Overview of coronary artery variants, aberrations and anomalies

Abstract

Coronary artery anomalies and variants are relatively uncommon congenital disorders of the coronary artery anatomy and constitute the second most common cause of sudden cardiac death in young competitive athletes. The rapid advancement of imaging techniques, including computed tomography, magnetic resonance imaging, intravascular ultrasound and optical coherence tomography, have provided us with a wealth of new information on the subject. Anomalous origin of a coronary artery from the contralateral sinus is the anomaly most frequently associated with sudden cardiac death, in particular if the anomalous coronary artery has a course between the aorta and the pulmonary artery. However, other coronary anomalies, like anomalous origin of the left coronary artery from the pulmonary artery, atresia of the left main stem and coronary fistulae, have also been implicated in cases of sudden cardiac death. Patients are usually asymptomatic, and in most of the cases, coronary anomalies are discovered incidentally during coronary angiography or on autopsy following sudden cardiac death. However, in some cases, symptoms like angina, syncope, heart failure and myocardial infarction may occur. The aims of this article are to present a brief overview of the diverse coronary variants and anomalies, focusing especially on anatomical features, clinical manifestations, risk of sudden cardiac death and pathophysiologic mechanism of symptoms, as well as to provide valuable information regarding diagnostic workup, follow-up, therapeutic choices and timing of surgical treatment.

Keywords: Ectopic coronary arteries; Coronary artery anomalies; Coronary fistulae; Coronary artery variants; Myocardial bridging; Coronary artery anatomy; Sudden cardiac death

Core tip: Coronary artery anomalies and variants are a diverse group of congenital disorders of the coronary artery anatomy with a wide variety of clinical manifestations. Though relatively uncommon and usually discovered incidentally during coronary angiography, they have garnered interest because they are the second most common cause of sudden cardiac death in young competitive athletes. Though by no means entirely exhaustive, this overview aims to act as a guide for the practicing cardiologist along the complex web of these disorders and may facilitate the assessment, investigation, follow-up and treatment of patients diagnosed with or suspected of having a coronary artery anomaly.