Myocardial ischaemia in a case of a solitary coronary ostium in the right aortic sinus with retroaortic course of the left coronary artery: documentation of the underlying pathophysiological mechanisms of ischaemia by intracoronary Doppler and pressure measurements

• Published in: Heart (British Cardiac Society) Vol. 80; no. 3; pp. 307 - 311
• Main Authors: Schwarz, E R, Hager, P K, Uebis, R, Hanrath, P, Klues, H G
• Format: Journal Article
• Language: English
• Published: London BMJ Publishing Group Ltd and British Cardiovascular Society 01.09.1998; BMJ; BMJ Publishing Group LTD
• Subjects: Adult; Angina pectoris; Atherosclerosis; Biological and medical sciences; Cardiac arrhythmia; Cardiology. Vascular system; Cardiovascular disease; Case Report; Congenital diseases; congenital disorders; Congenital heart diseases. Malformations of the aorta, pulmonary vessels and vena cava; Coronary Angiography; coronary anomaly; Coronary Artery Bypass; Coronary Vessel Anomalies - complications; Coronary Vessel Anomalies - diagnostic imaging; Coronary Vessel Anomalies - physiopathology; Coronary vessels; Doppler; Electrocardiography; Female; Flow velocity; Heart; Heart attacks; Humans; intravascular ultrasound; Medical imaging; Medical sciences; Myocardial Ischemia - diagnostic imaging; Myocardial Ischemia - etiology; Myocardial Ischemia - physiopathology; Patients; Pulmonary arteries; single coronary ostium; Sinuses; Ultrasonic imaging; Ultrasonography, Interventional; Sonography; Anomalous origin of the left coronary artery; Doppler ultrasound study; Human; Pathophysiology; Cardiovascular disease; Exploration; Left coronary artery; Coronary heart disease; Congenital disease; Myocardial disease; Arterial disease; Vascular disease; Case study; Phenotype; Treatment; Ischemia; Malformation; Surgery; Myocardium; Complication; Diagnosis
• ISSN: 1355-6037; 1468-201X
• DOI: 10.1136/hrt.80.3.307

Only a few cases of a single coronary ostium and retroaortic course of the coronary artery have been described. Almost all cases reported so far had additional coronary artery or valvar disease. However, myocardial ischaemia may be caused by the coronary malformation alone. A 40 year old woman with severe myocardial ischaemia in the absence of clinically relevant coronary atherosclerosis is described. To clarify the origin and mechanisms of ischaemia, intracoronary Doppler, pressure and ultrasound studies were performed using microtransducers. In its outer portion along the course behind the ascending aorta, coronary blood flow velocities were increased, there was an external elliptical compression, and distal coronary flow reserve was reduced. Furthermore, an overshoot in diastolic pressure above aortic pressure was detectable within this portion. Dobutamine stimulation exaggerated the observed intracoronary haemodynamics and induced myocardial ischaemia. The intracoronary diagnostic procedures performed were helpful in clarifying the pathophysiological mechanisms of functional coronary obstruction and ischaemia in this malformation. Bypass surgery was successfully performed with symptomatic improvement.