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Anomalous left anterior descending, absent circumflex and unusual dominant course of right coronary artery: a case report—R1
International Journal of Cardiology 102 (2005) 147 – 148 www.elsevier.com/locate/ijcard
Letter to the Editor
Anomalous left anterior descending, absent circumflex and unusual dominant course of right coronary artery: a case report—R1 Rajesh Vijayvergiya*, Rakesh Kumar Jaswal Department of Cardiology, Mukat Hospital+Heart Institute, Chandigarh 160 034, India Received 27 November 2003; received in revised form 17 January 2004; accepted 5 March 2004 Available online 22 July 2004
Abstract A 40-years-old female presented with atypical chest pain. Selective coronary angiography revealed separate osteal origin of anomalous left anterior descending (LAD) and normal origin of right coronary artery (RCA) from right anterior coronary sinus. LAD had a septal course. Left circumflex (LCx) was absent. RCA, a dominant vessel, continued beyond the crux, along the entire length of atrioventricular groove as circumflex artery. There was no myocardial ischemia on stress thallium. As per our knowledge, this type of combination of anatomical variation of coronary circulation has not been described in the literature. D 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Anomalous coronary; Absent left circumflex; Angiography; Left coronary from right coronary sinus
1. Introduction Various anomalies of coronary artery origin have been described in the literature. These anatomical variations are discovered either by selective coronary angiography or at autopsy. We hereby report an unusual case of anomalous coronary artery circulation.
2. Case report A 40-years-old premenopausal, nondiabetic female was presented with atypical chest pain. Her physical examination was unremarkable. Electrocardiogram showed normal sinus rhythm and without any ischemic ST–T changes. Chest roentgenogram and 2D echocardiogram were normal. She underwent elective coronary angiography. Usual
* Corresponding author. Department of Cardiology, PGIMER, Chandigarh-160 012, India. Tel.: +91 172 747585x6512, 6513; fax: +91 172 744401. E-mail address: [email protected] (R. Vijayvergiya). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.03.075
catheters could not cannulate left coronary ostium. On selective cannulation of right anterior coronary sinus, it was observed that both left anterior descending (LAD) and right coronary artery (RCA) were arising from it. Their origin was from separate ostium. There was no separate ostium for left circumflex (LCx) as evident in aortic root angiogram. The LAD, after origin from the right coronary sinus, had a septal course (Figs. 1, 2). The RCA was a very dominant vessel and continued beyond crux along the entire length of atrioventricular groove as circumflex artery to supply posterior and lateral aspect of left ventricle (Figs. 1, 2). There was no stenosis of any of the coronary arteries. A stress thallium test was done on follow-up, which did not show any reversible ischemia of any territory.
3. Discussion Coronary artery anomalies are present since birth, but relatively few are symptomatic during childhood or later in life. Most of anomalies are incidentally detected during selective coronary angiography. The incidence varies between 0.6% and 1.3% in various series [1,2].
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R. Vijayvergiya, R. Kumar Jaswal / International Journal of Cardiology 102 (2005) 147–148
Fig. 1. Selective right coronary angiogram in 308 RAO view.
and continuation of RCA beyond crux along the entire length of atrioventricular groove, as was present in our case, is an unusual anomaly. Only few case reports are available in the literature in concern with this type of anomaly [5–7]. Anomalous origin of left coronary artery from right aortic sinus is being described in the literature [8]. Anomalous origin of the left coronary artery from the right anterior sinus or from the proximal part of RCA can be classified into four types, depending upon the course taken by it in relation to aorta and pulmonary trunk in route to left side of the heart. It’s course may be via anterior free wall, interarterial, retro-aortic or septal [9]. Interarterial course of left coronary artery causes serious risk to individual like angina, syncope, myocardial infarction and sudden cardiac death [9,10]. However, it is uncommon to have myocardial ischemia with septal course [11]. Our patient, who had septal course of LAD, did not have myocardial ischemia at rest or on stress. The combination of anomalous origin of LAD from right coronary sinus, the absence of LCx and the continuation of dominant RCA as circumflex artery along the entire length of atrio-ventricular groove is a rare presentation, and to our knowledge, the same has not been described in the literature to date.
References
Fig. 2. Selective right coronary angiogram in 608 LAO, 308 cranial view. Together with Fig. 1, it shows continuation of right coronary artery (RCA) beyond crux as circumflex, and separate left anterior descending (LAD) origin from right coronary sinus. LAD is taking septal course after its origin.
Anomalous origin of LCx from right coronary sinus or as first branch of RCA is one of the most common anatomic variation of the coronary artery circulation. It has been reported in 0.30–0.67% of patients subjected for selective coronary angiography [3,4]. However, the absence of LCx
[1] Kimbiris D, Iskandrian AS, Segal BL, Bemis CE. Anomalous aortic origin of coronary arteries. Circulation 1978;58:606 – 15. [2] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Catheter Cardiovasc Diagn 1990;21:28 – 40. [3] Liberthson RR, Dinsmore RE, Bharti S, et al. Aberrant coronary artery origin from the aorta: diagnosis and clinical significance. Circulation 1974;50:774 – 9. [4] Page Jr HL, Engel JH, Campbell WB, Thomas CS. Anomalous origin of the left circumflex coronary artery. Recognition, angiographic demonstration and clinical significance. Circulation 1974;50:768 – 73. [5] Ilia R, Jafari J, Weinstein JM, Battler A. Absent left circumflex coronary artery. Catheter Cardiovasc Diagn 1994;32:349 – 50. [6] Kumar K. Anomalous course and branches of human coronary arteries. Acta Anat 1989;136:315 – 8. [7] Barresi V, Susmano A, Colandrea MA, Bogdonoff M, Muenster JJ. Congenital absence of the circumflex coronary artery: clinical and cinearteriographic observations. Am Heart J 1973;86:811 – 6. [8] Gowda RM, Chamakura SR, Dogan OM, Sacchi TJ, Khan IA. Origin of left main and right coronary arteries from right aortic sinus of Valsalva. Int J Cardiol 2003;88:305 – 7. [9] Roberts WC, Bethesda Md. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986;111:941 – 63. [10] Roynard JL, Cattan S, Artigou JY, Desoutter P. Anomalous course of the left anterior descending coronary artery between the aorta and pulmonary trunk: a rare cause of myocardial ischaemia at rest. Br Heart J 1994;72:397 – 9. [11] Takenaka T, Horimoto M, Fujiwara M. Anomalous origin of the left anterior descending coronary artery from the right sinus of Valsalva associated with effort angina pectoris. Eur Heart J 1993;14:129 – 31.
Letter to the Editor
Anomalous left anterior descending, absent circumflex and unusual dominant course of right coronary artery: a case report—R1 Rajesh Vijayvergiya*, Rakesh Kumar Jaswal Department of Cardiology, Mukat Hospital+Heart Institute, Chandigarh 160 034, India Received 27 November 2003; received in revised form 17 January 2004; accepted 5 March 2004 Available online 22 July 2004
Abstract A 40-years-old female presented with atypical chest pain. Selective coronary angiography revealed separate osteal origin of anomalous left anterior descending (LAD) and normal origin of right coronary artery (RCA) from right anterior coronary sinus. LAD had a septal course. Left circumflex (LCx) was absent. RCA, a dominant vessel, continued beyond the crux, along the entire length of atrioventricular groove as circumflex artery. There was no myocardial ischemia on stress thallium. As per our knowledge, this type of combination of anatomical variation of coronary circulation has not been described in the literature. D 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Anomalous coronary; Absent left circumflex; Angiography; Left coronary from right coronary sinus
1. Introduction Various anomalies of coronary artery origin have been described in the literature. These anatomical variations are discovered either by selective coronary angiography or at autopsy. We hereby report an unusual case of anomalous coronary artery circulation.
2. Case report A 40-years-old premenopausal, nondiabetic female was presented with atypical chest pain. Her physical examination was unremarkable. Electrocardiogram showed normal sinus rhythm and without any ischemic ST–T changes. Chest roentgenogram and 2D echocardiogram were normal. She underwent elective coronary angiography. Usual
* Corresponding author. Department of Cardiology, PGIMER, Chandigarh-160 012, India. Tel.: +91 172 747585x6512, 6513; fax: +91 172 744401. E-mail address: [email protected] (R. Vijayvergiya). 0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.03.075
catheters could not cannulate left coronary ostium. On selective cannulation of right anterior coronary sinus, it was observed that both left anterior descending (LAD) and right coronary artery (RCA) were arising from it. Their origin was from separate ostium. There was no separate ostium for left circumflex (LCx) as evident in aortic root angiogram. The LAD, after origin from the right coronary sinus, had a septal course (Figs. 1, 2). The RCA was a very dominant vessel and continued beyond crux along the entire length of atrioventricular groove as circumflex artery to supply posterior and lateral aspect of left ventricle (Figs. 1, 2). There was no stenosis of any of the coronary arteries. A stress thallium test was done on follow-up, which did not show any reversible ischemia of any territory.
3. Discussion Coronary artery anomalies are present since birth, but relatively few are symptomatic during childhood or later in life. Most of anomalies are incidentally detected during selective coronary angiography. The incidence varies between 0.6% and 1.3% in various series [1,2].
148
R. Vijayvergiya, R. Kumar Jaswal / International Journal of Cardiology 102 (2005) 147–148
Fig. 1. Selective right coronary angiogram in 308 RAO view.
and continuation of RCA beyond crux along the entire length of atrioventricular groove, as was present in our case, is an unusual anomaly. Only few case reports are available in the literature in concern with this type of anomaly [5–7]. Anomalous origin of left coronary artery from right aortic sinus is being described in the literature [8]. Anomalous origin of the left coronary artery from the right anterior sinus or from the proximal part of RCA can be classified into four types, depending upon the course taken by it in relation to aorta and pulmonary trunk in route to left side of the heart. It’s course may be via anterior free wall, interarterial, retro-aortic or septal [9]. Interarterial course of left coronary artery causes serious risk to individual like angina, syncope, myocardial infarction and sudden cardiac death [9,10]. However, it is uncommon to have myocardial ischemia with septal course [11]. Our patient, who had septal course of LAD, did not have myocardial ischemia at rest or on stress. The combination of anomalous origin of LAD from right coronary sinus, the absence of LCx and the continuation of dominant RCA as circumflex artery along the entire length of atrio-ventricular groove is a rare presentation, and to our knowledge, the same has not been described in the literature to date.
References
Fig. 2. Selective right coronary angiogram in 608 LAO, 308 cranial view. Together with Fig. 1, it shows continuation of right coronary artery (RCA) beyond crux as circumflex, and separate left anterior descending (LAD) origin from right coronary sinus. LAD is taking septal course after its origin.
Anomalous origin of LCx from right coronary sinus or as first branch of RCA is one of the most common anatomic variation of the coronary artery circulation. It has been reported in 0.30–0.67% of patients subjected for selective coronary angiography [3,4]. However, the absence of LCx
[1] Kimbiris D, Iskandrian AS, Segal BL, Bemis CE. Anomalous aortic origin of coronary arteries. Circulation 1978;58:606 – 15. [2] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Catheter Cardiovasc Diagn 1990;21:28 – 40. [3] Liberthson RR, Dinsmore RE, Bharti S, et al. Aberrant coronary artery origin from the aorta: diagnosis and clinical significance. Circulation 1974;50:774 – 9. [4] Page Jr HL, Engel JH, Campbell WB, Thomas CS. Anomalous origin of the left circumflex coronary artery. Recognition, angiographic demonstration and clinical significance. Circulation 1974;50:768 – 73. [5] Ilia R, Jafari J, Weinstein JM, Battler A. Absent left circumflex coronary artery. Catheter Cardiovasc Diagn 1994;32:349 – 50. [6] Kumar K. Anomalous course and branches of human coronary arteries. Acta Anat 1989;136:315 – 8. [7] Barresi V, Susmano A, Colandrea MA, Bogdonoff M, Muenster JJ. Congenital absence of the circumflex coronary artery: clinical and cinearteriographic observations. Am Heart J 1973;86:811 – 6. [8] Gowda RM, Chamakura SR, Dogan OM, Sacchi TJ, Khan IA. Origin of left main and right coronary arteries from right aortic sinus of Valsalva. Int J Cardiol 2003;88:305 – 7. [9] Roberts WC, Bethesda Md. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986;111:941 – 63. [10] Roynard JL, Cattan S, Artigou JY, Desoutter P. Anomalous course of the left anterior descending coronary artery between the aorta and pulmonary trunk: a rare cause of myocardial ischaemia at rest. Br Heart J 1994;72:397 – 9. [11] Takenaka T, Horimoto M, Fujiwara M. Anomalous origin of the left anterior descending coronary artery from the right sinus of Valsalva associated with effort angina pectoris. Eur Heart J 1993;14:129 – 31.