Schütze Jonathan, Stark Anselm W, Bigler Marius R, Räber Lorenz, Gräni Christoph
Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, CH - 3010 Bern, Switzerland.
Eur Heart J Case Rep. 2024 Jul 30;8(8):ytae380. doi: 10.1093/ehjcr/ytae380. eCollection 2024 Aug.
The notion that the 'interarterial' segment of anomalous aortic origin of a coronary artery (AAOCA) is 'malignant' and 'scissor-like' compressed between the aorta and pulmonary artery (PA) is debated, owing to the lower pressure in the pulmonary system compared with that in the coronary system. However, data supporting or refuting this belief under stress conditions are lacking.
Three cases of right AAOCA with interarterial/intramural courses (52, 66, and 51 years old) were assessed. Invasively measured fractional flow reserve (FFR) under dobutamine was 0.85, 0.82, and 0.81, respectively. Intravascular ultrasound illustrated lateral vessel compression of the intramural course with a decrease of minimal lumen area (MLA) (i.e. 5.71-3.47 mm, 5.88-4.00 mm, and 5.85-4.06 mm) under stress conditions with heart rates of 130, 140, and 150 b.p.m., respectively. Pulmonary artery pressure (PAP) increased from rest {s/d (m) [systolic/diastolic (mean)] 22/11 (15), 15/2 (5), and 24/6 (14) mmHg} to stress [s/d (m) 47/24 (36), 30/3 (11), and 36/22 (24) mmHg] and remained below aortic peak pressure (blood pressure, BP) rest [s/d (m) 116/64 (91), 94/48 (71), 99/53 and (62) mmHg]; BP stress [s/d (m) 142/63 (80), 123/63 (88), and 86/46 (62) mmHg]; coronary pressure (CoP) rest [s/d (m) 100/59 (80), 80/45 (62), and 83/47 (63) mmHg]; and CoP stress [s/d (m) 95/60 (69),101/54 (72), and 70/32 (50) mmHg].
This case series challenges the assumption that the interarterial segment of AAOCA is scissor-like compressed by both the aorta and PA. The decrease in MLA and FFR under stress is due to the aorta's unidirectional lateral compression on the intramural segment. Additionally, the term 'malignant' should not be universally applied to all AAOCA cases with an interarterial course, as not all result in haemodynamic significance.
冠状动脉异常起源于主动脉（AAOCA）的“动脉间”段在主动脉和肺动脉（PA）之间呈“恶性”和“剪刀样”受压的观点存在争议，因为肺循环系统压力低于冠状动脉系统。然而，缺乏在应激条件下支持或反驳这一观点的数据。
评估了3例右冠状动脉AAOCA伴动脉间/壁内走行的病例（年龄分别为52、66和51岁）。多巴酚丁胺负荷下经有创测量的血流储备分数（FFR）分别为0.85、0.82和0.81。血管内超声显示，在心率分别为130、140和150次/分钟的应激条件下，壁内走行的血管出现侧向受压，最小管腔面积（MLA）减小（即分别从5.71 - 3.47 mm、5.88 - 4.00 mm和5.85 - 4.06 mm减小）。肺动脉压力（PAP）从静息时{s/d (m) [收缩压/舒张压（平均压）] 22/11 (15)、15/2 (5)和24/6 (14) mmHg}升至应激时[s/d (m) 47/24 (36)、30/3 (11)和36/22 (24) mmHg]，且仍低于主动脉峰值压力（血压，BP）静息时[s/d (m) 116/64 (91)、94/48 (71)、99/53和(62) mmHg]；BP应激时[s/d (m) 142/63 (80)、123/63 (88)和86/46 (62) mmHg]；冠状动脉压力（CoP）静息时[s/d (m) 100/59 (80)、80/45 (62)和83/47 (63) mmHg]；CoP应激时[s/d (m) 95/60 (69)、101/54 (72)和70/32 (50) mmHg]。
该病例系列对AAOCA的动脉间段被主动脉和PA剪刀样压迫这一假设提出了质疑。应激状态下MLA和FFR的降低是由于主动脉对壁内段的单向侧向压迫。此外，“恶性”一词不应一概适用于所有有动脉间走行的AAOCA病例，因为并非所有病例都具有血流动力学意义。
