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Coronary ostial dimple (in the posterior aortic sinus) in the absence of other coronary arterial abnormalities
CASE REPORTS
Coronary Ostial Dimple (in the Posterior Aortic Sinus) in the Absence of Other Coronary Arterial Abnormalities Jamshid Shirani, MD, and William C. Roberts, MD ormally 2 coronary arteriesarise N from the aorta, 1 from the aortic wall enclosing the right aortic sinus and the other from the aortic wall enclosing the left aortic sinus; the wall enclosing the posterior, i.e., noncoronary sinus, is smooth and From the Pathology Branch, National Heart, Lung, and Blood Institute, National Instikes of Health, Building 10,Room 2N258, Bethesda, Maryland 20892. Dr. Robert’s current addressis: Baylor CardiovascularInstitute, Baylor University Medical Center, 3701 Junius Street, PO. Box EOlO,Dallas, Texas 75246. Manuscript received December 7, 1992; revised manuscript received January 29, 1993, and acceptedFebruary 1.
devoid of any “dimples” or “buds” or other suggestionsof a residua of a potential coronary ostium. Recently, we examined a heart with 2 normally arising coronary ostia and a dimple of an undeveloped coronary ostium in the third aortic sinus. Such an occurrence has not been seen by us in approximately 10,000 other heartsexamined in a similar manner. This report briefly describesthe cardisc morphologic linding in this 1 patient A 20-year-old man died of gunshot wounds. There was no injury to the heart. At necropsy, the heart
weighed 250 g. The left and right ventricular cavities were normal and no grossly visible myocardial scars were seen. The left main and the right coronary arteries arose normally from the left and right aortic sinuses, respectively (Figure 1). The left main coronary artery then divided into the left anterior descending and left circumflex coronary arteries, both of which thereafter coursed normally. In addition to the left main and the right coronavy ostia, a coronary ostial dimple was present in the wall of the aorta slightly above the posterior aortic sinus (Figures 1 and 2). It measured 4 mm in diameter and 3 mm in maximum depth. Coronary artery ostia arise from the wall of the aortopulmonary trunk at the time of embryonic division of
TABLE I Reported Casesof Coronary Ostial Dimple in the Presenceof “Single Coronary
Artery” Location of
Patient
Ref.
Age (yr) &Sex
“Single Ostium”
Ostial Dimple
1 2 3 4 5 6
3 4 5 6 7 8
37M 68M 8OF 76F 84F 83F
LAS LAS LAS RAS RAS LAS
RAS RAS RAS LAS LAS PAS
AP
AMI
SD
CAD
-
-
-
-
0 0 + 0
0 0 + 0
0 0 + +
+ 0 + +
HW (g)
LV Scar
340 370 530 320
0 0 + 0
Cause of Death Infective endocarditis Cancer Cancer Cancer AMI Ruptured CA aneurysm
AMI = acute myocardial infarct; AP = angina pectoris; CA = coranaiy artery,; CAD = atherosclerotic c~mary artery disease; F = female; HW = heart weight; LAS = left aortlc sinus; LV = left ventricular; M = male; PAS = posterior aortic sinus; RAS = right aortic sinus; SD = sudden death: - = information not available; + = present; 0 = absent.
FlGURE 1. Diagram (a) and photograph (b) of the longitudinally opened aortic valve showing the positions of the 2 normal coronary ostia in the walls of the left (L) and the ri&t (R) aortic sinuses and the coronary ostial dimple above the paste liar (P) aortic sinus. The boffzontd hoken line separates the sinus and the tubular portions of the ascending aorta (sinatubular junction). The right and left coronary ostia are located in the wall of the aorta slightly below and at this &otubular junction, res@ectlvely. The coronary o&al dimple is located slimly above the sinotubular junction,
118 THE AMERICANJOURNALOF CARDIOLOGY VOLUME72 JULY 1,1993
6 cases,however, differed from the present one in that the dimple was at a site where a coronary artery should have arisen but did not. In other words, all 6 previously reported casesof coronary dimple were in actuality examples of single coronary artery.9 In our patient, on the other hand, a coronary dimple was present at a site where a coronary ostium is not normally present.
FIGURE 2. Photomicrograph of longitudinal sections of aorta through the right coronary ostium (a), the coronary ostial dimple (b) and the left main coronary ostium (c)- The sections are taken as shown by the broken vertical lines through the coronary ostia in Figure la. The aortic media @tier staining tissue) contirr ues through the wall of the ostial dimple. Movat stain x13, reduced by 36%.
the trunk.’ It is not known why the coronary arteries consistently arise from the left and right aortic sinuses, with only minor variations in their locations in most individuals. It has been suggestedthat the development of the coronary ostial dimples in the wall of the aortopulmonary trunk require the presence of a developing network of epicardial vesselsin the heart2 This epicardial vascular network, then, induces the
formation of the coronary ostial dimples as it approachesthe aortopulmonary trunk. This hypothesis, however,would not explain the presence of coronary ostial dimples in the opposite aortic sinus in patients with ‘ ‘single coronary artery’ ’ and in the patient described here. In addition to the heretofore described patient, at least 6 other cases of coronary ostial dimples or buds have been reported (Table I).3-8 All
1. Angelini P. Normal and anomalous comnay artaies: definitions and classitication. AmHeart.! 1989; 117: 41&434. 2. Come G, Pellegki A. On the development of the coronary arteries in human embryos, stage 14-19. Anat Embiyol 1984,169:209-218. 3. Plaut A. Versorgung des Herzens durch nur eine Kranmterie. Frankf Z Path01 1922;27:84-90. 4. Ogden JA, Goodyer AVN. Patterns of dishibution of the single coronary artery. Yale J Biol Med 1970;43: 11-21. J. Smith JC. Review of single coronary artery with report of 2 cases. Circulation 1950;1:1168-1175. 9. Leivo IV, Lamila PK. Atresia of left corc~nay ostium and left main coronary stay. Arch Pathol Lab Med 1987;111:1173-1175. 7. Vlodavex 2, Amplatz K, Burchell HB, Edwards JE. Single coronary ostium in the aorta. In: Coronary Heat Disease: Clinical, A&graphic and Pathologic ProEles. New York: Springer-Verlag, 1976: 18%216. 9. Causing WP, Shuster M, Pribor HC, Amboy P. Single coronary artery with ruptured coronary artery aneurysm. Arch Path01 1967;83:419-421. 9. Shimi J, Roberts WC. Solitxy coronary osticm in the aorta in the absence of other major congenital cardiovascular anomalies. / Am Coil Cardiol 199221: 137-143.
CASEREPORTS 119
Coronary Ostial Dimple (in the Posterior Aortic Sinus) in the Absence of Other Coronary Arterial Abnormalities Jamshid Shirani, MD, and William C. Roberts, MD ormally 2 coronary arteriesarise N from the aorta, 1 from the aortic wall enclosing the right aortic sinus and the other from the aortic wall enclosing the left aortic sinus; the wall enclosing the posterior, i.e., noncoronary sinus, is smooth and From the Pathology Branch, National Heart, Lung, and Blood Institute, National Instikes of Health, Building 10,Room 2N258, Bethesda, Maryland 20892. Dr. Robert’s current addressis: Baylor CardiovascularInstitute, Baylor University Medical Center, 3701 Junius Street, PO. Box EOlO,Dallas, Texas 75246. Manuscript received December 7, 1992; revised manuscript received January 29, 1993, and acceptedFebruary 1.
devoid of any “dimples” or “buds” or other suggestionsof a residua of a potential coronary ostium. Recently, we examined a heart with 2 normally arising coronary ostia and a dimple of an undeveloped coronary ostium in the third aortic sinus. Such an occurrence has not been seen by us in approximately 10,000 other heartsexamined in a similar manner. This report briefly describesthe cardisc morphologic linding in this 1 patient A 20-year-old man died of gunshot wounds. There was no injury to the heart. At necropsy, the heart
weighed 250 g. The left and right ventricular cavities were normal and no grossly visible myocardial scars were seen. The left main and the right coronary arteries arose normally from the left and right aortic sinuses, respectively (Figure 1). The left main coronary artery then divided into the left anterior descending and left circumflex coronary arteries, both of which thereafter coursed normally. In addition to the left main and the right coronavy ostia, a coronary ostial dimple was present in the wall of the aorta slightly above the posterior aortic sinus (Figures 1 and 2). It measured 4 mm in diameter and 3 mm in maximum depth. Coronary artery ostia arise from the wall of the aortopulmonary trunk at the time of embryonic division of
TABLE I Reported Casesof Coronary Ostial Dimple in the Presenceof “Single Coronary
Artery” Location of
Patient
Ref.
Age (yr) &Sex
“Single Ostium”
Ostial Dimple
1 2 3 4 5 6
3 4 5 6 7 8
37M 68M 8OF 76F 84F 83F
LAS LAS LAS RAS RAS LAS
RAS RAS RAS LAS LAS PAS
AP
AMI
SD
CAD
-
-
-
-
0 0 + 0
0 0 + 0
0 0 + +
+ 0 + +
HW (g)
LV Scar
340 370 530 320
0 0 + 0
Cause of Death Infective endocarditis Cancer Cancer Cancer AMI Ruptured CA aneurysm
AMI = acute myocardial infarct; AP = angina pectoris; CA = coranaiy artery,; CAD = atherosclerotic c~mary artery disease; F = female; HW = heart weight; LAS = left aortlc sinus; LV = left ventricular; M = male; PAS = posterior aortic sinus; RAS = right aortic sinus; SD = sudden death: - = information not available; + = present; 0 = absent.
FlGURE 1. Diagram (a) and photograph (b) of the longitudinally opened aortic valve showing the positions of the 2 normal coronary ostia in the walls of the left (L) and the ri&t (R) aortic sinuses and the coronary ostial dimple above the paste liar (P) aortic sinus. The boffzontd hoken line separates the sinus and the tubular portions of the ascending aorta (sinatubular junction). The right and left coronary ostia are located in the wall of the aorta slightly below and at this &otubular junction, res@ectlvely. The coronary o&al dimple is located slimly above the sinotubular junction,
118 THE AMERICANJOURNALOF CARDIOLOGY VOLUME72 JULY 1,1993
6 cases,however, differed from the present one in that the dimple was at a site where a coronary artery should have arisen but did not. In other words, all 6 previously reported casesof coronary dimple were in actuality examples of single coronary artery.9 In our patient, on the other hand, a coronary dimple was present at a site where a coronary ostium is not normally present.
FIGURE 2. Photomicrograph of longitudinal sections of aorta through the right coronary ostium (a), the coronary ostial dimple (b) and the left main coronary ostium (c)- The sections are taken as shown by the broken vertical lines through the coronary ostia in Figure la. The aortic media @tier staining tissue) contirr ues through the wall of the ostial dimple. Movat stain x13, reduced by 36%.
the trunk.’ It is not known why the coronary arteries consistently arise from the left and right aortic sinuses, with only minor variations in their locations in most individuals. It has been suggestedthat the development of the coronary ostial dimples in the wall of the aortopulmonary trunk require the presence of a developing network of epicardial vesselsin the heart2 This epicardial vascular network, then, induces the
formation of the coronary ostial dimples as it approachesthe aortopulmonary trunk. This hypothesis, however,would not explain the presence of coronary ostial dimples in the opposite aortic sinus in patients with ‘ ‘single coronary artery’ ’ and in the patient described here. In addition to the heretofore described patient, at least 6 other cases of coronary ostial dimples or buds have been reported (Table I).3-8 All
1. Angelini P. Normal and anomalous comnay artaies: definitions and classitication. AmHeart.! 1989; 117: 41&434. 2. Come G, Pellegki A. On the development of the coronary arteries in human embryos, stage 14-19. Anat Embiyol 1984,169:209-218. 3. Plaut A. Versorgung des Herzens durch nur eine Kranmterie. Frankf Z Path01 1922;27:84-90. 4. Ogden JA, Goodyer AVN. Patterns of dishibution of the single coronary artery. Yale J Biol Med 1970;43: 11-21. J. Smith JC. Review of single coronary artery with report of 2 cases. Circulation 1950;1:1168-1175. 9. Leivo IV, Lamila PK. Atresia of left corc~nay ostium and left main coronary stay. Arch Pathol Lab Med 1987;111:1173-1175. 7. Vlodavex 2, Amplatz K, Burchell HB, Edwards JE. Single coronary ostium in the aorta. In: Coronary Heat Disease: Clinical, A&graphic and Pathologic ProEles. New York: Springer-Verlag, 1976: 18%216. 9. Causing WP, Shuster M, Pribor HC, Amboy P. Single coronary artery with ruptured coronary artery aneurysm. Arch Path01 1967;83:419-421. 9. Shimi J, Roberts WC. Solitxy coronary osticm in the aorta in the absence of other major congenital cardiovascular anomalies. / Am Coil Cardiol 199221: 137-143.
CASEREPORTS 119