Anomalous Placement of the Coronary Arteries as a Cause of Sudden Cardiac Death in Athletes
MW Cruise, TS Giles, TJ Green, RL Legallo. University of Virginia, Charlottesville, VA
Background: Sudden cardiac death in previously healthy adolescents is rare; the estimated prevalence of athletic field related deaths is 0.5:100,000. In the United States, the most common cause of these deaths are hypertrophic cardiomyopathy, while in Europe it is reported to be arrythmogenic right ventricular cardiomyopathy. Sports physicals with ECG can help identify patients at risk for these afflictions. However, other minor structural abnormalities, such as coronary artery abnormalities can not typically be appreciated by standard methods.
Design: Case Report: A previously healthy 12-year-old gifted athlete, with no pertinent personal or family medical history, experienced his first syncopal episode while playing soccer. A subsequent neurological examination was normal. Six months later, he developed a similar episode while playing soccer and a cardiac workup demonstrated a normal ECG, echocardiogram, and treadmill stress test. A third syncopal episode occurred, again during physical exertion, with a quick recovery and no other findings. Fifteen months after the patient's first syncopal episode, the patient experienced a fourth syncopal episode and collapsed while playing soccer. An AED applied showed wide complex tachycardia without pulses. Resuscitative efforts were attempted immediately, however the patient remained pulses and apneic.
Results: At autopsy, the decedent was a well developed 13 year-old with BMI=18. The heart was structurally normal aside from anomalous coronary arteries. There was rotational insertion of the right and left coronary arteries; the right coronary ostia was located in the posterior right cusp and the left coronary ostia was located in the anterior portion of the right cusp just behind the commisure. This resulted in an acute angle take-off of the left coronary artery from the aorta with a reduced-sized orifice and a left coronary path between the aorta and pulmonary artery. Microscopically the cardiac tissue contained patchy myocardial fibrosis as well as subendocardial contraction band necrosis consistent with both new and old ischemic events.
Conclusions: The patient's death was due to an arrhythmic event initiated by intermittent occlusion of the left coronary artery and the resulting episodic ischemia. Given that this condition is surgically repairable, it is important to identify these patients. In the face of normal neurological, psychological, and cardiac workup with continued syncopal episodes, it may be appropriate to consider additional imaging studies such as thin section CT, cardiac MRI, or aortogram.
Wednesday, March 24, 2010 9:30 AM
Poster Session V # 6, Wednesday Morning