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Clinical Research Advances in Congenital Heart Disease

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (20 June 2023) | Viewed by 25302

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Dr. Raffaele Giordano

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Department of Advanced Biomedical Science, Division of Adult and Pediatric Cardiac Surgery, University of Naples Federico II, Via Pansini 5, Napoli, Naples, Italy
Interests: cardiovascular sciences; adult and pediatric cardiac surgery; congenital heart disease
Special Issues, Collections and Topics in MDPI journals

Dr. Massimiliano Cantinotti

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Department of Pediatric Cardiology, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
Interests: congenital heart disease; pediatric cardiac surgery

Special Issue Information

Dear Colleagues,

Though the number of infants born with heart disease each year is relatively small (approximately 1% of the population), it is still a substantial issue worthy of investigation, which is why this Special Issue focuses on congenital heart disease in both children and adults. Advances in the treatment of such malformations have led to increased life spans for this population. Consequently, today, most patients treated for congenital heart disease are adults. The purpose of this Special Issue is to deal with the latest developments in the care of the fetus, infants, children, and how these patients should be treated, as well as describe the results of follow-ups and the potential special needs of adults with congenital heart disease.

We welcome original manuscripts or other types of papers concerning all aspects of heart disease in infants, children, and adolescents, including embryology and anatomy, physiology and pharmacology, biochemistry, pathology, genetics, radiology, clinical aspects, investigative cardiology, electrophysiology and echocardiography, and cardiac surgery.

Dr. Raffaele Giordano
Dr. Massimiliano Cantinotti
Guest Editors

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Keywords

congenital heart diseases
pediatric cardiology
pediatric cardiac surgery

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Related Special Issue

Perspectives on Congenital Heart Disease from Children to Adults in Journal of Clinical Medicine

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Research

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14 pages, 9967 KiB

Open AccessArticle

Catheter-Based Techniques for Addressing Atrioventricular Valve Regurgitation in Adult Congenital Heart Disease Patients: A Descriptive Cohort

by Abdelhak El Bouziani, Lars S. Witte, Berto J. Bouma, Monique R. M. Jongbloed, Daniëlle Robbers-Visser, Bart Straver, Marcel A. M. Beijk, Philippine Kiès, David R. Koolbergen, Frank van der Kley, Martin J. Schalij, Robbert J. de Winter and Anastasia D. Egorova

J. Clin. Med. 2023, 12(14), 4798; https://doi.org/10.3390/jcm12144798 - 20 Jul 2023

Cited by 2 | Viewed by 1452

Abstract

Introduction: Increasing survival of adult congenital heart disease (ACHD) patients comes at the price of a range of late complications—arrhythmias, heart failure, and valvular dysfunction. Transcatheter valve interventions have become a legitimate alternative to conventional surgical treatment in selected acquired heart disease patients. However, literature on technical aspects, hemodynamic effects, and clinical outcomes of percutaneous atrioventricular (AV) valve interventions in ACHD patients is scarce. Method: This is a descriptive cohort from CAHAL (Center of Congenital Heart Disease Amsterdam-Leiden). ACHD patients with severe AV valve regurgitation who underwent a transcatheter intervention in the period 2020–2022 were included. Demographic, clinical, procedural, and follow-up data were collected from patient records. Results: Five ACHD patients with severe or torrential AV valve regurgitation are described. Two patients underwent a transcatheter edge-to-edge repair (TEER), one patient underwent a valve-in-valve procedure, one patient received a Cardioband system, and one patient received both a Cardioband system and TEER. No periprocedural complications occurred. Post-procedural AV valve regurgitation as well as NYHA functional class improved in all patients. The median post-procedural NYHA functional class improved from 3.0 (IQR [2.5–4.0]) to 2.0 (IQR [1.5–2.5]). One patient died 9 months after the procedure due to advanced heart failure with multiorgan dysfunction. Conclusion: Transcatheter valve repair is feasible and safe in selected complex ACHD patients. A dedicated heart team is essential for determining an individualized treatment strategy as well as pre- and periprocedural imaging to address the underlying mechanism(s) of AV regurgitation and guide the transcatheter intervention. Long-term follow-up is essential to evaluate the clinical outcomes of transcatheter AV valve repair in ACHD patients. Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

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11 pages, 1152 KiB

Open AccessArticle

Mild Acquired von Willebrand Syndrome and Cholestasis in Pediatric and Adult Patients with Fontan Circulation

by Katharina Meinel, Felicitas Korak, Martin Dusleag, Tanja Strini, Daniela Baumgartner, Ante Burmas, Hannes Sallmon, Barbara Zieger, Axel Schlagenhauf and Martin Koestenberger

J. Clin. Med. 2023, 12(3), 1240; https://doi.org/10.3390/jcm12031240 - 3 Feb 2023

Viewed by 1610

Abstract

Background: Hemodynamic alterations in Fontan patients (FP) are associated with hemostatic dysbalance and Fontan-associated liver disease. Studies of other hepatopathologies indicate an interplay between cholestasis, tissue factor (TF), and von Willebrand factor (VWF). Hence, we hypothesized a relationship between the accumulation of bile acids (BA) and these hemostatic factors in FP. Methods: We included 34 FP (Phenprocoumon n = 15, acetylsalicylic acid (ASA) n = 16). BA were assessed by mass spectrometry. TF activity and VWF antigen (VWF:Ag) were determined by chromogenic assays. VWF collagen-binding activity (VWF:CB) was assessed via ELISA. Results: Cholestasis was observed in 6/34 FP (total BA ≥ 10 µM). BA levels and TF activity did not correlate (p = 0.724). Cholestatic FP had lower platelet counts (p = 0.013) from which 5/6 FP were not treated with ASA. VWF:Ag levels were increased in 9/34 FP and significantly lower in FP receiving ASA (p = 0.044). Acquired von Willebrand syndrome (AVWS) was observed in 10/34-FP, with a higher incidence in cholestatic FP (4/6) (p = 0.048). Conclusions: Cholestasis is unexpectedly infrequent in FP and seems to be less frequent under ASA therapy. Therefore, ASA may reduce the risk of advanced liver fibrosis. FP should be screened for AVWS to avoid bleeding events, especially in cholestatic states. Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

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9 pages, 246 KiB

Open AccessArticle

Pregnancy Outcomes in Women after the Fontan Procedure

by Agnieszka Bartczak-Rutkowska, Lidia Tomkiewicz-Pająk, Katarzyna Kawka-Paciorkowska, Natalia Bajorek, Aleksandra Ciepłucha, Mariola Ropacka-Lesiak and Olga Trojnarska

J. Clin. Med. 2023, 12(3), 783; https://doi.org/10.3390/jcm12030783 - 18 Jan 2023

Cited by 4 | Viewed by 2174

Abstract

Women with single ventricle physiology after the Fontan procedure, despite numerous possible complications, can reach adulthood and give birth. Pregnancy poses a hemodynamic burden for distorted physiology of Fontan circulation, but according to the literature, it is usually well tolerated unless the patient is a “failing” Fontan. Our study aimed to assess maternal and fetal outcomes in patients after the Fontan procedure followed up in two tertiary Polish medical centers. We retrospectively evaluated all pregnancies in women after the Fontan procedure who were followed up between 1995–2022. During the study period, 15 women after the Fontan procedure had 26 pregnancies. Among 26 pregnancies, eleven ended with miscarriages, and 15 pregnancies resulted in 16 live births. Fetal complications were observed in 9 (56.3%) live births, with prematurity being the most common complication (n = 7, 43.8%). We recorded 3 (18.8%) neonatal deaths. Obstetrical complications were present in 6 (40%) out of 15 completed pregnancies—two (13.3%) cases of abruptio placentae, two (13.3%) pregnancies with premature rupture of membranes, and two (13.3%) patients with antepartum hemorrhage. There was neither maternal death nor heart failure decompensation during pregnancy. In two (13.3%) women, atrial arrhythmia developed. One (6.7%) patient in the second trimester developed ventricular arrhythmia. None of the patients suffered from systemic thromboembolism during pregnancy. Pregnancy in women after the Fontan procedure is well tolerated. However, it is burdened by a high risk of miscarriage and multiple obstetrical complications. These women require specialized care provided by both experienced cardiologists and obstetricians. Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

11 pages, 891 KiB

Open AccessArticle

Interventional Occlusion of Large Patent Ductus Arteriosus in Adults with Severe Pulmonary Hypertension

by Zeming Zhou, Yuanrui Gu, Hong Zheng, Chaowu Yan, Qiong Liu, Shiguo Li, Huijun Song, Zhongying Xu, Jinglin Jin, Haibo Hu and Jianhua Lv

J. Clin. Med. 2023, 12(1), 354; https://doi.org/10.3390/jcm12010354 - 2 Jan 2023

Cited by 4 | Viewed by 2292

Abstract

(1) Background: the indications for transcatheter closure of large patent ductus arteriosus (PDA) with severe pulmonary hypertension (PH) are still unclear, and scholars have not fully elucidated the factors that affect PH prognosis. (2) Methods: we retrospectively enrolled 134 consecutive patients with a PDA diameter ≥10 mm or a ratio of PDA and aortic >0.5. We collected clinical data to explore the factors affecting follow-up PH. (3) Results: 134 patients (mean age 35.04 ± 10.23 years; 98 women) successfully underwent a transcatheter closure, and all patients had a mean pulmonary artery pressure (mPAP) >50 mmHg. Five procedures were deemed to have failed because their mPAP did not decrease, and the patients experienced uncomfortable symptoms after the trial occlusion. The average occluder (pulmonary end) size was almost twice the PDA diameter (22.33 ± 4.81 mm vs. 11.69 ± 2.18 mm). Left ventricular end-diastolic dimension (LVEDD), mPAP, and left ventricular ejection fraction (LVEF) significantly reduced after the occlusion, and LVEF recovered during the follow-up period. In total, 42 of the 78 patients with total pulmonary resistance >4 Wood Units experienced clinical outcomes, and all of them had PH in the follow-up, while 10 of them had heart failure, and 4 were hospitalized again because of PH. The results of a logistic regression analysis revealed that the postoperative mPAP had an independent risk factor (odds ratio = 1.069, 95% confidence interval: 1.003 to 1.140, p = 0.040) with a receiver operating characteristic curve cut-off value of 35.5 mmHg (p < 0.001). (4) Conclusions: performing a transcatheter closure of large patent ductus arteriosus is feasible, and postoperative mPAP was a risk factor that affected the follow-up PH. Patients with a postoperative mPAP >35.5 mmHg should be considered for targeted medical therapy or should undergo right heart catheterization again after the occlusion. Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

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23 pages, 616 KiB

Open AccessArticle

Becoming a Teenager after Early Surgical Ventricular Septal Defect (VSD) Repair: Longitudinal Biopsychological Data on Mental Health and Maternal Involvement

by Laura Lang, Jennifer Gerlach, Anne-Christine Plank, Ariawan Purbojo, Robert A. Cesnjevar, Oliver Kratz, Gunther H. Moll and Anna Eichler

J. Clin. Med. 2022, 11(23), 7242; https://doi.org/10.3390/jcm11237242 - 6 Dec 2022

Cited by 4 | Viewed by 2400

Abstract

Beside somatic strains of congenital heart diseases (CHD), affected children often show developmental impairments in the long term. Ventricular septal defect (VSD) is the most common congenital heart defect and early surgical repair is associated with positive somatic outcomes. However, psychological adjustment is of lifelong relevance. We investigated 24 children with a surgically-corrected isolated VSD and their mothers from primary school (6–9 years) to adolescence (10–14 years) and compared them to controls. Both times, mothers reported child internalizing/externalizing problems, mothers and children rated child quality of life, and children performed neurodevelopmental tests. Adolescents also rated internalizing/externalizing problems themselves, and their hair cortisol levels were analyzed. Maternal anxiety and proactive parenting behavior were considered as moderators. Results revealed no group differences in child neurodevelopment (language, cognition), externalizing problems, and cortisol levels at any time. In reports from mothers, internalizing problems (depression, anxiety) were elevated in children with a VSD at both times—when mothers reported anxiety symptoms themselves. In adolescent reports, VSD patients’ quality of life was increased and internalizing problems were decreased—proactive parenting behavior went along with decreased symptoms in VSD-affected adolescents and with increased symptoms in controls. The findings pronounce the crucial role of parenting behavior and the influence of maternal anxieties on child mental health after surgical VSD repair and might highlight the need for parent-centered interventions. Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

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9 pages, 259 KiB

Open AccessArticle

Neuroimaging and Cerebrovascular Changes in Fetuses with Complex Congenital Heart Disease

by Flaminia Vena, Lucia Manganaro, Valentina D’Ambrosio, Luisa Masciullo, Flavia Ventriglia, Giada Ercolani, Camilla Bertolini, Carlo Catalano, Daniele Di Mascio, Elena D’Alberti, Fabrizio Signore, Antonio Pizzuti and Antonella Giancotti

J. Clin. Med. 2022, 11(22), 6740; https://doi.org/10.3390/jcm11226740 - 14 Nov 2022

Cited by 5 | Viewed by 1685

Abstract

Background: Congenital heart diseases (CHDs) are often associated with significant neurocognitive impairment and neurological delay. This study aims to elucidate the correlation between type of CHD and Doppler velocimetry and to investigate the possible presence of fetal brain abnormalities identified by magnetic resonance imaging (MRI). Methods: From July 2010 to July 2020, we carried out a cross-sectional study of 63 singleton pregnancies with a diagnosis of different types of complex CHD: LSOL (left-sided obstructive lesions; RSOL (right-sided obstructive lesions) and MTC (mixed type of CHD). All patients underwent fetal echocardiography, ultrasound evaluation, a magnetic resonance of the fetal brain, and genetic counseling. Results: The analysis of 63 fetuses shows statistically significant results in Doppler velocimetry among the different CHD groups. The RSOL group leads to higher umbilical artery (UA-PI) pressure indexes values, whereas the LSOL group correlates with significantly lower values of the middle cerebral artery (MCA-PI) compared to the other subgroups (p = 0.036), whereas the RSOL group shows a tendency to higher pulsatility indexes in the umbilical artery (UA-PI). A significant correlation has been found between a reduced head circumference (HC) and the presence of brain injury at MRI (p = 0.003). Conclusions: Congenital left- and right-sided cardiac obstructive lesions are responsible for fetal hemodynamic changes and brain growth impairment. The correct evaluation of the central nervous system (CNS) in fetuses affected by CHD could be essential as prenatal screening and the prediction of postnatal abnormalities. Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

12 pages, 1364 KiB

Open AccessArticle

Detection of Coronary Artery and Aortic Arch Anomalies in Patients with Tetralogy of Fallot Using CT Angiography

by Zsófia Kakucs, Erhard Heidenhoffer and Marian Pop

J. Clin. Med. 2022, 11(19), 5500; https://doi.org/10.3390/jcm11195500 - 20 Sep 2022

Cited by 6 | Viewed by 1826

Abstract

Background: Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease (CHD). Furthermore, the prevalence of anomalous origin of a coronary artery is higher in patients with TOF than in the general population (6% vs. ≤1%). Preoperative assessment of cardiovascular anatomy using computed tomography (CT) angiography enables the adaptation of the surgical approach to avoid potentially overlooked anomalies. Our purpose was to determine the prevalence of coronary artery and aortic arch anomalies in a cohort of TOF patients. Methods: In this retrospective analysis, data were collected from CT reports (2015–2021) of 105 TOF patients. All images were acquired using a 64-slice multi-detector CT (MDCT) scanner. Results: The median age of the patients was 38.7 months, with a male-to-female ratio of 1.39. The overall prevalence of coronary artery anomalies (CAAs) was 7.61% (8 of 105 cases). The anomalous origin and course of coronary arteries across the right ventricular outflow tract (RVOT; prepulmonic course) were defined in 5.71% of cases (six patients). In four of these, the left anterior descending artery (LAD) originated from the right coronary artery (RCA), while in two cases, the RCA arose from the LAD. In the remaining two patients, the coronary arteries followed an interarterial course. The most frequent anomalous aortic arch pattern in the overall TOF population was the right aortic arch (RAA) with mirror image branching, seen in 20% of patients (21 cases). The most frequent anomaly of the supra-aortic trunks was bovine configuration, found in 17.14% (18 cases). Conclusions: The prevalence of CAAs and aortic arch anomalies detected by CT angiography was in line with the data reported in anatomical specimens. Therefore, this technique represents a powerful tool for the evaluation of congenital cardiovascular anomalies. Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

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11 pages, 1178 KiB

Open AccessArticle

Atrial Function Impairments after Pediatric Cardiac Surgery Evaluated by STE Analysis

by Massimiliano Cantinotti, Pietro Marchese, Marco Scalese, Eliana Franchi, Nadia Assanta, Martin Koestenberger, Alessandra Pizzuto, Vitali Pak, Giuseppe Santoro, Vivek Jani, Shelby Kutty and Raffaele Giordano

J. Clin. Med. 2022, 11(9), 2497; https://doi.org/10.3390/jcm11092497 - 29 Apr 2022

Cited by 2 | Viewed by 1535

Abstract

Background: Applications of atrial speckle tracking echocardiography (STE) strain (ε) analysis in pediatric cardiac surgery have been limited. This study aims to evaluate the feasibility of atrial STE ε analysis and the progression of atrial ε values as a function of post-operative time in children after pediatric cardiac surgery. Methods: 131 children (mean 1.69 ± 2.98; range 0.01–15.16 years) undergoing cardiac surgery were prospectively enrolled. Echocardiographic examinations were performed pre-operatively and at 3 different post-operative intervals: Time 1 (24–36 h), Time 2 (3–5 days), Time 3 (>5 days, before discharging). The right and left atrium longitudinal systolic contractile (Ct), Conduit (Cd), and Reservoir (R) ε were evaluated with a novel atrial specific software with both P- and R-Gating methods. One hundred and thirty-one age-matched normal subjects (mean 1.7 ± 3.2 years) were included as controls. Results: In all, 309 examinations were performed over the post-operative times. For each post-operative interval, all STE atrial ε parameters assessed were significantly lower compared to controls (all p < 0.0001). The lowest atrial ε values were found at Time 1, with only partial recovery thereafter (p from 0.02 to 0.04). All atrial ε values at discharge were decreased compared to the controls (all p < 0.0001). Significant correlations of the atrial ε values with cardio-pulmonary-bypass time, left and right ventricular ε values (p < 0.05), and ejection fraction (p < 0.05) were demonstrated. Conclusions: Atrial ε is highly reduced after surgery with only partial post-operative recovery in the near term. Our study additionally demonstrates that post-surgical atrial and ventricular ε responses correlated with each other. Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

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Review

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11 pages, 1659 KiB

Open AccessReview

Echocardiographic Parameters for Risk Prediction in Borderline Right Ventricle: Review with Special Emphasis on Pulmonary Atresia with Intact Ventricular Septum and Critical Pulmonary Stenosis

by Massimiliano Cantinotti, Colin Joseph McMahon, Pietro Marchese, Martin Köstenberger, Marco Scalese, Eliana Franchi, Giuseppe Santoro, Nadia Assanta, Xander Jacquemyn, Shelby Kutty and Raffaele Giordano

J. Clin. Med. 2023, 12(14), 4599; https://doi.org/10.3390/jcm12144599 - 10 Jul 2023

Cited by 3 | Viewed by 2032

Abstract

The aim of the present review is to highlight the strengths and limitations of echocardiographic parameters and scores employed to predict favorable outcome in complex congenital heart diseases (CHDs) with borderline right ventricle (RV), with a focus on pulmonary atresia with intact ventricular septum and critical pulmonary stenosis (PAIVS/CPS). A systematic search in the National Library of Medicine using Medical Subject Headings and free-text terms including echocardiography, CHD, and scores, was performed. The search was refined by adding keywords “PAIVS/CPS”, Ebstein’s anomaly, and unbalanced atrioventricular septal defect with left dominance. A total of 22 studies were selected for final analysis; 12 of them were focused on parameters to predict biventricular repair (BVR)/pulmonary blood flow augmentation in PAIVS/CPS. All of these studies presented numerical (the limited sample size) and methodological limitations (retrospective design, poor definition of inclusion/exclusion criteria, variability in the definition of outcomes, differences in adopted surgical and interventional strategies). There was heterogeneity in the echocardiographic parameters employed and cut-off values proposed, with difficultly in establishing which one should be recommended. Easy scores such as TV/MV (tricuspid/mitral valve) and RV/LV (right/left ventricle) ratios were proven to have a good prognostic accuracy; however, the data were very limited (only two studies with <40 subjects). In larger studies, RV end-diastolic area and a higher degree of tricuspid regurgitation were also proven as accurate predictors of successful BVR. These measures, however, may be either operator and/or load/pressure dependent. TV Z-scores have been proposed by several authors, but old and heterogenous nomograms sources have been employed, thus producing discordant results. In summary, we provide a review of the currently available echocardiographic parameters for risk prediction in CHDs with a diminutive RV that may serve as a guide for use in clinical practice. Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

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34 pages, 2058 KiB

Open AccessReview

Artificial Intelligence in Pediatric Cardiology: A Scoping Review

by Yashendra Sethi, Neil Patel, Nirja Kaka, Ami Desai, Oroshay Kaiwan, Mili Sheth, Rupal Sharma, Helen Huang, Hitesh Chopra, Mayeen Uddin Khandaker, Maha M. A. Lashin, Zuhal Y. Hamd and Talha Bin Emran

J. Clin. Med. 2022, 11(23), 7072; https://doi.org/10.3390/jcm11237072 - 29 Nov 2022

Cited by 14 | Viewed by 5205

Abstract

The evolution of AI and data science has aided in mechanizing several aspects of medical care requiring critical thinking: diagnosis, risk stratification, and management, thus mitigating the burden of physicians and reducing the likelihood of human error. AI modalities have expanded feet to the specialty of pediatric cardiology as well. We conducted a scoping review searching the Scopus, Embase, and PubMed databases covering the recent literature between 2002–2022. We found that the use of neural networks and machine learning has significantly improved the diagnostic value of cardiac magnetic resonance imaging, echocardiograms, computer tomography scans, and electrocardiographs, thus augmenting the clinicians’ diagnostic accuracy of pediatric heart diseases. The use of AI-based prediction algorithms in pediatric cardiac surgeries improves postoperative outcomes and prognosis to a great extent. Risk stratification and the prediction of treatment outcomes are feasible using the key clinical findings of each CHD with appropriate computational algorithms. Notably, AI can revolutionize prenatal prediction as well as the diagnosis of CHD using the EMR (electronic medical records) data on maternal risk factors. The use of AI in the diagnostics, risk stratification, and management of CHD in the near future is a promising possibility with current advancements in machine learning and neural networks. However, the challenges posed by the dearth of appropriate algorithms and their nascent nature, limited physician training, fear of over-mechanization, and apprehension of missing the ‘human touch’ limit the acceptability. Still, AI proposes to aid the clinician tomorrow with precision cardiology, paving a way for extremely efficient human-error-free health care. Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

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Other

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6 pages, 30159 KiB

Open AccessCase Report

CT Detection of an Anomalous Left Circumflex Coronary Artery from Pulmonary Artery (ALXCAPA) in 81-Year-Old Female Patient

by Marian Pop, Zsófia Kakucs and Simona Coman

J. Clin. Med. 2023, 12(1), 226; https://doi.org/10.3390/jcm12010226 - 28 Dec 2022

Viewed by 1968

Abstract

Background: The left circumflex coronary artery from the pulmonary artery is a very rare congenital anomaly with few cases described, so far, worldwide. Case report: An 81-year-old female presented complaining of dyspnea. The transthoracic echocardiogram revealed severe degenerative aortic stenosis in addition to a hypertrophied left ventricle with normal function and no wall motion abnormalities. As part of the pre-TAVI planning, she underwent a CT examination, which revealed an anomalous left circumflex artery originating from the right pulmonary artery. The case is currently being managed conservatively. Conclusion: The presented congenital coronary anomaly is, to our knowledge, the first to be described in the literature in this age group (80+). Full article

(This article belongs to the Special Issue Clinical Research Advances in Congenital Heart Disease)

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