Rare anomalous of left coronary artery

[Gisela_Maria]

Dear experts,

I am a cardiologist from Berlin, Germany. I have a female patient with mysterious symptoms. She became seriously ill at age 16 and complaints of heart problems. The female patient with childhood lagging behind in physical development. With 11 years of she has supraventricular tachycardia. She has a myocardial bridging of the mid and distal LAD and possibly variant angina. I suspect that the patient has a coronary artery crossing, but not sure. In our country, there were no such cases. I ask you to help, if possible.
Do you experience a the crossing of the coronary arteries? Or maybe you heard about such cases?
I know that crossing is not a normal variant. I talked to two experts who had patients with similar cases, but there is no clarity.
My questions: Necessarily if there is whether the crossing branch of the left coronary artery( LAD and LCx)(or major branches of the coronary arteries) should have separate origins? For example, should the LAD and LCx necessarily have a separate origin from the left aortic sinus? Or LAD artery must necessarily come from the left aortic sinus and LCX from the right aortic sinus? Must necessarily LCx crossed inferior to the LAD artery?
Could the patient be left behind in physical development because of myocardial bridging?

Best regards,

Gisela K. M.D.

[Jeffrey R Boris, M.D.]

Dear Dr. K,

I discussed our case with Dr. Julie Brothers, who is our resident expert on coronary artery anomalies.  We are not exactly sure what you mean by "crossing" of the coronary arteries.  If you could define that better, that would be helpful.  Certainly, the left anterior descending (LAD) and left circumflex (LCx) coronary arteries typically arise from the left main coronary artery.  However, there are normal variants in which these two arise from separate orifices in the left coronary cusp of the aortic valve.  There are reports of the LCx arising from the right coronary cusp of the aortic valve.  These are typically felt to be benign, ALTHOUGH there may be a higher risk of atherosclerosis in the LCx, especially if it passes in a retroaortic fashion.  We also don't understand what you mean by your question regarding the LCx crossing inferiorly to the LAD.  Finally, myocardial briding does not cause a delay in physical development unless it has been associated with severe myocardial dysfunction due to ischemia or infarction.  Certainly, persistent supraventricular tachycardia can cause a tachycardia-induced cardiomyopathy, which can obviously delay physical development.  

I hope that is at least somewhat helpful.  If you can further define or describe those statements for which we didn't quite understand, we can try to help you further.

[Jeffrey R Boris, M.D.]

Dear Dr. K,

I apologize in the delay in getting back with you, as we had the holidays lus I had one of our interventional cardiologist, Dr. Matt Gillespie, review the case.  He was not able to view the angiograms on Dropbox.  However, he felt that if there is no evidence of ischemia or infarction, the symptoms are not related to the coronary artery anatomy.  I will say that if you would like to more formally have this reviewed, please contact our Cardiac Center Nurse Navigators on our website, http://heart.chop.edu, so that they can coordinate a true second opinion, if this is required.

[Gisela_Maria]

The chances are almost there.
The patient already renal angiography was performed. It is normal.  The patient has a strong lag in physical development and angina-like attacks.

P.S. I wish all a Merry Christmas.

[MLWTR]

Any chance that a pheochromocytoma is causing some of this?

[Gisela_Maria]

Dear Dr.Boris,

I thank you for your good, detailed answer. I'll try to explain to you simply: Researcher from Cyprus wrote to me that when Crossing the left coronary artery must be those features, that I have listed in the letter in the form of questions. I wrote to him about the diagnosis of the patient. And I wrote to him, because he had one such case.

Here is an excerpt of his letter: The crossing between the LAD and LCx arteries seen in the LAO view is just because of the projection.
Previously reported cases of proximal crossing between these 2 vessels demonstrated separate origin of the
LAD and LCx from the left aortic sinus or a LAD artery origin from the left aortic sinus and a LCx artery origin
from the right aortic sinus. In such cases the LCx arises from a more anterior location relative to the LAD artery
and in order to join its normal location in the left atrioventricular groove it has to course posteriorly and to the left;
in all these cases the LCx crossed inferior to the LAD artery.

Anomalies of intrinsic coronary arterial anatomy(by P.Angelini):
4) Intramural coronary artery(muscular bridge)
6) Coronary crossing

As a rule epicardial coronary arteries do not cross one another.
Source: P.Angelini Normal and Anomalous Coronary Arteries in Humans.

For example: http://www.ncbi.nlm.nih.gov/pubmed/17612677

My patient (155 cm, 35 kg ) with early childhood developmentally delayed.
Her mother gave birth to her at 41. Throughout the pregnancy her mother worked on harmful manufacture and could not go on maternity leave.
The female patient was born weighing 900 gr. and from an early age had a low immunity, poor weight gain and often cold hands and feet. Due to frequent viral infections she missed many lessons, she learned individually.
Since the birth of her funnel chest on the left side. Experts from large clinic where she addressed and where she could not help doing her MRI and found that bone breastbone does not clamp the heart.
Already in childhood, other specialists have found a heart murmur. In the early school years she bore the usual load (cycling, brisk walking, fast sprint). Physical training lessons she could not attend.
Somewhere in 12 years or 14 she has stopped growing, and in 16,5 strongly fell ill. She had chest pain, shortness of breath, severe fatigue and drowsiness , sweating , elevated systolic and diastolic blood pressure especially, periodic pains in the legs . June 1, 2010 for the first time she had an attack of severe pain in the left lower jaw. At first, she had seizures several times a week, and then almost every day. The pain was unbearable and she was the very first to take nitroglycerin, and then nifedipin. .Nitroglycerin helped her sometimes , and only for weak attacks , sometimes with the help of nifedipine average , but did not act with strong attacks. In autumn 2010, she was discharged from the metoprolol tachycardia episodes of pain in the left lower jaw became less frequent .
These attacks occurred after administration of either black or green tea before a storm or during it, the heat and cold , with unstable geomagnetic conditions and lasted from a few minutes to 2-4 hours. Since May 2013 the pain appeared in the right lower jaw.More recently she had started to toes turning blue . The last 2 years she periodically suffer from severe insomnia.
There is a suspicion that the high blood pressure she had since childhood.
During tachycardia her pulse been 110-180. If her blood pressure elevated, it is from 110/90 to 160/100. Pulse in this case from 70-80 to 90-100 and sometimes up to 120.
In 2010, she had a blood test 2 days after a severe attack of pain in the left lower jaw. Then the level of CK-MB was 79.0. CK was normal.
In 2012 CK-MB level without attack - 29. LDH - 274.
I'm not sure, but I admit that the patient could have a silent ischemia since childhood.

In autumn 2012 , her underwent coronary angiography with ergonovine  . During the administration of ergonovine , she had severe pain in chest. To remove it , her was introduced nitroglycerin, but it did not help . During the administration of ergonovine left coronary artery disappeared (total occlusion). Variant angina?  It was the same after nitroglycerin.
Also appears to have step-up step-down phenomenon ( allusion to myocardial bridging ).
If necessary, her coronarography: https://www.dropbox.com/s/noy4tczflcnw71p/Coronary%20angiography.rar

In 2011, her made ​​CT of the heart and blood vessels, but to no avail. Disk with imaging she was not given.

Could all of this be due to tachycardia-induced cardiomyopathy?

P.S. Later, if you want I can put the results of X-ray and tomography.

Kind regards, Dr.Gisela K.