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CLINICAL STUDY: PEDIATRIC CARDIOLOGY

Major coronary artery anomalies in a pediatric population: incidence and clinical importance

^a Department of Cardiology, Children’s Hospital and Regional Medical Center, Seattle, Washington, USA

Manuscript received May 11, 2000; revised manuscript received August 1, 2000, accepted October 12, 2000.

Reprint requests and correspondence: Dr. Michael A. Portman, Department of Cardiology, Children’s Hospital and Regional Medical Center, Cardiology/CH11, 4800 Sand Point Way NE, Seattle, Washington 98105
mportm{at}chmc.org

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 coronary 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 proximal 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 and 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 prevalence 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 are necessary.

Abbreviations and Acronyms   ALMCA = anomalous origin of left main coronary artery   AOCA = anomalous origin of a coronary artery   ARCA = anomalous origin of right coronary artery   CABG = coronary artery bypass graft   ECG = electrocardiogram   LAD = left anterior descending artery   LCA = left circumflex artery   LMCA = left main coronary artery   RCA = right coronary artery   TTE = transthoracic two-dimensional echocardiography

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