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Dual Origin of the Left Anterior Descending Artery: A Rare Coronary Anomaly With Longstanding Variant Angina
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LETTERS TO THE EDITOR
3. Noble S, Basmadjianb A, Ibrahim R: Transcatheter prosthetic paravalvular leak closure. Cardiovasc Med 15:245-252, 2012 4. Nietlispach F, Johnson M, Moss RR, et al: Transcatheter closure of paravalvular defects using a purpose-specific occluder. JACC Cardiovasc Interv 3:759-765, 2010 http://dx.doi.org/10.1053/j.jvca.2013.01.024
Dual Origin of the Left Anterior Descending Artery: A Rare Coronary Anomaly With Longstanding Variant Angina
To the Editor: Congenital coronary anomalies are observed in 1% of the population who undergo coronary angiograms. Autopsy series have revealed an even lower incidence of 0.3%.1 Congenital coronary anomaly is a very common cause of sudden death in young patients with cardiovascular pathology, second only to hypertrophic cardiomyopathy.2 The incidence of sudden death varies from 25% for anomalous right coronary artery (ARCA) to 57% for anomalous left coronary artery (ALCA).1,2 Herein, we report a case of a 50-year-old male patient with a greater than 18-month history of angina. He had a positive exercise tolerance test, which showed ST elevation in the anterior leads but without a troponin rise. Angiography showed an anomalous origin of the distal part of the left anterior descending artery (LAD) coming off the right coronary artery. There was no angiographic
Fig 1. Right coronary angiogram. This is a right anterior oblique view showing a right common trunk dividing into the right coronary artery and the left anterior descending coronary artery (black arrow). The initial portion of the left anterior descending coronary artery loops in a U shape.
Fig 2. Volume-rendered image. This image clearly shows the origin and course of the anomalous LAD. Note the normal take off of the LAD from the left main coronary artery as well (yellow arrows).
evidence of atherosclerosis or compression of the LAD (Fig 1). Stress echocardiography then was performed, which found normal left ventricular function at rest, with evidence of distal LAD territory ischemia. The patient underwent coronary revascularization with his left internal mammary artery anastomosed to the anomalous LAD. His postoperative period was uneventful. He had an uneventful postoperative period, and at 6-months’ follow-up, the patient was free of angina. The incidence of an anomalous LAD arising from the coronary sinus was found to be 0.03% of all coronary anomolies in one of the biggest series from the Cleveland Clinic.3 Clinical manifestations range from being completely asymptomatic to angina, syncope, myocardial ischemia, or sudden death. Coronary anomalies also can present with ventricular tachycardia, as in the case reported by Kriatselis et al, in which the left main coronary artery originated from the right aortic sinus with the synchronous existence of a Mahaim bundle.4 Rigatelli and Rigatelli described a classification of coronary artery anomalies based on their clinical significance.5 Surgical revascularization is indicated in situations for which there is evidence of myocardial ischemia. The objective of the surgery is to maintain antegrade coronary perfusion. In the present case, the anomalous LAD was found to be anterior to the RVOT and had an acute angle takeoff (Fig 2). Interventional cardiologists and surgeons should be aware of these coronary variations for the better interpretation of angiographies and avoidance of possible complications. Imthiaz Manoly, MRCS* Dimos Karangelis, MD, PhD* Charles Peebles, MD† Geoffrey Tsang, FRCS* Departments of *Cardiothoracic Surgery, and †Cardiothoracic Radiology Southampton University Hospital Southampton, United Kingdom
e45
LETTERS TO THE EDITOR
REFERENCES 1. Taylor AJ, Rogan KM, Virmani R: Sudden cardiac death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol 20:640-647, 1992 2. Kosar F, Ermis N, Erdil N, et al: Anomalous LAD and CX artery arising separately from the proximal right coronary artery–a case report of single coronary artery with coronary artery disease. J Card Surg 21: 309-312, 2006 3. Yamanaka O, Hobbs RE: Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 21:28-40, 1990 4. Kriatselis C, Gohl K, Jessl J, et al: Mahaim fibre coexisting with anomalous origin of the left main coronary artery from the right aortic sinus and an intrarterial course. Hellenic J Cardiol 48: 302-305, 2007 5. Rigatelli G, Rigatelli G: Coronary artery anomalies: what we know and what we have to learn. A proposal for a new clinical classification. Ital Heart J 4:305–310, 2003. http://dx.doi.org/10.1053/j.jvca.2013.02.001
Bullet Embolization From the Right Internal Jugular Vein to the Right Ventricle To the Editor: I read with great interest the case report by Soong et al entitled ‘‘Transesophageal Echocardiography in the Management of Right Ventricular Bullet Embolization from the Left Brachiocephalic Vein’’.1 We encountered a similar case. A 24-year-old man was transferred to our trauma unit with penetrating injuries. He had gunshot wounds to the posterior aspect of his neck, right shoulder, and right thigh. He was
Fig 1.
Chest x-ray.
Fig 2.
CT of the chest.
hemodynamically stable, breathing spontaneously, and neurologically intact. X-rays from the referring hospital showed a radioopaque object overlying the cardiac silhouette (Fig 1). Computed tomography (CT), at our institution, of the head and neck showed soft tissue injury of the posterior aspect of the neck, small fragments of radioopaque material scattered from the right scapular tip to around the right carotid sheath, and a hematoma in the right sternocleidomastoid muscle. Chest CT revealed a radioopaque object within the tip of the right ventricle without associated hemothorax or pneumothorax (Fig 2). Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) (Figs 3, 4, and 5) showed the bullet lodged in the apex of the right ventricle. There was no pericardial effusion, right ventricular wall penetration, or damage to the papillary muscles or tricuspid valve. Cardiovascular surgery opted for conservative management, and he was sent home after an uneventful 6-day stay. He was recovering
Fig 3. TTE—bright echodensity (1cm x 0.7 cm) in the apex of the right ventricle.
LETTERS TO THE EDITOR
3. Noble S, Basmadjianb A, Ibrahim R: Transcatheter prosthetic paravalvular leak closure. Cardiovasc Med 15:245-252, 2012 4. Nietlispach F, Johnson M, Moss RR, et al: Transcatheter closure of paravalvular defects using a purpose-specific occluder. JACC Cardiovasc Interv 3:759-765, 2010 http://dx.doi.org/10.1053/j.jvca.2013.01.024
Dual Origin of the Left Anterior Descending Artery: A Rare Coronary Anomaly With Longstanding Variant Angina
To the Editor: Congenital coronary anomalies are observed in 1% of the population who undergo coronary angiograms. Autopsy series have revealed an even lower incidence of 0.3%.1 Congenital coronary anomaly is a very common cause of sudden death in young patients with cardiovascular pathology, second only to hypertrophic cardiomyopathy.2 The incidence of sudden death varies from 25% for anomalous right coronary artery (ARCA) to 57% for anomalous left coronary artery (ALCA).1,2 Herein, we report a case of a 50-year-old male patient with a greater than 18-month history of angina. He had a positive exercise tolerance test, which showed ST elevation in the anterior leads but without a troponin rise. Angiography showed an anomalous origin of the distal part of the left anterior descending artery (LAD) coming off the right coronary artery. There was no angiographic
Fig 1. Right coronary angiogram. This is a right anterior oblique view showing a right common trunk dividing into the right coronary artery and the left anterior descending coronary artery (black arrow). The initial portion of the left anterior descending coronary artery loops in a U shape.
Fig 2. Volume-rendered image. This image clearly shows the origin and course of the anomalous LAD. Note the normal take off of the LAD from the left main coronary artery as well (yellow arrows).
evidence of atherosclerosis or compression of the LAD (Fig 1). Stress echocardiography then was performed, which found normal left ventricular function at rest, with evidence of distal LAD territory ischemia. The patient underwent coronary revascularization with his left internal mammary artery anastomosed to the anomalous LAD. His postoperative period was uneventful. He had an uneventful postoperative period, and at 6-months’ follow-up, the patient was free of angina. The incidence of an anomalous LAD arising from the coronary sinus was found to be 0.03% of all coronary anomolies in one of the biggest series from the Cleveland Clinic.3 Clinical manifestations range from being completely asymptomatic to angina, syncope, myocardial ischemia, or sudden death. Coronary anomalies also can present with ventricular tachycardia, as in the case reported by Kriatselis et al, in which the left main coronary artery originated from the right aortic sinus with the synchronous existence of a Mahaim bundle.4 Rigatelli and Rigatelli described a classification of coronary artery anomalies based on their clinical significance.5 Surgical revascularization is indicated in situations for which there is evidence of myocardial ischemia. The objective of the surgery is to maintain antegrade coronary perfusion. In the present case, the anomalous LAD was found to be anterior to the RVOT and had an acute angle takeoff (Fig 2). Interventional cardiologists and surgeons should be aware of these coronary variations for the better interpretation of angiographies and avoidance of possible complications. Imthiaz Manoly, MRCS* Dimos Karangelis, MD, PhD* Charles Peebles, MD† Geoffrey Tsang, FRCS* Departments of *Cardiothoracic Surgery, and †Cardiothoracic Radiology Southampton University Hospital Southampton, United Kingdom
e45
LETTERS TO THE EDITOR
REFERENCES 1. Taylor AJ, Rogan KM, Virmani R: Sudden cardiac death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol 20:640-647, 1992 2. Kosar F, Ermis N, Erdil N, et al: Anomalous LAD and CX artery arising separately from the proximal right coronary artery–a case report of single coronary artery with coronary artery disease. J Card Surg 21: 309-312, 2006 3. Yamanaka O, Hobbs RE: Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 21:28-40, 1990 4. Kriatselis C, Gohl K, Jessl J, et al: Mahaim fibre coexisting with anomalous origin of the left main coronary artery from the right aortic sinus and an intrarterial course. Hellenic J Cardiol 48: 302-305, 2007 5. Rigatelli G, Rigatelli G: Coronary artery anomalies: what we know and what we have to learn. A proposal for a new clinical classification. Ital Heart J 4:305–310, 2003. http://dx.doi.org/10.1053/j.jvca.2013.02.001
Bullet Embolization From the Right Internal Jugular Vein to the Right Ventricle To the Editor: I read with great interest the case report by Soong et al entitled ‘‘Transesophageal Echocardiography in the Management of Right Ventricular Bullet Embolization from the Left Brachiocephalic Vein’’.1 We encountered a similar case. A 24-year-old man was transferred to our trauma unit with penetrating injuries. He had gunshot wounds to the posterior aspect of his neck, right shoulder, and right thigh. He was
Fig 1.
Chest x-ray.
Fig 2.
CT of the chest.
hemodynamically stable, breathing spontaneously, and neurologically intact. X-rays from the referring hospital showed a radioopaque object overlying the cardiac silhouette (Fig 1). Computed tomography (CT), at our institution, of the head and neck showed soft tissue injury of the posterior aspect of the neck, small fragments of radioopaque material scattered from the right scapular tip to around the right carotid sheath, and a hematoma in the right sternocleidomastoid muscle. Chest CT revealed a radioopaque object within the tip of the right ventricle without associated hemothorax or pneumothorax (Fig 2). Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) (Figs 3, 4, and 5) showed the bullet lodged in the apex of the right ventricle. There was no pericardial effusion, right ventricular wall penetration, or damage to the papillary muscles or tricuspid valve. Cardiovascular surgery opted for conservative management, and he was sent home after an uneventful 6-day stay. He was recovering
Fig 3. TTE—bright echodensity (1cm x 0.7 cm) in the apex of the right ventricle.