**5.3 Coronary artery fistulas**

The clinical presentation associated with coronary artery fistulas is dependent on the type of fistula, shunt volume, in situ of the shunt and presence of other cardiac

**113**

**5.8 Additional tools**

wire.

**5.6 Femoral versus radial approach**

**5.7 Right versus left radial approach**

ence in access site or other procedural complications [28].

*Anomalous Origin of Coronary Arteries DOI: http://dx.doi.org/10.5772/intechopen.76912*

**5.4 Myocardial bridging**

conditions, although patients (50%) often remain asymptomatic [25]. Dyspnea on exertion, fatigue, congestive heart failure, pulmonary hypertension, bacterial endocarditis and arrhythmias are common presentations in symptomatic patients. Myocardial ischaemia may also occur, but the mechanism remains speculative [25]. Symptomatic patients or those with severe shunts may be treated with surgical closure, although percutaneous closure with coil embolization may also be tried.

A myocardial bridge occurs when one of the coronary arteries takes a tunneled intramuscular course under a bridge of overlying myocardium. The myocardial fibers passes over the involved segment of the LAD, and each contraction of these fibers can cause narrowing of the artery. On angiography, the bridged segment is of

Although bridging is not thought to have any hemodynamic significance in most cases, myocardial bridging has been associated with angina, arrhythmia, depressed left ventricular function, myocardial stunning, early death after cardiac transplantation, and sudden death [21, 26]. Intracoronary Doppler studies have shown that diastolic flow abnormalities may be present in patients with myocardial bridging. Medical treatment generally includes beta blockers, although nitrates should be avoided because they may worsen symptoms. Intracoronary stent and surgery have

normal caliber during diastole and abruptly narrows with each systole.

been attempted in selected patients, but the results have been mixed.

**5.5 Percutaneous coronary intervention and anomalous coronary artery**

Several problems may be encountered during the angiography and angioplasty of anomalous origin of culprit coronary artery (AOCCA), including precise diagnosis, selection of an appropriate guiding catheter, insufficient backup force, and difficulties in balloon or stent delivery. The final success of the procedure is depended from the careful assessment of the AOCCA configuration, proximal angulation, vessel course and subsequent selection of an appropriate guide catheter and guide

In case of AOCCA femoral access may offer better options allowing for easy, and multiple catheter exchanges [27]. Although, in the setting of ACS, the operator is usually unaware of AOCCA presence, having to make the best use of the chosen access site. Also, it seems best to use the approach one is most comfortable with as there is usually a way to perform successful PCI of AOCCA regardless of access site.

In a meta-analysis of 12 prospective randomized trials comparing above-mentioned approaches there was a small but statistically significant difference in terms of contrast use and fluoroscopy time in favor of coronary procedures performed via left radial approach compared to the right radial approach, but without any differ-

Anchoring balloons or anchor wire techniques may be helpful tools [29]. The latter maneuver was used to treat one of the present patients. Still, this culprit was

#### *Anomalous Origin of Coronary Arteries DOI: http://dx.doi.org/10.5772/intechopen.76912*

conditions, although patients (50%) often remain asymptomatic [25]. Dyspnea on exertion, fatigue, congestive heart failure, pulmonary hypertension, bacterial endocarditis and arrhythmias are common presentations in symptomatic patients. Myocardial ischaemia may also occur, but the mechanism remains speculative [25]. Symptomatic patients or those with severe shunts may be treated with surgical closure, although percutaneous closure with coil embolization may also be tried.
