monary artery; (3.) septal: LM has an intramyocardialseptal course; (4.) posterior: LM turns posteriorly behindthe aorta in infero-posterior direction [8-10]. The inter-arterial course has been known as cause of sudden car-diac death (>50%) [11]. Other types can present withmyocardial ischaemia, congestive heart failure and sud-den cardiac death. Myocardial ischaemia is thought tooccur due to the impaired coronary flow reserve andalso secondary to the anatomic and functional anomalyof the ostium (acute aortocoronary angulation, slit-likeostium, ostial tissue flaps and initial course of the coron-ary artery within the aortic wall) [8]. In the inter-arterialvariant, ischaemia or sudden death are assumed to becaused by vascular compression or kinking [8,11,12].Our case was the posterior variant judged as non-malignant anomaly without remarkable changes in car-diovascular risk [8,10]. It is very important to define theDe Rosa et al. Annals of Occupational and Environmental Medicine  (2015) 27:4 Page 3 of 4course of the coronary anomaly because some misinter-pretations of the coronary angiography are possible.Therefore, additional nonivasive imaging methods withbetter spatial resolution like MSCT have been suggested[4,13-16]. Since the overall number of patients is small,the treatment strategy varies and is not clearly defined.Generally when an adult or older patient is incidentallydiagnosed wrong sinus coronary malformations, in ab-sence of coronary artery disease and in considerationthat sudden death occurs at a young age, this occasionalfinding has likely no clinical significance and most prob-ably needs no surgical therapy [17-19]. Neverthelesswhen these subjects are symptomatic, a clear guidelineshave not yet been defined and the treatment is still con-troversial. The finding, in our case, of posterior courseof the LM without atherosclerotic lesions has provedcrucial to determine the therapeutic treatment with onlyantihypertensive drugs and to allow the patient to re-entry into the workforce even with suggestion to reducethe effort under 6 METs (as the transport of weightsabove 15 kilos) and to avoiding work on overhead linestoo, although the patient reported that he had neverworked on power lines [20,21].In fact, in our case, although the anatomical varianthas been classified as benign, the non-certain cause ofhigh level of TnT and CK and the presence of atrial fib-rillation after a strenuous work, maybe due to a coron-ary artery spasm associated with abnormal course of thecoronary vessels, has led us to reduce the possible car-diovascular risks related to the professional activity ofthe patient.In fact due to Haskell et al. [22] three major cardiacpathophysiologic processes due to ischemic heart diseasein historical and clinical data of the patient may impairhis physical working capacity: left ventricular dysfunc-tion, myocardial ischemia and electrophysiologic distur-bances as in our patient.ConclusionIn conclusion in heart disease worker, the focus of phys-ician is to determine whether or not the increase in car-diac demands produced by physical, psychological andenvironmental stressors will exceed the threshold for a“safe and sure working capacity” [23,24], especially whenthere are same anatomical anomaly that con influencethis capacity.ConsentWritten informed consent was obtained from the patientfor publication of this Case report and any accompany-ing images.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsGR and CT interpreted results, revised the draft of this manuscript, RD wrotethe article. ML and DG identified relevant references. All of the authors readand approved the final manuscript.AcknowledgmentsRDR was responsible for the radiological assessment. GR and CT wasinvolved in the cardiological evaluation. DG and ML wrote the manuscript.Author details1Department of Radiology, PSI ASL Napoli 1, (Via Ciccarelli 1), Naples (80100),Italy. 2Department of Cardiology, San Giovanni Hospital, ASL Napoli 1, (ViaFilippo Maria Briganti 255), Naples (80100), Italy. 3Department ofExperimental Medicine, Section of Hygiene, Occupational Medicine andForensic Medicine, Second University of Naples, (Via dei Crecchio 16), Naples(80100), Italy. 4Department of Cardiology, San Gennaro Hospital, ASL Napoli1, (Via San Gennaro dei Poveri, 25), Naples (80100), Italy.Received: 27 May 2014 Accepted: 9 January 2015References1. Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated singlecoronary artery: diagnosis, angiographic classification, and clinicalsignificance. Radiology. 1979;130:39–47.2. Shirani J, Roberts WC. 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BMJ Case Rep. 2014;28:2014.pii:bcr2014207424. doi:10.1136/bcr-2014-207424.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color ﬁgure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submit

Single coronary artery originating from the right sinus Valsalva and ability to work

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Single coronary artery originating from the right sinus Valsalva and ability to work

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