- Email: [email protected]
Anomalous Origin of the Common Left Coronary Artery From the Right Coronary Sinus
JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 7, NO. 10, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jcin.2014.03.014
IMAGES IN INTERVENTION
Anomalous Origin of the Common Left Coronary Artery From the Right Coronary Sinus An Unusual Anatomical Variation Pankaj Jariwala, MD, DNB, DNB, MNAMS,* Sunitha Lingareddy, MD,y Sarat Koduganti, MD, DM*
A
56-year-old male patient who was hyperten-
The electrocardiogram was normal, and 2-dimensional
sive and nondiabetic presented with chest
echocardiography revealed normal left ventricular
discomfort on exertion for the last 3 months.
function, no left ventricular regional wall motion
F I G U R E 1 Stepwise Figures of Transradial Coronary Angiography
(A) Injection of contrast into the left coronary sinus revealed a small, rudimentary left coronary artery. (B) Origin of the left coronary artery as a main stem from the right coronary sinus giving rise to the left anterior descending coronary artery (LAD), diagonal (D1) in a left anterior oblique cranial view. There was collateral between LAD and diagonal artery (multiple arrows).The left coronary main stem had 80% eccentric stenosis before the origin of the first obtuse marginal (OM1) (thick arrow). (C) Right anterior oblique caudal view showing origins of the first to fifth obtuse marginal arteries. (D) The right coronary artery had a normal course, and the posterior descending artery had 99% stenosis (thin arrow) of its proximal segment.
From the *Indo-US Superspeciality Hospitals, Ameerpet, Hyderabad, India; and yLucid Diagnostics, Banjara Hills, Hyderabad, India. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received March 19, 2014; accepted March 27, 2014.
e148
Jariwala et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 10, 2014 OCTOBER 2014:e147–9
ALCA From RCS: A Rare Anomaly
abnormalities. Hence, he was given a stress test, which was positive for inducible ischemia at low workload. Coronary angiography showed a small rudimentary left coronary artery; while searching for the left
CT coronary angiography determined the coursing of the anomalous left coronary artery and showed no interarterial or intramyocardial course of the coronary arteries (Figures 2A to 2D).
coronary artery, to our surprise, the origin of the left
Percutaneous transluminal coronary angioplasty
coronary artery was found to be from the right coro-
was done using 2 drug-eluting stents to the main stem
nary sinus. It had a main stem artery giving separate
left coronary artery and posterior descending artery
origins to the left anterior descending, diagonal, and
stenoses.
obtuse marginal (first to fifth) coronary arteries.
The origin of the left main coronary artery in
There was an eccentric 80% stenosis of the main stem
the right coronary sinus has been described in 0.02%
of the left coronary artery before the origin of the first
of autopsy series (1) and from 0.05% to 0.19% in
obtuse marginal artery. The right coronary artery
angiographic series (2). A main stem of the left coro-
had a normal course, and the posterior descending
nary artery arising from the right sinus of Valsalva
artery showed 99% stenosis of the proximal segment
has 4 anatomical courses (3):
(Figures 1A to 1D). Before planning his revascularization strategy, we performed computed tomography (CT) coronary angiography on the patient for better delineation of the anatomy of the coronary arteries.
1. Anterior course: turns anterior in front of right ventricular outflow tract, as in our case. 2. Interarterial course: between the great vessels, aorta, and pulmonary artery.
F I G U R E 2 CT Coronary Angiography With Volume Rendering Images to Delineate Coronary Anatomy in 3 Dimensions
(A) Showing origin of the left coronary artery main stem from the right coronary sinus adjacent to the origin of the right coronary artery (RCA). (B) The anomalous origin of the left coronary artery turns anterior in front of the right ventricular outflow tract to reach the left atrioventricular (AV) groove. (C) Before that is the origin to the LAD, which runs normally into the interventricular groove and the diagonal artery. (D) After the left AV groove, there are the origins of obtuse marginal arteries. The right coronary has a normal origin and course. CT ¼ computed tomography; LCX ¼ left circumflex coronary artery; other abbreviations as in Figure 1.
Jariwala et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 10, 2014 OCTOBER 2014:e147–9
ALCA From RCS: A Rare Anomaly
3. Septal course: intramyocardial septal continuation. 4. Posterior course: turns posterior behind the aorta.
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
Pankaj Jariwala, Indo-US Superspeciality Hospitals, Percutaneous angioplasty was done in view of no
Shyam Karan Road, Anand Bagh, Ameerpet, Hyderabad,
interarterial course of the coronary arteries.
India, 500016. E-mail: [email protected].
REFERENCES 1. Alexander RW, Griffith GC. Anomalies of the coronary arteries and their clinical significance. Circulation 1956;4:800–5. 2. Kimbiris D. Anomalous origin of the left main coronary artery from the right sinus of Valsalva. Am J Cardiol 1985;55:765–9.
3. Madea B, Dettmeyer R. Sudden death in cases with anomalous origin of the left coronary artery. Forensic Sci Int 1998;96:91–100.
KEY WORDS coronary angiography, coronary artery anomalies, computed tomography
e149
VOL. 7, NO. 10, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jcin.2014.03.014
IMAGES IN INTERVENTION
Anomalous Origin of the Common Left Coronary Artery From the Right Coronary Sinus An Unusual Anatomical Variation Pankaj Jariwala, MD, DNB, DNB, MNAMS,* Sunitha Lingareddy, MD,y Sarat Koduganti, MD, DM*
A
56-year-old male patient who was hyperten-
The electrocardiogram was normal, and 2-dimensional
sive and nondiabetic presented with chest
echocardiography revealed normal left ventricular
discomfort on exertion for the last 3 months.
function, no left ventricular regional wall motion
F I G U R E 1 Stepwise Figures of Transradial Coronary Angiography
(A) Injection of contrast into the left coronary sinus revealed a small, rudimentary left coronary artery. (B) Origin of the left coronary artery as a main stem from the right coronary sinus giving rise to the left anterior descending coronary artery (LAD), diagonal (D1) in a left anterior oblique cranial view. There was collateral between LAD and diagonal artery (multiple arrows).The left coronary main stem had 80% eccentric stenosis before the origin of the first obtuse marginal (OM1) (thick arrow). (C) Right anterior oblique caudal view showing origins of the first to fifth obtuse marginal arteries. (D) The right coronary artery had a normal course, and the posterior descending artery had 99% stenosis (thin arrow) of its proximal segment.
From the *Indo-US Superspeciality Hospitals, Ameerpet, Hyderabad, India; and yLucid Diagnostics, Banjara Hills, Hyderabad, India. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received March 19, 2014; accepted March 27, 2014.
e148
Jariwala et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 10, 2014 OCTOBER 2014:e147–9
ALCA From RCS: A Rare Anomaly
abnormalities. Hence, he was given a stress test, which was positive for inducible ischemia at low workload. Coronary angiography showed a small rudimentary left coronary artery; while searching for the left
CT coronary angiography determined the coursing of the anomalous left coronary artery and showed no interarterial or intramyocardial course of the coronary arteries (Figures 2A to 2D).
coronary artery, to our surprise, the origin of the left
Percutaneous transluminal coronary angioplasty
coronary artery was found to be from the right coro-
was done using 2 drug-eluting stents to the main stem
nary sinus. It had a main stem artery giving separate
left coronary artery and posterior descending artery
origins to the left anterior descending, diagonal, and
stenoses.
obtuse marginal (first to fifth) coronary arteries.
The origin of the left main coronary artery in
There was an eccentric 80% stenosis of the main stem
the right coronary sinus has been described in 0.02%
of the left coronary artery before the origin of the first
of autopsy series (1) and from 0.05% to 0.19% in
obtuse marginal artery. The right coronary artery
angiographic series (2). A main stem of the left coro-
had a normal course, and the posterior descending
nary artery arising from the right sinus of Valsalva
artery showed 99% stenosis of the proximal segment
has 4 anatomical courses (3):
(Figures 1A to 1D). Before planning his revascularization strategy, we performed computed tomography (CT) coronary angiography on the patient for better delineation of the anatomy of the coronary arteries.
1. Anterior course: turns anterior in front of right ventricular outflow tract, as in our case. 2. Interarterial course: between the great vessels, aorta, and pulmonary artery.
F I G U R E 2 CT Coronary Angiography With Volume Rendering Images to Delineate Coronary Anatomy in 3 Dimensions
(A) Showing origin of the left coronary artery main stem from the right coronary sinus adjacent to the origin of the right coronary artery (RCA). (B) The anomalous origin of the left coronary artery turns anterior in front of the right ventricular outflow tract to reach the left atrioventricular (AV) groove. (C) Before that is the origin to the LAD, which runs normally into the interventricular groove and the diagonal artery. (D) After the left AV groove, there are the origins of obtuse marginal arteries. The right coronary has a normal origin and course. CT ¼ computed tomography; LCX ¼ left circumflex coronary artery; other abbreviations as in Figure 1.
Jariwala et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 10, 2014 OCTOBER 2014:e147–9
ALCA From RCS: A Rare Anomaly
3. Septal course: intramyocardial septal continuation. 4. Posterior course: turns posterior behind the aorta.
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
Pankaj Jariwala, Indo-US Superspeciality Hospitals, Percutaneous angioplasty was done in view of no
Shyam Karan Road, Anand Bagh, Ameerpet, Hyderabad,
interarterial course of the coronary arteries.
India, 500016. E-mail: [email protected].
REFERENCES 1. Alexander RW, Griffith GC. Anomalies of the coronary arteries and their clinical significance. Circulation 1956;4:800–5. 2. Kimbiris D. Anomalous origin of the left main coronary artery from the right sinus of Valsalva. Am J Cardiol 1985;55:765–9.
3. Madea B, Dettmeyer R. Sudden death in cases with anomalous origin of the left coronary artery. Forensic Sci Int 1998;96:91–100.
KEY WORDS coronary angiography, coronary artery anomalies, computed tomography
e149