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Inferior myocardial infarction and extensive atherosclerosis in a patient with double right coronary artery
International Journal of Cardiology 111 (2006) 321 – 323 www.elsevier.com/locate/ijcard
Letter to the Editor
Inferior myocardial infarction and extensive atherosclerosis in a patient with double right coronary artery Ibrahim Sari *, Nevzat Uslu, Sevket Gorgulu, Zekeriya Nurkalem, Mehmet Eren Siyami Ersek Thoracic and Cardiovascular Surgery Center, Cardiology Department, I˙stanbul, Turkey Received 2 October 2005; accepted 5 November 2005 Available online 18 January 2006
Keywords: Coronary angiography; Coronary anomaly; Double right coronary artery
1. Introduction The incidence of coronary artery anomalies is about 1 – 2% in angiographic studies of adult population [1]. Most commonly involved are the anomalies of the left coronary system [1]. Double right coronary artery (RCA) is one of the rarest coronary anomaly which was reported nine times in the literature so far [3– 11]. Only three of them were complicated with atherosclerosis and two presented with acute coronary syndrome. To the best of our knowledge our case with double RCA and extensive atherosclerosis presenting with inferior myocardial infarction is the first in the literature.
2. Case report An 84-year-old woman presented to the emergency department with typical chest pain started 3 days ago. Except ramipril 5 mg and acethylsalicylate 100 mg daily she was free of any medicine and free of any disease except hypertension for 12 years. Her blood pressure and pulse rate were 130/80 mm Hg and 85 bpm, respectively. Her physical examination was completely normal. On electrocardiogram there was first degree atrioventricular block and pathological Q waves in leads III and aVF. Her CK – MB was 142 IU/L and troponin-I was 3.21 ng/dl on admission. She was
* Corresponding author. Tel.: +90 505 3556797; fax: +90 216 5504433 (4095-4186). E-mail address: [email protected] (I. Sari). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.11.028
admitted to intermediate coronary care unit with the diagnosis of subacute inferior myocardial infarction and treated medically. On the following day, her chest pain recurred despite intensive medical treatment and she underwent coronary angiogram. The left coronary arteries were of normal origin and distribution but there were critical stenotic lesions in proximal parts of left anterior descending artery, first diagonal branch and first obtuse marginal branch vessels (Fig. 1A). Injection of radiopaque material into the right sinus revealed two separate RCAs originating from a single ostium in the right sinus of Valsalva (Fig. 1B). Main trunk of the right coronary system was relatively long and atherosclerotic. The anterior RCA had luminal irregularities after separating from the main trunk and had almost a subtotal stenosis just before giving the right ventricular branch. The posterior RCA had total occlusion that was responsible from the infarction. A guidewire was introduced into the occluded RCA which enabled a faint late anterograde flow but we couldn’t perform complete percutaneous revascularisation because of the highly angulated anatomy of main trunk of the right coronary system (Fig. 1C and D). The patient was followed up medically and she was recommended to have coronary artery bypass surgery.
3. Discussion Double RCA is a very rare coronary abnormality. There is no mention about this anomaly in a series that involved 126,595 patients who underwent coronary angiography [1]. It may be because patients with separate origin of the
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I. Sari et al. / International Journal of Cardiology 111 (2006) 321 – 323
Fig. 1. A: Right anterior oblique view of the left coronary system showing critical stenoses in proximal left anterior descending artery (short black arrow), proximal obtuse marginal branch (long black arrow) and diagonal branch (white arrow). B: Left anterior oblique (LAO) view of the right coronary system showing two separate RCAs originating from a single ostium with a long and atherosclerotic main trunk. The anterior RCA has almost a subtotal just before giving the right ventricular branch (white arrow) and the posterior RCA has total occlusion. C: LAO view of the right coronary system with the guidewire introduced into the posterior RCA. D: LAO view of the right coronary system showing a faint late anterograde flow in the posterior RCA after flow in the anterior RCA has washed out.
conus branch or right ventricular branch from the right sinus of Valsalva were excluded [1]. Some authors claim that it is very difficult to interpret as either double RCA arising from a single ostium or a high take off of a large right ventricular branch by looking at angiographic views [2]. Although controversy and confusion exists about definition of this entity it is important keep in mind to prevent inadequate diagnosis and treatment that can be quite troublesome. So far double RCA abnormality has been reported in nine cases [3– 11]. Only three of them were complicated with atherosclerosis and two presented with acute coronary syndrome [9– 11]. The one reported by Timurkaynak et al. was hospitalized with the diagnosis of unstable angina pectoris had double RCA, both were atherosclerotic and one had aneurysmal dilatation in its mid portion [10]. He had multiple severe stenoses in both left anterior descending (LAD) and circumflex (CX) arteries which makes it difficult to define the responsible vessel from the clinical scenario [10]. The case reported by Ozeren et al. also presented with acute coronary syndrome and ventricular tachycardia who had 70% stenosis in one of the RCAs and ectasias in both LAD and CX arteries [11]. Although unlikely, ectasias of the left coronary arteries could be the cause of ischemia and arrhythmia [11]. In our case, patient had severe stenoses both in LAD and CX arteries in the left coronary system but more
importantly had almost subtotal occlusion in the RCA located anteriorly and total occlusion in the RCA located posteriorly which makes our case unique. To our knowledge our case with double RCA having total occlusion in one of them causing inferior myocardial infarction has not been reported previously. References [1] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28 – 40. [2] Altun A, Akdemir O, Erdogan O, Ozbay G. An interesting diagnostic dilemma: double right coronary artery or high take off of a large right ventricular branch. Int J Cardiol Jan 2002;82(1):99 – 102. [3] Barthe JE, Benito M, Sala J, et al. Double right coronary artery. Am J Cardiol Mar 15 1994;73(8):622. [4] Aydogdu S, Ozdemir M, Diker E, Korkmaz P, Sozutek Y, Kutuk E. Double right coronary artery. a rare coronary artery anomaly. Acta Cardiol 1997;52(4):359 – 61. [5] Harikrishnan S, Bhat A, Tharakan JM. Double right coronary artery. Int J Cardiol Feb 2001;77(2 – 3):315 – 6. [6] Altunkeser BB, Ozdemir K, Murat SN. A unique double right coronary artery abnormality. Acta Cardiol Aug 2001;56(4):259 – 60. [7] Garg N, Goel PK, Sinha N. Double right coronary artery with anomalous left main and septal arteries originating from the right coronary sinus. Indian Heart J Jul – Aug 2002;54(4):428 – 31. [8] Nair K, Krishnamoorthy KM, Tharakan JA. Double right coronary artery with anomalous origin of septal arteries from the right coronary sinus. Int J Cardiol May 25 2005;101(2):309 – 10.
I. Sari et al. / International Journal of Cardiology 111 (2006) 321 – 323 [9] Resatoglu AG, Elnur EE, Yener N, Elhassan H, Yener A. Double right coronary artery; fistula and atherosclerosis: rare combination. Jpn J Thorac Cardiovasc Surg May 2005;53(5):283 – 5. [10] Timurkaynak T, Ciftci H, Cengel A. Double right coronary artery with atherosclerosis: a rare coronary artery anomaly. J Invasive Cardiol Jun 2002;14(6):337 – 9.
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[11] Ozeren A, Aydin M, Bilge M, Dursun A, Onuk T. Atherosclerotic double right coronary artery and ectasia of left coronary arteries in a patient with presented acute coronary syndrome and ventricular tachycardia. Int J Cardiol Jul 10 2005;102(2):341 – 3.
Letter to the Editor
Inferior myocardial infarction and extensive atherosclerosis in a patient with double right coronary artery Ibrahim Sari *, Nevzat Uslu, Sevket Gorgulu, Zekeriya Nurkalem, Mehmet Eren Siyami Ersek Thoracic and Cardiovascular Surgery Center, Cardiology Department, I˙stanbul, Turkey Received 2 October 2005; accepted 5 November 2005 Available online 18 January 2006
Keywords: Coronary angiography; Coronary anomaly; Double right coronary artery
1. Introduction The incidence of coronary artery anomalies is about 1 – 2% in angiographic studies of adult population [1]. Most commonly involved are the anomalies of the left coronary system [1]. Double right coronary artery (RCA) is one of the rarest coronary anomaly which was reported nine times in the literature so far [3– 11]. Only three of them were complicated with atherosclerosis and two presented with acute coronary syndrome. To the best of our knowledge our case with double RCA and extensive atherosclerosis presenting with inferior myocardial infarction is the first in the literature.
2. Case report An 84-year-old woman presented to the emergency department with typical chest pain started 3 days ago. Except ramipril 5 mg and acethylsalicylate 100 mg daily she was free of any medicine and free of any disease except hypertension for 12 years. Her blood pressure and pulse rate were 130/80 mm Hg and 85 bpm, respectively. Her physical examination was completely normal. On electrocardiogram there was first degree atrioventricular block and pathological Q waves in leads III and aVF. Her CK – MB was 142 IU/L and troponin-I was 3.21 ng/dl on admission. She was
* Corresponding author. Tel.: +90 505 3556797; fax: +90 216 5504433 (4095-4186). E-mail address: [email protected] (I. Sari). 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.11.028
admitted to intermediate coronary care unit with the diagnosis of subacute inferior myocardial infarction and treated medically. On the following day, her chest pain recurred despite intensive medical treatment and she underwent coronary angiogram. The left coronary arteries were of normal origin and distribution but there were critical stenotic lesions in proximal parts of left anterior descending artery, first diagonal branch and first obtuse marginal branch vessels (Fig. 1A). Injection of radiopaque material into the right sinus revealed two separate RCAs originating from a single ostium in the right sinus of Valsalva (Fig. 1B). Main trunk of the right coronary system was relatively long and atherosclerotic. The anterior RCA had luminal irregularities after separating from the main trunk and had almost a subtotal stenosis just before giving the right ventricular branch. The posterior RCA had total occlusion that was responsible from the infarction. A guidewire was introduced into the occluded RCA which enabled a faint late anterograde flow but we couldn’t perform complete percutaneous revascularisation because of the highly angulated anatomy of main trunk of the right coronary system (Fig. 1C and D). The patient was followed up medically and she was recommended to have coronary artery bypass surgery.
3. Discussion Double RCA is a very rare coronary abnormality. There is no mention about this anomaly in a series that involved 126,595 patients who underwent coronary angiography [1]. It may be because patients with separate origin of the
322
I. Sari et al. / International Journal of Cardiology 111 (2006) 321 – 323
Fig. 1. A: Right anterior oblique view of the left coronary system showing critical stenoses in proximal left anterior descending artery (short black arrow), proximal obtuse marginal branch (long black arrow) and diagonal branch (white arrow). B: Left anterior oblique (LAO) view of the right coronary system showing two separate RCAs originating from a single ostium with a long and atherosclerotic main trunk. The anterior RCA has almost a subtotal just before giving the right ventricular branch (white arrow) and the posterior RCA has total occlusion. C: LAO view of the right coronary system with the guidewire introduced into the posterior RCA. D: LAO view of the right coronary system showing a faint late anterograde flow in the posterior RCA after flow in the anterior RCA has washed out.
conus branch or right ventricular branch from the right sinus of Valsalva were excluded [1]. Some authors claim that it is very difficult to interpret as either double RCA arising from a single ostium or a high take off of a large right ventricular branch by looking at angiographic views [2]. Although controversy and confusion exists about definition of this entity it is important keep in mind to prevent inadequate diagnosis and treatment that can be quite troublesome. So far double RCA abnormality has been reported in nine cases [3– 11]. Only three of them were complicated with atherosclerosis and two presented with acute coronary syndrome [9– 11]. The one reported by Timurkaynak et al. was hospitalized with the diagnosis of unstable angina pectoris had double RCA, both were atherosclerotic and one had aneurysmal dilatation in its mid portion [10]. He had multiple severe stenoses in both left anterior descending (LAD) and circumflex (CX) arteries which makes it difficult to define the responsible vessel from the clinical scenario [10]. The case reported by Ozeren et al. also presented with acute coronary syndrome and ventricular tachycardia who had 70% stenosis in one of the RCAs and ectasias in both LAD and CX arteries [11]. Although unlikely, ectasias of the left coronary arteries could be the cause of ischemia and arrhythmia [11]. In our case, patient had severe stenoses both in LAD and CX arteries in the left coronary system but more
importantly had almost subtotal occlusion in the RCA located anteriorly and total occlusion in the RCA located posteriorly which makes our case unique. To our knowledge our case with double RCA having total occlusion in one of them causing inferior myocardial infarction has not been reported previously. References [1] Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28 – 40. [2] Altun A, Akdemir O, Erdogan O, Ozbay G. An interesting diagnostic dilemma: double right coronary artery or high take off of a large right ventricular branch. Int J Cardiol Jan 2002;82(1):99 – 102. [3] Barthe JE, Benito M, Sala J, et al. Double right coronary artery. Am J Cardiol Mar 15 1994;73(8):622. [4] Aydogdu S, Ozdemir M, Diker E, Korkmaz P, Sozutek Y, Kutuk E. Double right coronary artery. a rare coronary artery anomaly. Acta Cardiol 1997;52(4):359 – 61. [5] Harikrishnan S, Bhat A, Tharakan JM. Double right coronary artery. Int J Cardiol Feb 2001;77(2 – 3):315 – 6. [6] Altunkeser BB, Ozdemir K, Murat SN. A unique double right coronary artery abnormality. Acta Cardiol Aug 2001;56(4):259 – 60. [7] Garg N, Goel PK, Sinha N. Double right coronary artery with anomalous left main and septal arteries originating from the right coronary sinus. Indian Heart J Jul – Aug 2002;54(4):428 – 31. [8] Nair K, Krishnamoorthy KM, Tharakan JA. Double right coronary artery with anomalous origin of septal arteries from the right coronary sinus. Int J Cardiol May 25 2005;101(2):309 – 10.
I. Sari et al. / International Journal of Cardiology 111 (2006) 321 – 323 [9] Resatoglu AG, Elnur EE, Yener N, Elhassan H, Yener A. Double right coronary artery; fistula and atherosclerosis: rare combination. Jpn J Thorac Cardiovasc Surg May 2005;53(5):283 – 5. [10] Timurkaynak T, Ciftci H, Cengel A. Double right coronary artery with atherosclerosis: a rare coronary artery anomaly. J Invasive Cardiol Jun 2002;14(6):337 – 9.
323
[11] Ozeren A, Aydin M, Bilge M, Dursun A, Onuk T. Atherosclerotic double right coronary artery and ectasia of left coronary arteries in a patient with presented acute coronary syndrome and ventricular tachycardia. Int J Cardiol Jul 10 2005;102(2):341 – 3.