Reply
Dieter Ropers, MD, FACC*,
David Chew Soon Ping, MD,
Stephan Achenbach, MD, FACC
We very much welcome the response by Dr. Natarajan to our report (1) concerning the computed tomography (CT) appearance of anomalous left main coronary arteries. He voices his surprise that we did not classify anomalous left-sided right coronary arteries as harmful. Indeed, there is a remarkable divergence of opinions concerning the relevance of a left-sided origin of the right coronary artery with subsequent passage between the aorta and pulmonary artery. In an excellent review article concerning this issue, Gersony (2) provides a thorough review of the available data. Because anomalous right coronary arteries are substantially more frequent than left coronary arteries with an anomalous origin, many large series failed to demonstrate an association of anomalous right coronary arteries with sudden death (in a study with 6.3 million individuals followed, there were 21 exercise-related sudden deaths in patients with an anomalous left coronary artery but not a single one associated with the much more prevalent situation of an anomalous right coronary artery [3]), and a recent report describes the frequent occurrence of ischemia after surgical repair of previously asymptomatic anomalous right coronary arteries (4), he makes a convincing argument toward the benign nature of anomalous right coronary arteries for which he does not recommend any treatment, as long as the patients are asymptomatic. Symptomatic patients with signs of ischemia clearly require a different approach, and we should probably have made this distinction more clearly in our brief article.
We welcome this discussion, because coronary CT angiography frequently reveals coronary variants. In all cases, the potential associated dangers need to be weighed against the risk of treatment: first, do no harm. Complications after treatment of coronary anomalies are not zero, and it is imperative that we do not recommend therapies that cause more problems than the entity they are intended to cure.
* Department of Internal Medicine 2 (Cardiology), University of Erlangen, Ulmenweg 18, 91054 Erlangen, Germany (Email: dieter.ropers{at}uk-erlangen.de).
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REFERENCES
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- Ropers D, Ping DCS, Achenbach S. Right-sided origin of the left main coronary artery: typical variants and their visualization by cardiac computerized tomography J Am Coll Cardiol Img 2008;1:679-681.[Free Full Text]
- Gersony WM. Management of anomalous coronary artery from the contralateral coronary sinus J Am Coll Cardiol 2007;50:2083-2084.[Free Full Text]
- Eckart R, Scoville S, Campbell C, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits Ann Intern Med 2004;141:829-834.[Abstract/Free Full Text]
- Brothers JA, McBride MG, Seliem MA, et al. Evaluation of myocardial ischemia after surgical repair of anomalous aortic origin of a coronary artery in a series of pediatric patients J Am Coll Cardiol 2007;50:2078-2082.[Abstract/Free Full Text]
Related Article
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Cardiac Computed Tomography to Visualize Typical Variants of the Right-Sided Origin of the Left Main Coronary Artery
- Deepak Natarajan
J. Am. Coll. Cardiol. Img. 2008 1: 815-816.
[Full Text]
[PDF]
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