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Myocardial ischemia caused by a coronary anomaly left anterior descending coronary artery arising from right sinus of Valsalva
International Journal of Cardiology 112 (2006) e57 – e59 www.elsevier.com/locate/ijcard
Letter to the editor
Myocardial ischemia caused by a coronary anomaly left anterior descending coronary artery arising from right sinus of Valsalva Sait Mesut Dogan a,⁎, Metin Gursurer a , Mustafa Aydin a , Hakan Gocer a , Mehmet Cabuk b , Aydin Dursun a a
Department of Cardiology, Faculty of Medicine, Zonguldak Karaelmas University, Zonguldak, Turkey b Nuclear Medicine, Faculty of Medicine, Zonguldak Karaelmas University, Zonguldak, Turkey Received 26 December 2005; received in revised form 28 February 2006; accepted 11 March 2006 Available online 11 July 2006
Abstract We present the case of a patient in anomalous origin of the left anterior descending coronary artery that caused myocardial ischemia and led to positive myocardial scintigraphic results. Coronary angiography showed that the left anterior descending coronary artery arose from the right coronary ostium–an anomaly that has been associated with chest discomfort–without atherosclerotic lesions. Left circumflex artery and the diagonal branches were arising from the left main coronary artery and the whole coronary tree were free of atherosclerosis. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Coronary angiography; Coronary artery anomalies; Myocardial ischemia; Scintigraphy
Although all coronary artery anomalies (CAA) are present at birth, most of these are found incidentally during coronary angiography. Anomalous origin of a coronary artery does not generally lead to myocardial ischemia. Herein, we report a rarely seen one, a case of anomalous origin of the left anterior descending (LAD) coronary artery arising from the right sinus of Valsalva (RSV) as a rare cause of myocardial ischemia. 1. Case report A 45-year-old man presented at the Department of Cardiology of our institution with chest discomfort on exertion, which he had been experiencing for 5 years. He had no family history of ischemic heart disease and no known coronary risk factors. Upon detailed examination, he was
⁎ Corresponding author. Zonguldak Karaelmas Universitesi, Tip Fakultesi, Kardiyoloji Anabilimdali, Kozlu 67600, Zonguldak, Turkey. Tel.: +90 5422559200; fax: +90 372 2610155. E-mail address: [email protected] (S.M. Dogan). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.03.063
diagnosed as having chronic stable angina pectoris. An electrocardiogram showed normal sinus rhythm without significant ST-segment changes. A conventional exercise stress test was positive. Then, we scheduled myocardial perfusion scintigraphy. A single photon emission computed tomographic (SPECT) study was performed with 20 mCi of technetium–99m methoxyisobutylisonitrile (Tc-99 m MIBI) after an exercise stress test and again with the patient at rest. On the images taken after the stress, hypoperfusion was seen in the mid- and apical segments of the anterolateral wall of the heart. Perfusion of these segments returned to normal on the images taken with the patient at rest (Fig. 1). These disturbances suggested ischemic changes induced by the test. Therefore, we performed left heart catheterization; coronary angiography revealed coronary arteries that were free of any lesion. The left circumflex artery (LCx) and the diagonal branches were arising from the left main coronary artery (LMCA) (Fig. 2). The LAD artery was found to arise from the right coronary ostium and to course between the aorta and the pulmonary trunk (Figs. 3 and 4). As the diagonal branches and LCx artery were well developed, and the LAD artery was small, the jeopardized area was seen in limited
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Fig. 1. Scintigraphic images taken after the stress, hypoperfusion was seen in the mid- and apical segments of the anterolateral wall of the heart. Perfusion of these segments returned to normal on the images taken with the patient at rest.
Most of the coronary artery anomalies (CAA) are incidentally detected during selective coronary angiography. The incidence varies between 0.6% and 1.3% in various series [1,2]. Not all patients who have coronary anomalies have symptoms of ischemia. Anomalous origin of the left coronary artery from the right anterior sinus or from the proximal part of RCA can be classified upon the course taken by it in relation to aorta and pulmonary trunk in route to left side of the heart. The prognostic factor in CAA is the course of the coronary artery arising from the aorta. Of particular importance is the identification of cases in which the course of an anomalous
coronary artery from the contralateral coronary sinus is between aorta and the pulmonary trunk. This particular course is angiographically identified in the right anterior oblique projection when the coronary artery forms a cranioposterior loop [3]. Interarterial course of left coronary artery causes serious risk to subject like angina, syncope, myocardial infarction and sudden cardiac death [4,5]. Atherosclerosis and life-threatening arrhythmias [6–8] or abnormal myocardial perfusion [9] could be seen in patients with CAA. Our patient's symptoms occurred with exercise. We believe that his chest discomfort was caused by the pressure of the aorta on the LAD as it coursed between the aorta and the pulmonary trunk. During effort, the root of the aorta widens due to increased blood flow. In our patient, these conditions exerted additional pressure on the LAD; therefore, blood flow through the LAD artery could not meet the increased demand of blood flow for the myocardium, and
Fig. 2. Left lateral projection of the left main coronary artery. The LCx and the diagonal branches are free of any lesion; LAD artery cannot be seen.
Fig. 3. Left lateral projection of the right coronary artery. LAD artery with septal braches can be seen clearly.
scintigraphy. For that reason we prohibited the strenuous efforts to prevent LAD artery pressed between the aorta and the pulmonary trunk. 2. Discussion
S.M. Dogan et al. / International Journal of Cardiology 112 (2006) e57–e59
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the anomalous LAD from the RCA or the RSV are asymptomatic, therapeutic approach must be individualised in each subject. In asymptomatic subjects, age of the patient and type of the anomalous artery should be carefully evaluated during the therapeutic approach. Surgical correction is generally indicated for patients who have symptoms or when these anomalies are identified in the youth. Strenuous efforts should be prohibited in such patients with interarterial course. References
Fig. 4. Right anterior oblique projection of the right coronary artery. LAD artery is arising from RCA and it forms a cranioposterior loop defining that the course is between the aorta and the pulmonary trunk.
ischemia occurred. Our patient, who had interarterial course of LAD, have myocardial ischemia on stress. Taylor et al. reported extremely high sudden death rate (82%) in patients with the anomalous LMCA with interarterial course [10]. This suggests that patients with interarterial type anomalous LAD may also have a high possibility of serious ischemic events. Raynord et al. [5] reported one and Ono et al. [11] two cases of interarterial type anomalous LAD with angina at rest, in which LIMA-toLAD bypass were effective [5]. On the other hand, Mirchandani and Phoon [12] reported a 6-year-old with exertional chest pain. Transthoracic echocardiography revealed an anomalous right coronary artery arising from the left sinus of Valsalva, coursing between the aorta and the pulmonary artery. Without any intervention for 4 years of follow-up, he was remained clinically well. In our patient, it is of note that the LAD has an interarterial course, and the whole coronary tree was free of any coronary lesion. This fact may support the aforementioned possible mechanism for ischemia seen in the anomalous LAD. Although the majority of patients with
[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] Serota H, Barth CW, Seuc CA, et al. Rapid identification of the course of anomalous coronary arteries in adults: the ‘dot and eye’ method. Am J Cardiol 1990;65:891–5. [4] Roberts WC, Bethesda MD. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986;111:941–63. [5] Raynord 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. [6] 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 2005;102:341–3. [7] Vijayvergiya R, Kumar Jaswal R. Anomalous left anterior descending, absent circumflex and unusual dominant course of right coronary artery: a case report. Int J Cardiol 2005;102:147–8. [8] Avanzas P, Quiles J, Abeytua M, Garcia E. Anomalous origin of circumflex coronary artery arising from proximal right coronary artery. Int J Cardiol 2005;98:527–8. [9] Ozeren A, Aydin M, Bilge M, Cam F. Anomalous left coronary artery arising from the right sinus of Valsalva: a case report. Int J Cardiol Jun 8 2005;101(3):491–3. [10] Taylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol 1992;20:640–7. [11] Ono M, Brown DA, Wolf RK. Two cases of anomalous origin of LAD from right coronary artery requiring coronary artery bypass. Cardiovasc Surg 2003;11:90–2. [12] Mirchandani S, Phoon CK. Management of anomalous coronary arteries from the contralateral sinus. Int J Cardiol 2005;102:383–9.
Letter to the editor
Myocardial ischemia caused by a coronary anomaly left anterior descending coronary artery arising from right sinus of Valsalva Sait Mesut Dogan a,⁎, Metin Gursurer a , Mustafa Aydin a , Hakan Gocer a , Mehmet Cabuk b , Aydin Dursun a a
Department of Cardiology, Faculty of Medicine, Zonguldak Karaelmas University, Zonguldak, Turkey b Nuclear Medicine, Faculty of Medicine, Zonguldak Karaelmas University, Zonguldak, Turkey Received 26 December 2005; received in revised form 28 February 2006; accepted 11 March 2006 Available online 11 July 2006
Abstract We present the case of a patient in anomalous origin of the left anterior descending coronary artery that caused myocardial ischemia and led to positive myocardial scintigraphic results. Coronary angiography showed that the left anterior descending coronary artery arose from the right coronary ostium–an anomaly that has been associated with chest discomfort–without atherosclerotic lesions. Left circumflex artery and the diagonal branches were arising from the left main coronary artery and the whole coronary tree were free of atherosclerosis. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Coronary angiography; Coronary artery anomalies; Myocardial ischemia; Scintigraphy
Although all coronary artery anomalies (CAA) are present at birth, most of these are found incidentally during coronary angiography. Anomalous origin of a coronary artery does not generally lead to myocardial ischemia. Herein, we report a rarely seen one, a case of anomalous origin of the left anterior descending (LAD) coronary artery arising from the right sinus of Valsalva (RSV) as a rare cause of myocardial ischemia. 1. Case report A 45-year-old man presented at the Department of Cardiology of our institution with chest discomfort on exertion, which he had been experiencing for 5 years. He had no family history of ischemic heart disease and no known coronary risk factors. Upon detailed examination, he was
⁎ Corresponding author. Zonguldak Karaelmas Universitesi, Tip Fakultesi, Kardiyoloji Anabilimdali, Kozlu 67600, Zonguldak, Turkey. Tel.: +90 5422559200; fax: +90 372 2610155. E-mail address: [email protected] (S.M. Dogan). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.03.063
diagnosed as having chronic stable angina pectoris. An electrocardiogram showed normal sinus rhythm without significant ST-segment changes. A conventional exercise stress test was positive. Then, we scheduled myocardial perfusion scintigraphy. A single photon emission computed tomographic (SPECT) study was performed with 20 mCi of technetium–99m methoxyisobutylisonitrile (Tc-99 m MIBI) after an exercise stress test and again with the patient at rest. On the images taken after the stress, hypoperfusion was seen in the mid- and apical segments of the anterolateral wall of the heart. Perfusion of these segments returned to normal on the images taken with the patient at rest (Fig. 1). These disturbances suggested ischemic changes induced by the test. Therefore, we performed left heart catheterization; coronary angiography revealed coronary arteries that were free of any lesion. The left circumflex artery (LCx) and the diagonal branches were arising from the left main coronary artery (LMCA) (Fig. 2). The LAD artery was found to arise from the right coronary ostium and to course between the aorta and the pulmonary trunk (Figs. 3 and 4). As the diagonal branches and LCx artery were well developed, and the LAD artery was small, the jeopardized area was seen in limited
e58
S.M. Dogan et al. / International Journal of Cardiology 112 (2006) e57–e59
Fig. 1. Scintigraphic images taken after the stress, hypoperfusion was seen in the mid- and apical segments of the anterolateral wall of the heart. Perfusion of these segments returned to normal on the images taken with the patient at rest.
Most of the coronary artery anomalies (CAA) are incidentally detected during selective coronary angiography. The incidence varies between 0.6% and 1.3% in various series [1,2]. Not all patients who have coronary anomalies have symptoms of ischemia. Anomalous origin of the left coronary artery from the right anterior sinus or from the proximal part of RCA can be classified upon the course taken by it in relation to aorta and pulmonary trunk in route to left side of the heart. The prognostic factor in CAA is the course of the coronary artery arising from the aorta. Of particular importance is the identification of cases in which the course of an anomalous
coronary artery from the contralateral coronary sinus is between aorta and the pulmonary trunk. This particular course is angiographically identified in the right anterior oblique projection when the coronary artery forms a cranioposterior loop [3]. Interarterial course of left coronary artery causes serious risk to subject like angina, syncope, myocardial infarction and sudden cardiac death [4,5]. Atherosclerosis and life-threatening arrhythmias [6–8] or abnormal myocardial perfusion [9] could be seen in patients with CAA. Our patient's symptoms occurred with exercise. We believe that his chest discomfort was caused by the pressure of the aorta on the LAD as it coursed between the aorta and the pulmonary trunk. During effort, the root of the aorta widens due to increased blood flow. In our patient, these conditions exerted additional pressure on the LAD; therefore, blood flow through the LAD artery could not meet the increased demand of blood flow for the myocardium, and
Fig. 2. Left lateral projection of the left main coronary artery. The LCx and the diagonal branches are free of any lesion; LAD artery cannot be seen.
Fig. 3. Left lateral projection of the right coronary artery. LAD artery with septal braches can be seen clearly.
scintigraphy. For that reason we prohibited the strenuous efforts to prevent LAD artery pressed between the aorta and the pulmonary trunk. 2. Discussion
S.M. Dogan et al. / International Journal of Cardiology 112 (2006) e57–e59
e59
the anomalous LAD from the RCA or the RSV are asymptomatic, therapeutic approach must be individualised in each subject. In asymptomatic subjects, age of the patient and type of the anomalous artery should be carefully evaluated during the therapeutic approach. Surgical correction is generally indicated for patients who have symptoms or when these anomalies are identified in the youth. Strenuous efforts should be prohibited in such patients with interarterial course. References
Fig. 4. Right anterior oblique projection of the right coronary artery. LAD artery is arising from RCA and it forms a cranioposterior loop defining that the course is between the aorta and the pulmonary trunk.
ischemia occurred. Our patient, who had interarterial course of LAD, have myocardial ischemia on stress. Taylor et al. reported extremely high sudden death rate (82%) in patients with the anomalous LMCA with interarterial course [10]. This suggests that patients with interarterial type anomalous LAD may also have a high possibility of serious ischemic events. Raynord et al. [5] reported one and Ono et al. [11] two cases of interarterial type anomalous LAD with angina at rest, in which LIMA-toLAD bypass were effective [5]. On the other hand, Mirchandani and Phoon [12] reported a 6-year-old with exertional chest pain. Transthoracic echocardiography revealed an anomalous right coronary artery arising from the left sinus of Valsalva, coursing between the aorta and the pulmonary artery. Without any intervention for 4 years of follow-up, he was remained clinically well. In our patient, it is of note that the LAD has an interarterial course, and the whole coronary tree was free of any coronary lesion. This fact may support the aforementioned possible mechanism for ischemia seen in the anomalous LAD. Although the majority of patients with
[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] Serota H, Barth CW, Seuc CA, et al. Rapid identification of the course of anomalous coronary arteries in adults: the ‘dot and eye’ method. Am J Cardiol 1990;65:891–5. [4] Roberts WC, Bethesda MD. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986;111:941–63. [5] Raynord 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. [6] 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 2005;102:341–3. [7] Vijayvergiya R, Kumar Jaswal R. Anomalous left anterior descending, absent circumflex and unusual dominant course of right coronary artery: a case report. Int J Cardiol 2005;102:147–8. [8] Avanzas P, Quiles J, Abeytua M, Garcia E. Anomalous origin of circumflex coronary artery arising from proximal right coronary artery. Int J Cardiol 2005;98:527–8. [9] Ozeren A, Aydin M, Bilge M, Cam F. Anomalous left coronary artery arising from the right sinus of Valsalva: a case report. Int J Cardiol Jun 8 2005;101(3):491–3. [10] Taylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol 1992;20:640–7. [11] Ono M, Brown DA, Wolf RK. Two cases of anomalous origin of LAD from right coronary artery requiring coronary artery bypass. Cardiovasc Surg 2003;11:90–2. [12] Mirchandani S, Phoon CK. Management of anomalous coronary arteries from the contralateral sinus. Int J Cardiol 2005;102:383–9.