Acquired and congenital coronary artery abnormalities
Ming-Lon Young1, Michael McLeary2, Kak-Chen Chan1
11Heart Institute,Joe DiMaggio Children's Hospital,Hollywood,Florida,United States of America.
Insights
Coronary artery abnormalities cause sudden cardiac death in young athletes. Kawasaki disease and anomalous origins require careful management, with surgical correction for symptomatic cases and ongoing research for asymptomatic ones.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Sports Cardiology
Background:
- Congenital and acquired coronary artery abnormalities are implicated in approximately 20% of sudden unexpected cardiac deaths in young athletes.
- Kawasaki disease is a primary cause of acquired coronary artery abnormalities, potentially leading to severe sequelae like aneurysms, stenosis, and thrombosis.
- Anomalous coronary artery origins, such as ALCAPA and those originating from the opposite sinus, can manifest as myocardial ischemia, arrhythmias, and sudden death, particularly with interarterial courses.
Purpose of the Study:
- To review the causes and clinical manifestations of coronary artery abnormalities in young athletes.
- To discuss the diagnostic and management strategies for various coronary artery anomalies.
- To highlight the current gaps in consensus regarding the management of specific asymptomatic coronary artery anomalies.
Main Methods:
- Review of literature on coronary artery abnormalities, Kawasaki disease, and sudden cardiac death in athletes.
- Analysis of clinical presentations, diagnostic findings, and treatment outcomes.
- Discussion of current guidelines and areas lacking consensus in management.
Main Results:
- Kawasaki disease and anomalous coronary artery origins are significant contributors to exercise-related sudden cardiac death in athletes.
- Anomalous left coronary artery from the pulmonary artery can present in adulthood with ischemic events despite initial collateralization.
- Anomalous coronary arteries with an interarterial course, especially originating from the opposite sinus, pose a high risk of sudden cardiac death during exercise.
- Myocardial bridging is generally benign but can rarely cause exercise-induced syndromes or cardiac death.
Conclusions:
- Symptomatic patients with coronary artery abnormalities require surgical correction.
- Asymptomatic patients with anomalous right coronary artery from the left sinus of Valsalva typically do not require treatment.
- Management of asymptomatic patients with anomalous left coronary artery from the right sinus of Valsalva and an interarterial course remains controversial.
- Further research is needed to establish clear management guidelines for all types of coronary artery anomalies in athletes.
Abstract:
Sudden unexpected cardiac deaths in approximately 20% of young athletes are due to acquired or congenital coronary artery abnormalities. Kawasaki disease is the leading cause for acquired coronary artery abnormalities, which can cause late coronary artery sequelae including aneurysms, stenosis, and thrombosis, leading to myocardial ischaemia and ventricular fibrillation. Patients with anomalous left coronary artery from the pulmonary artery can develop adequate collateral circulation from the right coronary artery in the newborn period, which remains asymptomatic only to manifest in adulthood with myocardial ischaemia, ventricular arrhythmias, and sudden death. Anomalous origin of coronary artery from the opposite sinus occurs in 0.7% of the young general population aged between 11 and 15 years. If the anomalous coronary artery courses between the pulmonary artery and the aorta, sudden cardiac death may occur during or shortly after vigorous exercise, especially in patients where the anomalous left coronary artery originates from the right sinus of Valsalva. Symptomatic patients with evidence of ischaemia should have surgical correction. No treatment is needed for asymptomatic patients with an anomalous right coronary artery from the left sinus of Valsalva. At present, there is no consensus regarding how to manage asymptomatic patients with anomalous left coronary artery from the right sinus of Valsalva and interarterial course. Myocardial bridging is commonly observed in cardiac catheterisation and it rarely causes exercise-induced coronary syndrome or cardiac death. In symptomatic patients, refractory or β-blocker treatment and surgical un-bridging may be considered.
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