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Practice Lesson of the week

Anomalous origin of left coronary artery in young athletes with syncope

BMJ 2006; 332 doi: (Published 11 May 2006) Cite this as: BMJ 2006;332:1139
  1. Matthias Kumpf, senior registrar1,
  2. Ludger Sieverding, professor1,
  3. Matthias Gass, senior registrar (,
  4. Renate Kaulitz, professor1,
  5. Gerhard Ziemer, director2,
  6. Michael Hofbeck, director1
  1. 1 Department of Pediatric Cardiology, Pulmonology and Intensive Care, Universitätsklinikum Tübingen, Tübingen, Germany
  2. 2 Department of Thoracic and Cardiovascular Surgery, Universitätsklinikum Tübingen
  1. Correspondence to: Dr Matthias Kumpf, Kinderheilkunde II, Universitätsklinikum Tübingen, Hoppe-Seyler-Strasse 3, D-72076 Tübingen, Germany
  • Accepted 24 October 2006

Possible causes of exercise induced syncope or sudden death in young athletes include undetected cardiomyopathies, myocarditis, arrhythmias (especially inherited arrhythmia syndromes—such as long QT syndrome, Brugada syndrome), coronary artery abnormalities and disease, and aortic rupture.1 2 3 Coronary artery anomalies are of special interest as they are potentially treatable lesions.4 5 The most frequent coronary artery anomaly is anomalous origin of the left coronary or the left anterior descending artery from the right coronary sinus of the aorta. According to a recent north Italian study, anomalous origin of left or right coronary artery from the opposite aortic sinus is the third most frequent cardiovascular cause of deaths associated with exercise among athletes aged 12-35 years.2

Fig 1

Coronary artery anatomy in case 1 as shown by echocardiography from the parasternal short axis: both the right and left coronary arteries originate from the right aortic sinus. The main left coronary artery courses between the aorta and pulmonary artery and divides into left anterior descending artery and left circumflex branch

We report on two adolescents who presented with a history of recurrent exertional pain and syncope during exercise. The results of previous cardiological evaluation—including 12 lead electrocardiography, exercise testing, and echocardiography—had been normal. Both patients were admitted to our hospital after life threatening events of ventricular fibrillation. The diagnosis of the coronary artery anomaly was detected in both patients by transthoracic echocardiography. These two cases show that this potentially fatal anomaly cannot be excluded by a negative exercise test.1 4

Case reports

Case 1

This 15 year old boy was a talented, competitive soccer player with a history of recurrent syncope during soccer training at the age of 6, 7, and 11. Previous …

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