Interposed coronary artery between aorta and pulmonary
artery.
Image courtesy of Sudha Patel.
Interposed coronary artery between aorta and pulmonary
artery.
Image courtesy of Sudha Patel.
J Am Soc Echocardiogr. 2003 Jul;16(7):756-63.
Aberrant coronary arteries: a reliable echocardiographic screening method.
Jureidini SB, Marino CJ, Singh GK, Balfour IC, Rao PS, Chen SC.
Section of Cardiology, Department of Pediatrics, Saint Louis University School of Medicine/Cardinal Glennon Children's Hospital, St Louis, Missouri 63104, USA. jureidsb@slu.edu
BACKGROUND: Aberrant origin (ABO) of a coronary artery (CA) from the contralateral aortic sinus with a subsequent interarterial course is a life-threatening condition. It carries a 28% to 55% risk for a sudden coronary event or death, but there are no rel iable screening methods. OBJECTIVE: We sought to determine whether imaging a cross section of a coronary segment in the anterior aortic wall on the long-axis view may be used as an echocardiographic screening sign for ABO CA. METHODS: The echocardiograms of all patients with ABO CA were evaluated for the screening sign and compared with those of age-matched control patients. RESULTS: Between January 1989 and October 2002, we identified 8 patients with ABO CA (median age: 15 years). Of these patients, 4 we re symptomatic and 4 were discovered incidentally. The electrocardiogram produced normal findings in 5 of 8 patients, maximal stress test produced normal findings in 5 of 6 patients, and thallium perfusion test produced negative results in 2 of 3 patients . There were 4 patients with ABO in the main left CA, 3 with ABO in the right CA, and 1 with ABO in the circumflex CA branch. The screening sign was readily visible in 7 of the 8 patients (88%), and all 7 of these patients had ABO in a main CA. Only in th e ABO in the circumflex CA branch was the screening sign not detected. The 1743 control patients (median age: 14 years) showed normal anterior aortic wall, which was void of any CA segment. In 5 control patients (0.3%, P <.001) the normal right CA was vis ible on the long-axis view, but was not confused for a false-positive screening sign. CONCLUSION: We concluded that the proposed screening sign for ABO CA is reliable and easily recognizable, and should prompt a comprehensive assessment of the CA.
1: J Am Coll Cardiol. 2001 Feb;37(2):593-7.
Comment in:
J Am Coll Cardiol. 2001 Feb;37(2):598-600.
J Am Coll Cardiol. 2001 Nov 1;38(5):1587-8.
J Am Coll Cardiol. 2001 Oct;38(4):1269-70; author reply 1270-1.
J Am Coll Cardiol. 2001 Oct;38(4):1270-1.
Major coronary artery anomalies in a pediatric population: incidence and clinical importance.
Davis JA, Cecchin F, Jones TK, Portman MA.
Department of Cardiology, Children's Hospital and Regional Medical Center, Seattle, Washington 98105, USA.
OBJECTIVES: We sought to prospectively determine the incidence and clinical significance of major coronary artery anomalies in asymptomatic children using transthoracic two-dimensional echocardiography. BACKGROUND: Anomalous origins of the left main coron ary artery (ALMCA) from the right sinus of Valsalva or anomalous origins the right coronary artery (ARCA) from the left sinus are rarely diagnosed in children and can cause sudden death, especially in young athletes. Because most patients are asymptomatic , the diagnosis is often made post mortem. No study to date has prospectively identified anomalous coronary arteries in asymptomatic children in the general population. METHODS: After serendipitously identifying an index case with ALMCA, we examined proxi mal coronary artery anatomy in children with otherwise anatomically normal hearts who were referred for echocardiography. In those diagnosed with ALMCA or ARCA, we performed further tests. RESULTS: Within a three-year period, echocardiograms were obtained in 2,388 children and adolescents. Four children (0.17%) were identified with anomalous origin of their coronary arteries, and angiograms, exercise perfusion studies and/or stress tests were then performed. One ARCA patient had decreased perfusion in the right coronary artery (RCA) perfusion area and showed ventricular ectopy on electrocardiogram (ECG) at rest that diminished but did not resolve with exercise. A second patient with ALMCA had atrial tachycardia immediately after exercise, with inferior an d lateral ischemic changes on ECG and frequent junctional and/or ventricular premature complexes both at rest and recovery. CONCLUSIONS: This study demonstrates that although anomalous origins of coronary arteries are rare in asymptomatic children, the pr evalence is greater than that found in other prospective studies. Ischemia can occur with both ALMCA and ARCA even though patients remain asymptomatic. Because of the high risk of sudden cardiac death, aggressive surgical management and close follow-up ar e necessary.
J Am Soc Echocardiogr. 2000 Apr;13(4):255-63.
Main coronary artery and coronary ostial stenosis in children: detection by transthoracic color flow and pulsed Doppler echocardiography.
Jureidini SB, Marino CJ, Singh GK, Fiore A, Balfour IC.
Department of Pediatrics, Saint Louis University School of Medicine, St Louis, MO, USA.
Coronary artery stenosis (CAS) and coronary ostial stenosis (COS) are potentially life-threatening conditions. The echocardiographic diagnosis of CAS and COS in children has not been described. We report on the transthoracic echocardiography (TTE) finding s of CAS and COS in children. Six patients, aged 1 week to 12 years, with clinically confirmed COS (n = 5) and CAS (n = l) were diagnosed by TTE. Their echocardiographic findings were compared with 26 healthy control subjects of a similar age range. Left COS was associated with an aberrant left coronary artery (CA) from the contralateral aortic sinus (n = 2), an intramural left CA with d-transposition of the great vessels (n = l), and supravalvular aortic stenosis (n = l). Right COS was present in a patie nt with aortic valvular stenosis. Acquired left main CAS was diagnosed in the sixth patient 3 years after orthotopic heart transplantation. Coronary ostial stenosis was recognized when a color flow acceleration signal was present proximal to and extending into the coronary ostium (CO). Coronary artery stenosis was detected when a coarctated color flow stream was present within the stenosed CA segment with turbulent distal flow. These findings were not detected in the control cohort who demonstrated lamina r CA and CO flow signals. All patients had increased spectral velocity in the CA distal to the stenosed segment (patients = 50 +/- 5 cm/s, controls = 24 +/- 6 cm/sec; P <.01). Delayed peak diastolic velocity seemed to indicate severe stenosis. We conclude that (1) CO acceleration signals and turbulent coarctated CA flow signals are abnormal findings in TTE coronary Doppler assessment. They indicate COS and CAS, respectively. (2) Knowledge of the normal TTE CA flow velocity patterns is essential so that ab normal velocity signals such as seen with CAS and COS can be recognized and a timely diagnosis made.
Int J Card Imaging. 1998 Apr;14(2):89-95.
Coronary anomalies diagnosed with transesophageal echocardiography: complementary clinical value in adults.
Kasprzak JD, Kratochwil D, Peruga JZ, Drozdz J, Rafalska K, Religa W, Krzeminska-Pakula M.
Cardiology Dept, Medical University of Lodz, Poland. jdkasprzak@hotmail.com
INTRODUCTION: Coronary arteriography remains a gold standard for the evaluation of coronary anatomy. In the case of anatomical anomalies, understanding of vessel course based upon a coronary angiogram may be difficult. Transesophageal echocardiography is a noninvasive method allowing tomographic visualization of proximal coronary arteries. Experience concerning its usefulness for the assessment of anomalous coronary arteries is limited. MATERIAL: Eleven patients with confirmed coronary anomalies studied b etween 1993-96 were identified in the cohort of those undergoing transesophageal echocardiography. RESULTS: Transesophageal echocardiography revealed potentially serious anomalies (origin of left or right coronary artery from contralateral aortic sinus) i n 3 patients and benign in 8. Coronary ostia and proximal course could be delineated in all patients. Anatomical information was consistent between methods, except for a separate origin of the left anterior descending and circumflex artery, where the angi ogram missed a very short common left main coronary artery in 2 patients. The relationship between the coronary arteries, aorta and pulmonary trunk was better defined by the echocardiogram. Doppler flow analysis allowed us to exclude anomaly-related flow disturbances. CONCLUSIONS: Transesophageal echocardiography can be considered as a noninvasive technique with the potential for anatomical and functional evaluation of anomalous proximal coronary arteries and deserves a routine use whenever such a conditi on is suspected. This approach may simplify invasive procedures in this patient group.
Am Heart J. 1997 Apr;133(4):428-35.
Anomalous right or left coronary artery from the contralateral coronary sinus: "high-risk" abnormalities in the initial coronary artery course and heterogeneous clinical outcomes.
Taylor AJ, Byers JP, Cheitlin MD, Virmani R.
Department of Medicine, Walter Reed Army Medical Center, Armed Forces Institute of Pathology, Washington, DC 20307, USA.
Coronary artery anomalies are associated with sudden cardiac death, although individual patient outcomes are highly variable. We performed blinded pathologic analysis of 30 consecutive cases of anomalous right (n = 21) or left (n = 9) coronary artery from the contralateral coronary sinus to determine which, if any, features might aid in risk stratification for sudden cardiac death. We found no significant differences in length of aortic intramural segment, coronary ostial size, degree of displacement of t he anomalous coronary artery from the correct coronary sinus, or angle of coronary takeoff between patients with (n = 12) and without (n = 18) sudden cardiac death. All pathologic features showed considerable interpatient variability. Age > or = 30 years was the only variable associated with a decreased incidence of sudden cardiac death. Thus no simple relation exists between variations in the initial coronary artery course and clinical outcome in these anomalies.
Int J Cardiol. 1993 Jan;38(1):89-91.
Anomalous origin of the left coronary artery from the anterior aortic sinus: role of echocardiography.
Daliento L, Fasoli G, Mazzucco A.
Department of Cardiology, University of Padua, Medical School, Italy.
Sudden death in the young is a dramatic event which can be avoided with a preventive identification of the underlying cause. We report one case in which we identify the anomalous origin of the left coronary artery from the right sinus of Valsalva by trans thoracic and transesophageal echocardiography.
Chest. 1993 May;103(5):1617-8.
Transesophageal echocardiographic diagnosis of anomalous left coronary artery from the right aortic sinus.
Alam M, Brymer J, Smith S.
Heart and Vascular Institute, Henry Ford Hospital, Detroit 48202.
Patients with anomalous left main coronary artery arising from the right sinus of Valsalva and coursing posteriorly between the aorta and the pulmonary artery are prone to sudden death. We present a patient with this entity in whom the diagnosis was made by transesophageal two-dimensional echocardiography and coronary angiography.
Circulation. 1993 Sep;88(3):1136-41.
Diagnosis of intramural coronary artery in transposition of the great arteries using two-dimensional echocardiography.
Pasquini L, Parness IA, Colan SD, Wernovsky G, Mayer JE, Sanders SP.
Department of Cardiology, Children's Hospital, Boston, MA 02115.
BACKGROUND. An intramural coronary is an uncommon but potentially significant risk factor for transfer of the coronary arteries as part of the arterial switch operation for transposition of the great arteries. Preoperative diagnosis is advantageous becaus e it helps prevent accidental injury to the intramural coronary artery during transection of the aortic root and excision of the coronary artery ostium from the aorta. Therefore, we investigated the reliability of two-dimensional echocardiography for dete cting an intramural coronary artery in infants with d-transposition of the great arteries. METHODS AND RESULTS. All infants with d-transposition of the great arteries who underwent echocardiography and primary surgical repair at this institution between J anuary 1987 and June 1992 were identified by search of the cardiology data base. From this group, all patients diagnosed with an intramural coronary artery were identified by review of the echocardiographic, surgical, and autopsy reports. Among 435 infant s with transposition, 29 infants were diagnosed as having an intramural coronary artery. In 27 cases, the diagnosis was confirmed at surgery or autopsy, and there were two false-positive echocardiographic diagnoses (specificity, 99.5%). Twenty of the 27 p atients with an intramural coronary artery were correctly diagnosed prospectively by echocardiography (sensitivity, 75%), including 17 of 23 patients with an intramural left coronary artery or left anterior descending coronary artery and 3 of 4 patients w ith an intramural right coronary artery. Two primary diagnostic criteria were identified: a major coronary artery arising from the contralateral septal sinus, near the usually intercoronary commissure, and a course for this vessel within the posterior aor tic wall between the great arteries, creating a "double-border" appearance. Retrospective review using these criteria identified 26 of the 27 intramural arteries with no false-positive diagnoses. CONCLUSIONS. We conclude that coronary echocardiography is a very promising technique for detecting an intramural coronary artery in transposition of the great arteries. Careful prospective application of the identified diagnostic criteria should greatly improve the diagnostic accuracy.
Circulation. 1993 Dec;88(6):2532-40.
The role of transesophageal echocardiography in identifying anomalous coronary arteries.
Fernandes F, Alam M, Smith S, Khaja F.
Henry Ford Heart and Vascular Institute, Henry Ford Hospital, Detroit, Mich. 48202.
BACKGROUND. The study objective was to evaluate the role of transesophageal echocardiography in identifying the origin of anomalous coronary arteries and confirming their course in relation to the great vessels. The diagnosis of coronary anomalies is made by angiography. The anomalous left main artery with a course between the pulmonary artery and the aorta has been associated with myocardial infarction and sudden death. The course of these anomalous coronary arteries is difficult to demonstrate by angiog raphy alone. METHODS AND RESULTS. Nine patients with angiographically confirmed anomalous coronary arteries were studied by transesophageal echocardiography with color flow Doppler. The abnormal origin of the anomalous coronary arteries was confirmed by t ransesophageal echocardiography in all nine patients. In four patients, the left main coronary artery originated from the right sinus of Valsalva. In all of these patients, transesophageal echocardiography demonstrated the course of the anomalous left mai n coronary artery between the aorta and pulmonary artery better than angiography. Other anomalies that were visualized included two patients with origin of the right coronary arteries from the left aortic sinus, one patient with origin of the left anterio r descending from the right sinus, one patient with origin of circumflex from the right sinus, and one patient with origin of the left main coronary artery from the pulmonary artery. CONCLUSIONS. Transesophageal echocardiography is a useful noninvasive te st for diagnosing anomalous origin of the coronary arteries. Furthermore, it is a valuable adjunct to angiography in demonstrating the abnormal course of the left main coronary artery interposed between the aorta and the pulmonary artery, a potentially li fe-threatening entity.
Am Heart J. 1992 Apr;123(4 Pt 1):1062-5.
Origin of the right coronary artery from the left main coronary artery identified by transesophageal echocardiography.
Smolin MR, Gorman PD, Gaither NS, Wortham DC.
Cardiology Service, Walter Reed Army Medical Center, Washington, DC 20307.
Presse Med. 1992 Jul 4-11;21(25):1172-4.
Birth anomalies of coronary arteries. Responsibility in myocardial ischemia
Salloum JA, Thomas D, Grosgogeat Y.
Service de Cardiologie, Groupe hospitalier Pitie-Salpetriere, Paris.
Anomalous origin of the left or right coronary artery from the contralateral sinus of Valsalva with coursing between the aorta and the pulmonary trunk way cause angina, myocardial infarction or sudden death. This anomaly should be suspected especially whe n ischemic symptoms occur in young patients without risk factor for atherosclerosis. We believe that surgical operation after demonstration of myocardial ischemia is indicated to prevent severe myocardial ischemia or sudden death.
J Am Coll Cardiol. 1992 Sep;20(3):640-7.
Sudden cardiac death associated with isolated congenital coronary artery anomalies.
Taylor AJ, Rogan KM, Virmani R.
Department of Medicine, Walter Reed Army Medical Center, Washington, D.C.
OBJECTIVES AND BACKGROUND. Congenital coronary anomalies are associated with sudden death and exercise-related death. Clarification of the risk and mechanisms of sudden death in patients with coronary anomalies may aid in decisions on intervention. METHOD S. The clinicopathologic records of 242 patients with isolated coronary artery anomalies were reviewed for information on mode of death and abnormalities of the initial segment (acute angle takeoff, valvelike ridges or aortic intramural segments) and cour se of the anomalous coronary artery. RESULTS. Cardiac death occurred in 142 patients (59%); 78 (32%) of these deaths occurred suddenly. Of sudden deaths, 45% occurred with exercise. Sudden death (28 of 49, 57%) and exercise-related death (18 of 28, 64%) w ere most common with origin of the left main coronary artery from the right coronary sinus. Anomalous origin of the right coronary artery from the left coronary sinus was also commonly associated with exercise-related sudden death (6 of 13 sudden deaths, 46%). High risk anatomy involved abnormalities of the initial coronary artery segment or coursing of the anomalous artery between the pulmonary artery and aorta. Younger patients (less than or equal to 30 years old) were significantly more likely than old er patients (greater than or equal to 30 years old) to die suddenly (62% vs. 12%, p = 0.0001) or during exercise (40% vs. 2%, p = 0.00001) despite their low frequency of significant atherosclerotic coronary artery disease (1% vs. 40%, p = 0.00001). CONCLU SIONS. Younger patients (less than or equal to 30 years old) with an isolated coronary artery anomaly are at risk of dying suddenly and with exercise. Therefore, greater effort for early detection and surgical repair of these lesions is warranted.
J Am Coll Cardiol. 1992 Sep;20(3):640-7.
Sudden cardiac death associated with isolated congenital coronary artery anomalies.
Taylor AJ, Rogan KM, Virmani R.
Department of Medicine, Walter Reed Army Medical Center, Washington, D.C.
OBJECTIVES AND BACKGROUND. Congenital coronary anomalies are associated with sudden death and exercise-related death. Clarification of the risk and mechanisms of sudden death in patients with coronary anomalies may aid in decisions on intervention. METHOD S. The clinicopathologic records of 242 patients with isolated coronary artery anomalies were reviewed for information on mode of death and abnormalities of the initial segment (acute angle takeoff, valvelike ridges or aortic intramural segments) and cour se of the anomalous coronary artery. RESULTS. Cardiac death occurred in 142 patients (59%); 78 (32%) of these deaths occurred suddenly. Of sudden deaths, 45% occurred with exercise. Sudden death (28 of 49, 57%) and exercise-related death (18 of 28, 64%) w ere most common with origin of the left main coronary artery from the right coronary sinus. Anomalous origin of the right coronary artery from the left coronary sinus was also commonly associated with exercise-related sudden death (6 of 13 sudden deaths, 46%). High risk anatomy involved abnormalities of the initial coronary artery segment or coursing of the anomalous artery between the pulmonary artery and aorta. Younger patients (less than or equal to 30 years old) were significantly more likely than old er patients (greater than or equal to 30 years old) to die suddenly (62% vs. 12%, p = 0.0001) or during exercise (40% vs. 2%, p = 0.00001) despite their low frequency of significant atherosclerotic coronary artery disease (1% vs. 40%, p = 0.00001). CONCLU SIONS. Younger patients (less than or equal to 30 years old) with an isolated coronary artery anomaly are at risk of dying suddenly and with exercise. Therefore, greater effort for early detection and surgical repair of these lesions is warranted.
Ann Thorac Surg. 1992 Oct;54(4):732-40.
Congenital malformations of the coronary arteries: the Texas Heart Institute experience.
Fernandes ED, Kadivar H, Hallman GL, Reul GJ, Ott DA, Cooley DA.
Department of Cardiovascular Surgery, Texas Heart Institute, Houston.
Coronary artery anomalies, some of which are considered clinically insignificant, can be associated with other congenital heart defects, myocardial ischemia, and reduced life expectancy. We conducted a retrospective study to determine the efficacy of surg ical treatment in 191 patients who had a total of 202 coronary artery anomalies, which were classified as anomalies of origin (88 patients), termination (93), or distribution (10). Of the 88 patients with anomalies of origin, 60 had a coronary artery aris ing from the pulmonary artery, 18 had a right coronary artery arising from the left anterior descending artery, and 10 had a coronary artery arising from the contralateral sinus of Valsalva. All patients with an anomaly of termination had a coronary arter iovenous fistula, and all patients with an anomaly of origin had a single coronary artery. The diagnostic and operative techniques for each of the defects are evaluated. Based on our experience, early diagnosis and surgical intervention can yield satisfac tory results in patients with coronary artery anomalies, with most experiencing relief of symptoms. The operative procedures were associated with a low early and late mortality; in addition, few patients experienced complications.
Orv Hetil. 1991 Jul 21;132(29):1581-6.
Coronary artery anomalies studied by Doppler echocardiography in infancy and childhood--possibilities and limitations
Kadar K, Vazsonyi J, Kiss A, Bendig L.
Orszagos Kardiologiai Intezet, Budapest.
We investigated infants with Kawasaki disease, congenital coronary artery fistulas and anomalous origin of the left coronary artery from the pulmonary trunc (Bland-White-Garland syndrome) by 2-dimensional and Doppler echocardiography. We describe the syst ematic approach for visualizing in detail coronary anatomy by two-dimensional echocardiography. Our results suggest that this echocardiographic technique is useful for detecting coronary anomalies and has a great rolbefore angiocardiography especially in sick babies. We recommend performing 2-dimensional echocardiography in the acute and chronic stage of Kawasaki disease for evaluating coronary arterial aneurysms.
J Am Coll Cardiol. 1986 Feb;7(2):366-73.
Left main coronary artery originating from the right sinus of Valsalva and coursing between the aorta and pulmonary trunk.
Barth CW 3rd, Roberts WC.
Findings are described in five patients who at necropsy were found to have origin of the left main coronary artery from the right sinus of Valsalva and coursing of the anomalously arising artery between aorta and pulmonary trunk to reach the left side of the heart. Three of the five patients were boys and died suddenly at ages 13, 14 and 19 years, respectively: two of them had had one or more episodes of syncope and the third had an abnormal electrocardiogram. The fourth patient, a 64 year old woman, died of chronic congestive heart failure 1 year after an acute myocardial infarction. She had insignificant coronary atherosclerosis. The fifth patient, an 81 year old man, died of chronic alcoholism, having been free of symptoms of cardiac dysfunction during life. Additionally, clinical and necropsy findings are summarized in 38 previously reported necropsy patients with the coronary anomaly. Of these 38 (34 male [89%]), 23 (61%) died suddenly in the first two decades of life; death in 6 others (16%) appears to have been related to coronary atherosclerosis and 9 patients (24%) died from noncoronary causes. Thus, this anomaly is life-threatening. Why it frequently causes fatal cardiac arrest in some young individuals and allows a normal life span in others re mains unclear.
Am J Cardiol. 1982 Mar;49(4):863-8.
Origin of the right coronary artery from the left sinus of valsalva and its functional consequences: analysis of 10 necropsy patients.
Roberts WC, Siegel RJ, Zipes DP.
Clinical and necropsy findings are described in 10 patients in whom the right coronary artery arose from the left coronary sinus and then passed to the right atrioventricular (A-V) sulcus by coursing between the aorta and the pulmonary trunk. In 7 of the 10 patients, the coronary anomaly never caused symptoms of cardiac dysfunction. In the other three, all of whom died suddenly, the coronary anomaly was the only significant abnormality found at necropsy: One patient had recurring ventricular tachycardis, one had typical angina pectoris and, in one, sudden death was the initial manifestation of cardiac dysfunction. Review of previous angiographic studies during life of 31 patients reported to have origin of the right coronary artery from the left sinus of Valsalva indicated that 9 had symptoms of cardiac dysfunction in the absence of intraluminal coronary narrowing or associated noncoronary cardiac disease. Thus, origin of the right coronary artery from the left sinus may produce cardiac dysfunction that c an be fatal.
Circulation, Vol 59, 748-754,1979
Aberrant coronary artery origin from the aorta. Report of 18 patients, review of literature and delineation of natural history and management
RR Liberthson, RE Dinsmore and JT Fallon
To clarify the natural history and management of patients with aberrant origin of a coronary artery from the aorta, we reviewed 18 patients whose right (RCA) or left (LCA) coronary artery arose aberrantly and passed between the aorta and right ventricular infundibulum. Nine patients had aberrant LCA. Three young males died suddenly after exertion, each with proximal focal LCA stenosis. None of the six adults with angina (ages 36-70 years) studied angiographically had proximal LCA stenosis. Unlike the youn g, "sudden death-prone" patients in whom coronary bypass of proximal stenosis may have prophylactic value, our older patients with aberrant LCA did not have proximal stenosis or sudden death, and therefore LCA bypass for sudden death prophylaxis is not wa rranted. Nine patients (ages 18-60 years) had aberrant origin and course of the RCA. Seven patients studied angiographically because of angina had no focal proximal RCA stenosis, but two patients had hypoplastic RCA ostia. Although a potential concern in these latter patients, sudden death has not been reported with aberrant RCA, therefore in the absence of syncope, RCA bypass for sudden death prophylaxis is not indicated.
Circulation. 1974 Oct;50(4):774-9.
Aberrant coronary artery origin from the aorta. Diagnosis and clinical significance.
Leberthson RR, Dinsmore RE, Bharati S, Rubenstein JJ, Caulfield J, Wheeler EO, Harthorne JW, Lev M.
Circulation. 1974 Oct;50(4):780-7.
Sudden death as a complication of anomalous left coronary origin from the anterior sinus of Valsalva, A not-so-minor congenital anomaly.
Cheitlin MD, De Castro CM, McAllister HA.
Am J Cardiol. 1967 Mar;19(3):420-3. Related Articles, Links
Fatal myocardial infarction in an 11 year old boy associated with a unique coronary artery anomaly.
Cohen LS, Shaw LD.
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