coronary angiography from basic to troubleshooting

1. Coronary Angiography
LV angiogram
Coroanry anomalies
By Dr Salman Ahmed
Post fellow intervention cardiology

2. Definations
• “Coronary angiography is a procedure that
uses a special dye (contrast material) and x-
rays to see how contrast material filled
blood flows through the coronary arteries of the
Heart”
• The technique was first performed by Dr. Mason Sones at
the Cleveland Clinic in 1958

3. Importance
• it is possible to define all portions of the coronary arterial
circulation down to vessels as small as 0.3 mm, free of any
artifacts owing to vessel overlap or foreshortening.
• It remains Gold standard for detection of significant coronary
artery disease
• Also Provides Therapeutic option for the culprit lesion through
same acess site

4. Indications
coronary arteriography is indicated when a problem is
encountered whose resolution may be aided by the objective
demonstration of the coronary anatomy, provided competent
personnel and adequate facilities are available and the potential
risks are acceptable to the patient and physician

5. Indications
Suspected coronary artery disease and high pretest probabilty
ACS:
Acute ST eleveation MI
NSTE ACS with high risk features
SIHD
• CCS class III and IV angina on medical treatment.
• High-risk criteria on noninvasive testing .
• Patients who have been successfully resuscitated from sudden
cardiac death or have VT

6. • Other indications
• Presurgical Cardiac surgery (valvular heart disease, pericardial
disease.
Or non cardiac surgery with high risk features
• Survivor of sudden cardiac death/ ventricular arrythmias
• Etiology of heart failure
• Periodic assesment of cardiac transplantation

7. Contraindications
• No absolute contraindication
• Anemia
• Renal dysfunction
• Active infection
• High bleeding risk INR > 1.8
• Contrast Allergy
• Electrolytes imabalance

8. Requisite for coronary
angiogram:
 Cardiac cath lab.
 Puncture needle
 Introducer
 Short guide wire
 Cordis sheath with dilator
 Diagnostic cathters
 contrast media (ionic/non ionic)

9. For all catheterization
laboratories, the x-ray
source
is under the table and the
image intensifier is
directly on top of the
patient

10. Steps of Coronary Angiogram:
Step 1 ( pre cath):
 Written consent.
 Fasting for at least 4 hours
 Pre cath investigations.
 Selection of arterial access point.
 Shaving of the groin/ wrist according to the choice.
 Opening the I/V line.
 Connect with the cardiac monitor.
 Oral or I/V sedatives.

11. Cont….
Step 2:
 Radiation protection for the health care personnel.
 An area of the arm or groin, is cleaned and numbed with a local
numbing medicine (anesthetic 15 ml).
 Draping of the patient.
 Using local anesthetics around the puncture site.
 Puncture and introducing the short guide wire through the
puncture needle.
 Introducing the sheath and removal of dilator along with short guide
wire.
 Flush the channel with heparinized solution.

12. Cont….
Step 3:
 The cardiologist passes a thin hollow tube, called a catheter, through an artery
and carefully moves it up into the heart.
X-ray images help the operator positioning the catheter.
 Once the catheter is in place, dye (contrast material , better to use <30 ml to
prevent CIN) is injected into the catheter.
X-ray images are taken to see how the dye moves through the artery. The dye
helps highlight any blockages in blood flow.
 The procedure may last 30 to 60 minutes.

13. Coronary Anatomy
 The left and right coronary cusp give rise to their respective coronary arteries.
 The major epicardial vessels are the left main coronary artery that divides into
the Left anterior Descending artery and Left Circumflex Artery, anrespective
coronary arteriesd the Right Coronary artery.

14. Dominance
 Coronary dominance is based on the vessel that gives rise to the posterior descending
artery which supplies the Atrio-ventricular node.
 Recognized by the presence of septal perforating branches, arises from the RCA in
80% and from the LCX in 10% of the population.
 Co-Dominance is found in 10% of the population where the posterior drscending artery
is formed by both the RCA and LCx.

15. Left Main Coronary Artery (LMCA)
 The Left main coronary artery originates from the left coronary cusp and bifurcates to give
rise to the Left anterior descending and Left Circumflex arteries.
 Long LMCA when the length is > 15 mm.
 Short LMCA when the length is ≤ 5 mm.
 Occasionally, a third branch vessel, the Ramus Intermedius arises from the LMCA.
 In a small number of patients, the two major branch vessels arise
from separate origins.

16. Left Anterior Descending Artery (LAD)
 LAD provides blood supply to the anterior wall of the left ventricle.
 It provides multiple septal branches to the interventricular septum and
diagonal branches to the anterior lateral wall.
 The LAD in some patients wraps around the apex to supply a small amount
of the posterior apex.

17. Left Circumflex Artery (LCx)
 LCx courses around the lateral or left atrio-ventricular groove and gives
rise to multiple marginal or lateral branches. The branches are termed
obtuse marginal (OM) branches.
 OM branches are sequentially numbered (OM1, OM2 etc…).
 As the LCx courses the AV groove it also gives rise to atrial branches, and
occasionally the sino-atrial branch (40% of the population).

18. Right Coronary Artery (RCA)
 RCA arises from the right coronary cusp and follows the right AV groove.
 The most proximal branches of the RCA are the conus- branch which
supplies the Right ventricular outflow tract and a branch that supplies the
sino-atrial (SA) node (60% of patients).
 RCA gives off the postero lateral and posterior descending branches at the
crux cordis

19. Normal coronaries (LCA)

20. Normal coronaries (RCA)

21. Angiographic views
 Anatomic landmarks formed by the spine,
catheter and diaphragm
provide information to view the image.
In the LAO view the catheter and spine are seen on the left side of the
image, while in the RAO they are found on the right.

22. Cont…
PAimaging places these landmarks in the center.
Cranial can usually be distinguished from caudal angulations by the
presence of the diaphragm. For cranial imaging, the patient should be
asked to inspire to remove the diaphragmatic shadow from the image.

23. Left Coronary System
 Generally, for circumflex and proximal visualization the
LAD caudal views are most useful.
 For LAD and LAD/diagonal bifurcation visualization, the
cranial views are most useful.

24. Angiographic views
 Left Main : AP, LAO cranial, LAO caudal
 Proximal LAD : LAO cranial, RAO caudal
 Mid LAD : LAO cranial, RAO cranial,
Lateral
 Distal LAD : AP, RAO cranial, Lateral
 Diagonal : LAO cranial, RAO cranial

26. Angiographic views
 Proximal circumflex
 Intermediate
 Obtuse marginal
 Proximal RCA
 Mid RCA
Distal RCA
PDA
Posterolateral
: RAO caudal, LAO caudal
: RAO caudal,LAO caudal
: RAO caudal, LAO caudal, RAO
cranial and RAO
: LAO, LAO caudal
: LAO, Lateral,RAO 30
: LAO cranial, AP Cranial,Lateral
: LAO/AP cranial
: LAO cranial, RAO cranial

27. Grading stenosis
The severity or degree of stenosis is measured by comparing the area
of narrowing to an adjacent normal segment, and as a percentage
reduction and calculated in the projection which demonstrates the
most severe narrowing.

28. Classification of distal angiographic
contrast runoff (TIMI Grade)
TIMI Grade Contrast Flow
0 (No perfusion) Antegrade flow to lesion; no flow beyond occlusion
1 (Penetration with minimal perfusion) Contrast passes beyond
lesion but does not opacify distal vessel
during cine run
2 (Partial perfusion) Contrast passes obstruction
and fills distal vessel.However, rate
of filling and/or washout slower than
vessel segments outside lesion
3 (Complete perfusion) Contrast passes freely into distal at
same visual rate as unaffected adjacent vessels

29. Grading of collateral circulation
Grade Collateral appearance
0
1
No collateral circulation
Very weak reopcification
2 Reopacified segment, less dense than the feeding
vessel and filling slowly.
3
Reopacified segment as dense as the feeding
vessel and filling rapidly

30. Techniques of Cannulating Coronary Arteriesand Grafts
LeftCoronaryArtery
A short left main and separate ostia for left anterior descending and circumflex
arteries can present problems forcannulation.
In these casesit may be necessary to cannulate theLADand circumflex (CX)
arteries separately.
AnAmplatz-type catheter is especially useful to cannulate theCXartery separately but
must be used with care to avoid arterial dissection.
An unusually high origin of the left main coronary artery from the Aorta usually can be
cannulated using amultipurpose catheter or anAmplatz-type catheter (e.g.,AL2).

31. Techniques of Cannulating Coronary Arteriesand Grafts
RightCoronary Artery
The origin of the right coronary artery shows more variation than
that of the left coronary artery.
Acontrast injection low into the right coronary cusp will show the origin of the right
coronary artery and help the angiogapher direct the catheter.
If the right coronary artery is not seen with this injection, it may be totally occluded
or may have an anomalous origin, anteriorly on the Aorta or from the left sinus of
Valsalva.
A left Amplatz catheter or aleft bypass graftcatheter canbe used successfully to
engage the right coronary artery orifice located anteriorly or in the left cusp.

32. SaphenousVeinBypass Grafts
In general, saphenous vein bypassgrafts are anastomosed to
the anterior wall of the ascendingAorta.
Theright coronary artery graft usually is anastomosed afew
centimeters above and anterior to the rightcoronary
orifice.
Left anterior descending and diagonal grafts usually are
anastomosed somewhat higher and slightly to the left.
Obtuse marginal grafts are usually the highestand furthest left.
Techniques of Cannulating Coronary Arteriesand Grafts

33. Techniques of Cannulating Coronary Arteries and
Grafts
Internal Mammary Artery Graft Cannulation
The left internal mammary artery (IMA) originates anteriorly fromthe
caudal wall of the subclavian artery distal to the vertebral artery origin.
The left subclavian artery can be entered using aright Judkinscatheter but a
more sharply angled catheter tip on the IMA catheter is preferred.
.

34. Techniques of Cannulating Coronary Arteries and
Grafts
Internal Mammary Artery Graft Cannulation
Thecatheter tip is deflected cranially, usually engaging theleft subclavian artery at
the top of the aortic knob in the anteroposterior projection.
Oncethe subclavian artery is engaged, the catheter isadvanced over aJ-tipped or
flexible straight tip guidewire beyond the internal mammaryorifice.
After the catheter hasbeen advanced beyond the internal mammary artery takeoff, the
guidewire is withdrawn slowly and small contrast injections are given to visualize the
internal mammary artery orifice.
Because of the peculiar tip configuration, the internal mammary curve catheter and
especially the C-type IMA catheter usually engages into the IMA ostium without
much difficulty.

35. Techniques of CannulatingCoronary Arteries and Grafts
RightInternal Mammary Artery Graft Cannulation
Right internal mammary artery cannulation is less commonand more difficult than
left internal mammary artery cannulation.
Theright brachiocephalic truncus is entered using aright Judkins catheter by
deflecting the tip with a counterclockwise rotation at the level of the
brachiocephalic truncus.
Thecatheter is advanced into the subclavianartery.
The rest of the manipulation is similar to that described for left internal mammary
artery graftcannulation.

36. Complication:
Life threatening complications are rare (~1 in 1000) but more common in patients with serious
disease, eg. Left main stem disease, aortic or peripheral vascular disease.
Major complications:
1. MI
2. Stroke
3. Renal failure
4. Aortic or coronary dissection
5. Cardiac rupture
6. Air embolism
7. Arrythmia
8. Peripheral vascular damage
9. Death (0.1%)

37. Cont…
Minor complication:
1. Haematoma (at the puncture site)
2. Angina
3. Vaso vegal reaction
4. Allergies to contrast agents and drugs

38. Management of
complication:
Hematoma:
► Most hematomas don't need intervention. Only analgesia.
If it is tense, expansile,bruit or very tender then the altenative diagnosis will be femoral
artery pseudoaneurysm.
Pseudo aneurysm:
Represents partial rupture of the femoral artery with formation of false aneurysm. Diagnosed
by ultra sound.
► small – prolong compression for 20-30 min under ultra sound
guidance.
► large – needs surgical repair.

39. Cont….
Hemorrhage:
► Despite prolong pressure more than 30 min then use mechanical clamp or
haemostatic device .
►Check for coagulation profile.
►Toreverse the effect of heparin use protamine
►Retroperitoneal hemorrhage
Limb Ischemia:
► Rare but usually occurs in patients with significant
peripheral vascular disease.
► Check for the peripheral pedal pulses before and after angiogram
for comparison.

40. Cont…
Contrast reaction:
► Mild reaction: UrticariaI, mild fever and rigors- I/V or oral
chlorpheniramine 10mg.
I/V hydrocortisone (100-200 mg)
I/V chlorpheniramine (10mg)
Opiate analgesia
Anaphylaxis:
► I/V hydrocortisone 200mg,
► I/V chlorpheniramine 10 mg
► I/M adrenaline 0.5-1 mg
► Plasma expander

41. Cont…
Vaso-vegal reaction:
The patient will develop hypotension and bradycardia .
► Disengage catheter
► I/V atropine 1 mg
► I/V normal saline 200-500 ml rapidly.

42. Contrast
nephropathy(CIN):
 Radiocontrast media can lead to a usually reversible form of acute
kidney injury (formerly called ARF) that begins soon after the contrast is
administered .
In most cases, there are no permanent sequelae, but there is some evidence
that its development is associated with adverse outcomes.
 Contrast-mediated nephropathy (CIN) was defined by an absolute increase
of serum creatinine ≥0.5 mg/dL or a relative increase of ≥25% measured 2
to 5 days after the procedure. (AHA)

43. Prevention of CIN:
least Limit the contrast
 hold nephrotoxic drugs 48 hours
 Sodium chloride 0.9% 1 mL/kg/h for at
12h prior and after the procedure
N-acetyl cystein and bicarb are not beneficials

44. Follow up:
 Check for the peripheral pulses, local temperature of the limbs and any
abnormal feelings like numbness,coldness etc.
 Check for the hematoma, rashes, loin pain.
 Ask the patient for any chest pain or discomfort.
 Check for the urinary out put.
 Advice the patient to immobilize the limb where the procedure was
done for several hours.

45. Left ventriculogram

46. LV angiogram (advantages)
• Examination of the left ventriculogram helps identify viable
myocardium.
• LV angiography also documents mitral regurgitation
• Diagnosis of cardiomyopathy (TAKOTSUBO CMP)
• As a part of some congenital heart disease assesment
• LVEDP can provide important prognostic and therapeutic
decisons

47. Equipments
1.INJECTION CATHETERS
• -angled(145-155) pigtail catheters
• -straight tip ventriculographic catheters- sones catheter,
• Multipurpose catheter.
• -Balloon tip ventriculographic catheters- Berman

48. Equipments
2.Power injectors – flow injectors
(Medrad)- controls the
volume and rate of
delivery- maximal
pressure limit of 1000psi (600-800)

49. PROCEDURE
ar
 Approach to LV–
Retro aortic ,injection directly into the ventricles
Anterograde/trans septal approach
 Optimal catheter position –midcavitary adequate
delivery to body and apex will not interfere with MV
function avoid VPC,s
less endocardial staining and ventricul ectopy

50. PROCEDURE..
 Cine left ventriculography with
contrast vol – 30-36ml
rate – 10-12ml/sec(pig tail)
- 7-10 ml/sec(sones)
600-800 PSI
aging during normal quite breathing.

51. FILMING PROJECTION AND TECHNIQUE
 Cine left ventriculography
– 15-30 frames/sec
 Typically 30 deg RAO and 60 deg
LAO views are obtained
 30 deg RAO
eliminates overlap of LV
and the vertebral column
anterior apical inferior
segmental wall motion
mitral valve profile ideal for
assessment of MR

52. FILMING PROJECTION..
 60 deg LAO
-assess ventricular septal
integrity and motion
-lateral and posterior
segmental function
- aortic valvular anatomy
-15-30 deg cranial angulation
for profiling entire IVS

53. NORMAL LV ANGIOGRAM -SCHEMATIC

54. VIEWS FOR SPECIFIC CONDITIONS
CONDITION VIEW
LV FUNCTION 30 RAO/60 LAO
MEMBRANOUS VSD 70 LAO 30 CRANIAL / RAO
MUSCULAR VSD 4-C PROJECTION(45LAO-45CRANIAL)
70 LAO 30 CRANIAL / RAO
AVSD 4-C PROJECTION(45LAO-45CRANIAL)
45RAO-45CRANIAL
LVOTO 70 LAO 30 CRANIAL / RAO
DORV 70 LAO 30 CRANIAL / RAO
D-TGA 70 LAO 30 CRANIAL / RAO
L-TGA RAO CRANIAL/LAO CRANIAL

55. LV FUNCTION ASSESSMENT
 Cineventriculography was the
first method introduced in the
routine practice to determine
the LVEF.
 The area-length technique is
the most widely used method to
quantify the left ventricular
function.ricular diastolic and
systolic volumes.

56. STEPS IN LV VOLUME CALCULATION
 1.Tracing LV outline or
silhoutte
 2.Marking aortic valve border
 3.Calculation of LV volume
by computer based
algorithms
 4.Magnification
correction
 5.Applying Regression
Equation

57.  Angiographic stroke
volume,SV = EDV – ESV
 Ejection fraction,EF = (EDV
– ESV) / EDV
 LV wall thickness,h is measured
at end diastole at LV free wall
2/3 distance from aortic valve
to apex in RAO
 LV Mass = Vc+w - VC
CALCULATION OF LV MASSCALCULATION OF LV EF

58. LV FUNCTION ASSESSMENT..

59. REGIONAL LV DYSFUNCTION
 Regional wall motion can be graded qualitatively as normal,
hypokinetic, akinetic, dyskinetic,or hyperkinetic.
 The analyses of the RAO and LAO projections as
the following segments:

60. MITRAL REGURGITATION
 Diagnosis and assessment of severity of MR
DEGREE VENTRICULOGRAPHIC CRITERIA
1+ Faint opacification of the left atrium with clearing of
contrast during each beat
2+ Opacification of the atrium that does not clear but is
not as dense as the left ventricle
3+ Opacification of the atrium with the same density as
the ventricle
4+ Immediate, dense opacification of the atrium with filling of the
pulmonary veins

61. HYPERTROPHIC CARDIOMYOPATHIES
 In HCM, cavity obliteration is
commonly seen together with small
ventricular end- systolic volumes .
 Systolic anterior motion of the mitral
valve may result in severe degrees
of mitral regurgitation.
 The ventriculogram in the apical
variant typically appears with a
“spade”- shaped contour.

62. TAKOTSUBO CARDIOMYOPATHY
 Diffuse akinesis of LV apex
with preserved basal
contractilty.
 Characteristically resemble the
shape of a japanese octopus
trap(tako-tsubo)

63. VENTRICULAR SEPTAL DEFECT
 A standard view in the
evaluation of patients with
ASDs or muscular VSDs is the
hepatoclavicular view at 30◦
to 45◦ LAO and
30◦ to 45◦ cranial

64. NORMAL LEFT VENTRICULOGRAM

65. TAKOTSUBO cardiomyopathy

66. Mitral regurgitation

67. Ventricular septal defect

68. contraidcations
 Relative contraindiccations includes
• Severe aortic stenosis
• Sever lv dysfunction
• Left mainstem disease
• LVEDP> 25 mmhg

69. COMPLICATIONS…
 Ventricular extrasystole – mechanical
stimulation
 Ventricular tachycardia – mostly NSVT
 Intramyocardial injection/endocardial
staining
 Myocardial perforation
 Left anterior fascicular block
 Transient complete heart block
 Embolism- air/thrombus
 Complications of contrast
media

70. Congenital Anomalies of the Coronary
Circulation

71. Congenital Anomalies of the Coronary
Circulation
• Coronary artery anomalies are defined as those angiographic findings
in which the number, origin, course, and termination of these arteries
are rarely encountered in the general population.
• May occur in 1% to 5% of patients undergoing coronary arteriography.

72. Maron BJ et al. N Engl J Med
2003;349:1064-1075.

73. Congenital Anomalies of the Coronary
Challenges
• Documentation of precise ischemia
• Ischemia risk for some of these anomalies by conventional exercise stress
testing or intravascular Doppler flow studies is poorly predictive.
• Malignant features of anolamous coronaries include
– slitlike ostium
– acute angle of takeoff
– intramural course
– compression between the aorta and the pulmonary trunk

74. Angelini P et al. Coronary Artery Anomalies: A Comprehensive Approach 1999.

75. Coronary Artery Anomalies
• Overall 1,686 patients of 126,595 catheterization patients in one
database.
• 196 of 126,595 cases involved coronary origin from opposite sinus
Yamanaka, O. Catheterization and Cardiovascular Diagnosis. 21:28 1990.

77. Coronary Artery Anomalies
• Benign:
– LCx from Right sinus or RCA.
– separate LAD and LCx ostia.
– Split RCA
• Potentially serious:
– Anomalous left coronary artery from the pulmonic artery. (ALCAPA)
– Anomalous right coronary artery from the pulmonic artery (ARCAPA)
– Coronary Artery fistula (CAF)
– Anomalous coronary artery from the opposite sinus of
Valsalva (LM or LAD from R sinus or RCA from L sinus)
Yamanaka, O. Catheterization and Cardiovascular Diagnosis. 21:28 1990.

78. Bashore, T.M. ACCSAP8, 2012

79. Anomalous Coronary Artery from the
Opposite Sinus (ACAOS)
Paolo Angelini Circulation. 2007;115:1296-1305
4 subtypes of ACAOS:
1. Retrocardiac
2. Retroaortic
3. Preaortic, or between the aorta and
pulmonary artery
4. Intraseptal (supracristal)
5. Prepulmonary (precardiac).

80. Anomalous Coronary Artery from the
Opposite Sinus (ACAOS)
• Means LM or LAD origin from the proximal RCA or the right aortic sinus or vice
versa, with subsequent passage between the aorta and the right ventricular
outflow tract has been associated with sudden death during exercise in
young persons.
• Also includes RCA arising from LSOV and interarterial course
•LCX originating from RCA or right sinus of Valsalva not included in this

81. Anomalous Coronary Artery from the
Opposite Sinus (ACAOS)
• In rare cases of anomalous origin of the LCA from the right sinus,
myocardial ischemia may occur even if the LCA passes anterior to the
right ventricular outflow tract or posterior to the aorta.
• Although CABG has been the traditional revascularization approach in
patients with ACAOS, coronary stenting also has been reported to yield
acceptable medium-term success.

82. LCx from RCA
Braunwald’s Heart Disease 10th edition

83. Benign
Braunwald’s Heart Disease 10th edition

84. ACAOS

85. RCA from left coronary sinus
Braunwald’s Heart Disease 10th edition

87. Braunwald’s Heart Disease 10th edition

88. Anomalous Coronary from Opposite sinus of
Valsalva, How Frequent?
• 301 patients out of 210,700 cardiac
catheterizations.
• 79% of the 301 were anomalous RCA from L sinus.
• 21% of the 301 were anomalous LM or LAD from R sinus.
• 54 of the 301 (21%) had interarterial course.
Krasuski et al. Circulation. 2011;123:154-162

89. Anomalous Coronary Artery from the
Opposite Sinus (ACAOS), Diagnosis?
• Diagnosis
– Angiography
• ROA
• “laid-back” aortogram
– Cardiac CT with 3D.
– CMR

90. ACC/AHA Adult Congenital Guidelines for Management of
Anomalous Coronary Origin
• Class I:
– Surgical coronary revascularization for:
• Anomalous LM from R sinus with course between Aorta and PA(LOE B)
• Anomalous RCA from L sinus with course between the
great vessels and documented ischemia (LOE B)
• Documented ischemia with anomalous coronary course between the great
arteries (LOE B)
Warnes CA, et al. Circulation, 118:714, 2008.

91. ACC/AHA Adult Congenital Guidelines for Management of
Anomalous Coronary Origin
• Class IIa:
– Surgical coronary revascularization can be beneficial in the setting
of documented vascular wall hypoplasia, coronary compression,
or obstruction to coronary flow, regardless of documented
ischemia (LOE C).
• Class IIb:
– Surgical revascularization may be reasonable in patients with
anomalous LAD artery coursing between the aorta and PA (LOE
C).
Warnes CA, et al. Circulation, 118:714, 2008.

92. Anomalous Pulmonary Origin of the Coronary
Arteries (APOCA)
• The most common variant of this syndrome is an anomalous origin of
the LCA from the pulmonary artery (ALCAPA).
– Other variants: ARCAPA or single left vessel (LCx or LAD)
• Untreated, in the absence of an adequate collateral network, most
infants (95%) die within the first year. In the presence of an extensive
collateral network, patients may survive into adulthood, likely with ICM.

93. Anomalous Origin of the LCA from the
Pulmonary Artery (ALCAPA)
• Aortography findings:
 Large RCA
 Absence of a left coronary ostium.
 Late phase of the, LAD and LCx branches fill by collateral circulation from RCA
branches.
 Later in the filming sequence, retrograde flow from the LAD and LCx arteries
opacifies the LMCA and its origin from the main pulmonary artery.
• Findings can be confirmed with Cardiac CT.

94. Anomalous Origin of the LCA from the
Pulmonary Artery (ALCAPA)
Braunwald’s Heart Disease 10th edition

95. Anomalous Origin of the LCA from the
Pulmonary Artery (ALCAPA)

96. The Surgical Approach to ALCAPA
1. In young children, ligation and a left subclavian artery to LAD artery
• approach can be used.
2. Ligation with subsequent bypass grafting can be done, though competitive flow
places a disadvantage for graft survival on either the left internal mammary
artery or saphenous vein bypass.
3. The Takeuchi procedure can be performed. This amounts to creating an
aortopulmonary window, then placing a tunnel from the aorta to the orifice of the
anomalous coronary. The tunnel traverses the PA to supply blood directly into the
coronary.
4. The coronary and a button of tissue can be removed from the PA and then
reattached to the aorta. Current guidelines recommend noninvasive testing for
ischemia every 3-5 years after repair of ALCAPA.

97. Coronary Artery Fistulas
Abnormal Destination
• Coronary artery fistula is defined as an abnormal communication between a
coronary artery and a cardiac chamber or a major vessel.
• RCA in involved in about 50% of the cases.
• May become quite large and create a measurable left-to-right shunt.
• Coronary arteriography is the best method for demonstration of the origin of these
fistulas. Also echo, MRI and CT
– Congenital
– Iatrogenic

98. Congenital fistula to the pulmonary artery
Braunwald’s Heart Disease 10th edition

99. Coronary Artery Fistulas, Treat or not to treat?
• The decision as to when to close these fistulae remains controversial.
• Should be closes if:
– volume overload due to the shunt.
– myocardial ischemia (due to coronary steal)
– arrhythmia.
– unexplained LV dysfunction
• Many can be closed using percutaneous catheter methods.

100. ACC/AHA Adult Congenital Guidelines for Management of
Anomalous Coronary Origin
• Class I
– If a continuous murmur is present, its origin should be defined by
echocardiography, MRI, CT angiography, or cardiac catheterization (LOE C).
– A large fistula should be closed, regardless of symptomatology, via either a
transcatheter or surgical approach, if feasible (LOE C).
– A small or moderate fistula should be closed if there is evidence for
myocardial ischemia, arrhythmia, or otherwise unexplained systolic or
diastolic dysfunction or enlargement, or endarteritis, if feasible (LOE C).
Warnes CA, et al. Circulation, 118:714, 2008.

101. ACC/AHA Adult Congenital Guidelines for Management of
Anomalous Coronary Origin
• Class IIa
– Clinical follow-up with echocardiography every 3-5 years can be
useful for patients with asymptomatic, small fistula to exclude the
development of chamber enlargement (LOE C).
Warnes CA, et al. Circulation, 118:714, 2008.

102. Thank you