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A Rare Coronary Anomaly
IMAGES IN CT SURGERY AND CARDIOLOGY
Images in CT Surgery and Cardiology
A Rare Coronary Anomaly Richard Y.J. Chan, Brendan Gunalingam ∗ , Cardiology Department, Gosford Hospital, Holden Street, Gosford, NSW 2067, Australia
Keywords. Coronary vessels; Coronary vessel anomalies; Coronary artery anomalies; Coronary angiography; Coronary circulation
A
n 84-year-old woman with hypertension and recent onset stable angina underwent coronary angiography after a myocardial perfusion scan demonstrated anterior ischaemia. This revealed a single coronary artery ostium in the right sinus of Valsalva from which arose the left anterior descending (LAD) artery and right coronary artery (RCA). The LAD was found to take a route to the
Received 29 August 2007; received in revised form 13 November 2007; accepted 11 May 2008; available online 27 August 2008 ∗
Corresponding author. Tel.: +61 2 43202111; fax: +61 2 43202651. E-mail address: [email protected] (B. Gunalingam).
left in a retroaortic fashion (dorsal) before assuming its usual position in the anterior interventricular groove. It had a proximal 70% atheromatous stenosis. The RCA traversed the atrioventricular groove giving rise to a posterior descending branch at the crux before continuing as the circumflex coronary artery (Cx). Accompanying images are of conventional coronary angiography (left anterior oblique caudal view), 64-slice MDCT and 3D reconstructions from CT. The occurrence of a solitary coronary ostium in the aorta is a rare congenital anomaly. As an isolated finding it has an incidence of between 0.02 and 0.04% [1,2]
Crown Copyright © 2008 Published by Elsevier Inc. on behalf of Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. All rights reserved.
1443-9506/04/$36.00 doi:10.1016/j.hlc.2008.05.602
IMAGES IN CT SURGERY AND CARDIOLOGY
408
Images in CT Surgery and Cardiology
although it occurs with higher frequency in association with certain congenital cardiovascular anomalies [3]. In 1993 Shirani and Roberts proposed a classification system [4] for solitary coronary ostiums based on the location of the ostium relative to the aortic sinuses and the characteristics of aberrant-coursing arteries. Our patient would be subtype IIC4, at that time a theoretical possibility but yet to be reported. Since then many examples of retroaortic left main coronary artery (LMCA) arising from a common ostium with the RCA in the right sinus of Valsalva have been reported [5–9], although these have been subtype IIB4 where the LMCA bifurcates to the LAD and Cx. In contrast, in our patient the Cx arises from the RCA and hence is subtype IIC4 which to the best of our knowledge has not been reported.
References [1] Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology 1979;130: 39–47. [2] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary angiography. Catheter Cardiovasc Diagn 1990;21:28–40.
Heart, Lung and Circulation 2009;18:407–409
[3] Desmet W, Van Haecke J, Vrolix M, Van de Werf F, Piessens J, Willems J, De Geest H. Isolated single coronary artery: a review of 50,000 consecutive coronary angiographies. Eur Heart J 1992;13:1637–40. [4] Shirani J, Roberts WC. Solitary coronary ostium in the aorta in the absence of other major congenital cardiovascular anomalies. J Am Coll Cardiol 1993;21(1):137–43. [5] Kejriwal NK, Tan J, Gordon SP, Newman MA. Retroaortic course of the anomalous left main coronary artery: is it a benign anomaly? A case report and review of literature. Heart Lung Circ 2004;13(March (1)):97–100. [6] Schwarz ER, Hager PK, Uebis R, Hanrath P, Klues HG. Myocardial ischaemia in a case of a solitary coronary ostium in the right aortic sinus with retroaortic course of the left coronary artery: documentation of the underlying pathophysiological mechanisms of ischaemia by intracoronary Doppler and pressure measurements. Heart 1998;80:307–12. [7] Quintal R, Nguyen T, Glancy L. Successful percutaneous coronary angioplasty via a solitary coronary ostium in the aorta (single coronary artery). J Invasive Cardiol 2003;15(8): 446–7. [8] Reig J, Jornet A, Petit M. Anomalous left coronary artery originating in the right aortic sinus with retroaortic course: a postmortem study. Angiology 1994;45(January (1)):57–60. [9] Fiorilli R, Argento G, Lisanti P, Serino W. Single coronary artery–a case report. G Ital Cardiol 1998;28(September (9)):1021–4.
CT Coronary Angiography to Guide Intervention for Acute Myocardial Ischaemia in a Patient with an Anomalous Single Coronary Ostium W.Y. Wandy Chan, MB ChB a , Dougal R. McClean, MB ChB, MD, FRACP a,∗ , John M. Elliott, MB ChB, PhD, FRACP a and Sharyn MacDonald, MB ChB, FRANZCR b a
Cardiology Department, Christchurch Public Hospital, Private Bag 4710, Christchurch, New Zealand b Radiology Department, Christchurch Public Hospital, Christchurch, New Zealand
Keywords. Myocardial ischaemia; Anomalous coronary ostium; Computed tomography; Cardiology images
Case Report
A
56-year-old man presented with 48 h of crescendo angina pectoris and labile ECG changes with transient lateral ST elevation and deep anterior/inferior ST depression. Primary PCI was unsuccessful as nonselective cusp injections could not identify the left and
Received 18 April 2008; accepted 19 April 2008; available online 27 June 2008 ∗
Corresponding author. Tel.: +64 33641416; fax: +64 33641120. E-mail address: [email protected] (D.R. McClean).
right coronary ostia. On-table echocardiography revealed a dilated aortic root suggesting an acute aortic dissection. An urgent 64-slice multi-detector row CT (MDCT) gated scan of the thoracic aorta and coronary arteries showed a single coronary ostium arising higher and more anterior above the sinotubular ridge. Originating from the ostium were two vessels: a small anomalous left anterior descending artery (LAD), and a common trunk that branched into a small septal branch, a large anomalous circumflex artery (Cx), and a right coronary artery (Figure 1A and B). An atherosclerotic non-calcified “culprit” plaque was identified in the anomalous Cx (Figure 2). Repeat coronary
Crown Copyright © 2008 Published by Elsevier Inc. on behalf of Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. All rights reserved.
1443-9506/04/$36.00 doi:10.1016/j.hlc.2008.04.006
Images in CT Surgery and Cardiology
A Rare Coronary Anomaly Richard Y.J. Chan, Brendan Gunalingam ∗ , Cardiology Department, Gosford Hospital, Holden Street, Gosford, NSW 2067, Australia
Keywords. Coronary vessels; Coronary vessel anomalies; Coronary artery anomalies; Coronary angiography; Coronary circulation
A
n 84-year-old woman with hypertension and recent onset stable angina underwent coronary angiography after a myocardial perfusion scan demonstrated anterior ischaemia. This revealed a single coronary artery ostium in the right sinus of Valsalva from which arose the left anterior descending (LAD) artery and right coronary artery (RCA). The LAD was found to take a route to the
Received 29 August 2007; received in revised form 13 November 2007; accepted 11 May 2008; available online 27 August 2008 ∗
Corresponding author. Tel.: +61 2 43202111; fax: +61 2 43202651. E-mail address: [email protected] (B. Gunalingam).
left in a retroaortic fashion (dorsal) before assuming its usual position in the anterior interventricular groove. It had a proximal 70% atheromatous stenosis. The RCA traversed the atrioventricular groove giving rise to a posterior descending branch at the crux before continuing as the circumflex coronary artery (Cx). Accompanying images are of conventional coronary angiography (left anterior oblique caudal view), 64-slice MDCT and 3D reconstructions from CT. The occurrence of a solitary coronary ostium in the aorta is a rare congenital anomaly. As an isolated finding it has an incidence of between 0.02 and 0.04% [1,2]
Crown Copyright © 2008 Published by Elsevier Inc. on behalf of Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. All rights reserved.
1443-9506/04/$36.00 doi:10.1016/j.hlc.2008.05.602
IMAGES IN CT SURGERY AND CARDIOLOGY
408
Images in CT Surgery and Cardiology
although it occurs with higher frequency in association with certain congenital cardiovascular anomalies [3]. In 1993 Shirani and Roberts proposed a classification system [4] for solitary coronary ostiums based on the location of the ostium relative to the aortic sinuses and the characteristics of aberrant-coursing arteries. Our patient would be subtype IIC4, at that time a theoretical possibility but yet to be reported. Since then many examples of retroaortic left main coronary artery (LMCA) arising from a common ostium with the RCA in the right sinus of Valsalva have been reported [5–9], although these have been subtype IIB4 where the LMCA bifurcates to the LAD and Cx. In contrast, in our patient the Cx arises from the RCA and hence is subtype IIC4 which to the best of our knowledge has not been reported.
References [1] Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology 1979;130: 39–47. [2] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary angiography. Catheter Cardiovasc Diagn 1990;21:28–40.
Heart, Lung and Circulation 2009;18:407–409
[3] Desmet W, Van Haecke J, Vrolix M, Van de Werf F, Piessens J, Willems J, De Geest H. Isolated single coronary artery: a review of 50,000 consecutive coronary angiographies. Eur Heart J 1992;13:1637–40. [4] Shirani J, Roberts WC. Solitary coronary ostium in the aorta in the absence of other major congenital cardiovascular anomalies. J Am Coll Cardiol 1993;21(1):137–43. [5] Kejriwal NK, Tan J, Gordon SP, Newman MA. Retroaortic course of the anomalous left main coronary artery: is it a benign anomaly? A case report and review of literature. Heart Lung Circ 2004;13(March (1)):97–100. [6] Schwarz ER, Hager PK, Uebis R, Hanrath P, Klues HG. Myocardial ischaemia in a case of a solitary coronary ostium in the right aortic sinus with retroaortic course of the left coronary artery: documentation of the underlying pathophysiological mechanisms of ischaemia by intracoronary Doppler and pressure measurements. Heart 1998;80:307–12. [7] Quintal R, Nguyen T, Glancy L. Successful percutaneous coronary angioplasty via a solitary coronary ostium in the aorta (single coronary artery). J Invasive Cardiol 2003;15(8): 446–7. [8] Reig J, Jornet A, Petit M. Anomalous left coronary artery originating in the right aortic sinus with retroaortic course: a postmortem study. Angiology 1994;45(January (1)):57–60. [9] Fiorilli R, Argento G, Lisanti P, Serino W. Single coronary artery–a case report. G Ital Cardiol 1998;28(September (9)):1021–4.
CT Coronary Angiography to Guide Intervention for Acute Myocardial Ischaemia in a Patient with an Anomalous Single Coronary Ostium W.Y. Wandy Chan, MB ChB a , Dougal R. McClean, MB ChB, MD, FRACP a,∗ , John M. Elliott, MB ChB, PhD, FRACP a and Sharyn MacDonald, MB ChB, FRANZCR b a
Cardiology Department, Christchurch Public Hospital, Private Bag 4710, Christchurch, New Zealand b Radiology Department, Christchurch Public Hospital, Christchurch, New Zealand
Keywords. Myocardial ischaemia; Anomalous coronary ostium; Computed tomography; Cardiology images
Case Report
A
56-year-old man presented with 48 h of crescendo angina pectoris and labile ECG changes with transient lateral ST elevation and deep anterior/inferior ST depression. Primary PCI was unsuccessful as nonselective cusp injections could not identify the left and
Received 18 April 2008; accepted 19 April 2008; available online 27 June 2008 ∗
Corresponding author. Tel.: +64 33641416; fax: +64 33641120. E-mail address: [email protected] (D.R. McClean).
right coronary ostia. On-table echocardiography revealed a dilated aortic root suggesting an acute aortic dissection. An urgent 64-slice multi-detector row CT (MDCT) gated scan of the thoracic aorta and coronary arteries showed a single coronary ostium arising higher and more anterior above the sinotubular ridge. Originating from the ostium were two vessels: a small anomalous left anterior descending artery (LAD), and a common trunk that branched into a small septal branch, a large anomalous circumflex artery (Cx), and a right coronary artery (Figure 1A and B). An atherosclerotic non-calcified “culprit” plaque was identified in the anomalous Cx (Figure 2). Repeat coronary
Crown Copyright © 2008 Published by Elsevier Inc. on behalf of Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. All rights reserved.
1443-9506/04/$36.00 doi:10.1016/j.hlc.2008.04.006