Anomalies of the coronary arteries originating from the right sinus of Valsalva. (1) Single coronary artery originating from the right sinus associated with fusion of the left and the non coronary cusp and atrophy of the left coronary ostium (2)Three separate coronary arteries originating from the right sinus of Valsalva

We report three patients with the entire coronary origin arising from the right sinus of Valsalva. The first patient had a single right coronary ostium associated with a bi-leaflet aortic valve. The second patient was admitted with ST-elevation myocardial infarction (STEMI) for primary PCI. The third patient had 3 isolated ostia, all originating from the right sinus of Valsalva. Coronary anomalies are associated with increased mortality, depending on the myocardium at risk. A left main originating from the right coronary sinus is supplying a greater extent of the myocardium and is associated both with an increased incidence of symptoms and of sudden cardiac death. The possibility of such an artery anomaly should always be considered in young individuals with a history of chest pain or syncope.     

Anomalous origins of the left coronary arteries from the right sinus of Valsalva with an unusual course

We report and attempt to classify a previously undescribed coronary artery anomaly. Our patient had all three coronary arteries arising from a common ostium in the right sinus of Valsalva, with an unusual distribution to the left coronary artery system: the anomalous left circumflex system taking an intraseptal (intramyocardial) course and the anomalous left anterior descending system taking an interarterial (between the great vessels) course. Cathet. Cardiovasc. Diagn. 42:437–439, 1997. © 1997 Wiley-Liss, Inc.     

Left main coronary artery originating in the right sinus of Valsalva.

A forty-one-year-old male, with no risk factors for coronary artery disease (CAD) and with moderate alcohol intake, was admitted in 1992 to Portalegre Hospital with heart failure due to viral cardiomyopathy. He was re-admitted in 1998 with acute pulmonary edema and was put on mechanical ventilation for 48 hours, and transferred to Pulido Valente Hospital when stable. The physical exam was without abnormalities. ECG showed first degree AV block, left ventricular hypertrophy and 2 mm ST depression in the precordial leads. The echocardiogram revealed left ventricular dilatation and depressed systolic function. Coronary angiography showed single-vessel CAD and coronary artery anomaly. Dobutamine stress echocardiography was halted due to hypertension, making it impossible to evaluate ischemic response. Holter monitoring showed five-complex ventricular tachycardia. The patient was discharged medicated with amiodarone, with indication for cardiac scintigraphy and electrophysiological study.     

Management of anomalous coronary arteries from the contralateral sinus

Anomalous origin of the coronary artery from the contralateral sinus of Valsalva, coursing between the aorta and pulmonary artery, has garnered much attention because of its association with sudden death. Current medical opinion is heavily skewed toward "successful" intervention. However, two key issues have not been critically analyzed: what is the true risk of sudden death from an anomalous coronary artery, and how does this risk balance against the risk of surgical intervention? Common misconceptions about risk derive from citations of autopsy data. In fact, the scant available data suggest a far lower absolute risk than commonly cited. The risks of surgical intervention, while likely quite low, remain real, and include aortic valve damage and neurological sequelae. The lack of long-term outcomes data precludes any definite recommendations in most patients. The decision to intervene is thus not straightforward, and should be approached cautiously and only after appropriate counseling of the patient.     

Anomalous origin of all three coronary arteries from right sinus of Valsalva in a patient with angina pectoris

Anomalous origin of coronary arteries is uncommon, and all 3 coronary arteries arising from a single sinus of Valsalva is very rare. The anomaly has been associated with myocardial infarction and sudden cardiac death in particular when the anomalous left coronary artery courses between the great vessels. Imaging modalities have a complementary role to angiography in the diagnosis. Percutaneous interventions are technically difficult. Surgical options like direct repair of anomalous artery or coronary artery bypass graft can be helpful. We report a case of a patient who presented with chest pain and was found to have all 3 coronary arteries arising from the right sinus of Valsalva.     

Anomalous left coronary artery from the right sinus of Valsalva associated with coronary atheromatosis

Anomalous origin of the left coronary artery from the right sinus of Valsalva is an anatomical abnormality that is usually associated with myocardial ischemia and sudden death. Although this abnormality may coexist with obstructive atherosclerotic coronary disease, disease is not usually found in the anomalous course of the artery. When this coronary anomaly and obstructive coronary disease are both present, it is difficult to determine the cause of ischemic symptoms. We report a case in which three different diagnostic techniques were used to find the cause of ischemic symptoms in a patient whose left coronary artery originated anomalously in the right sinus of Valsalva and followed a course between the aorta and the pulmonary trunk and who had obstructive atherosclerotic lesions in the right coronary artery. The techniques were conventional angiography, which was used for the initial diagnosis, multislice computerized tomography, which was used to determine the anomalous course of the artery and its relationship with vascular structures, and exercise echocardiography, which was used to evaluate ischemia in the left coronary artery territory after treatment of the stenoses in the right coronary artery.     

Anomalous origin of the right coronary high above the left sinus of Valsalva

Anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva is exceedingly rare and previously has been reported to be associated with congenital aortic valve disease. We report a case of the right coronary artery arising from the mid ascending aorta, high above the left sinus, with a clinically and angiographically normal aortic valve.     

An anomalous left main coronary artery with coronary torsion originating from the right sinus Valsalva

A 52-year old woman developed inferior ST elevation myocardial infarction and was found to have both an anomalous left coronary artery originating from the right sinus of Valsalva, and total atherosclerotic occlusion of the proximal right coronary artery. Coronary angiography showed the torsion of left main coronary artery. Multislice computed tomography was used to assess the left main coronary artery.     

Anomalous origin of coronary arteries: When one sinus fits all

A right coronary artery origin from the left coronary sinus and a left coronary origin from the right sinus although rarely encountered during routine cardiac catheterization, they represent two relatively common autopsy findings in young patients suffering sudden cardiac death. The interarterial course of the aberrant artery, between the aortic root and the pulmonary artery has been considered as a malignant variant, because of the higher risk of myocardial ischemia and sudden death. We present two rare cases of ectopic coronary origin from the opposite sinus of Valsalva.     

Anomalous origin of coronary arteries: When one sinus fits all

A right coronary artery origin from the left coronary sinus and a left coronary origin from the right sinus although rarely encountered during routine cardiac catheterization, they represent two relatively common autopsy findings in young patients suffering sudden cardiac death. The interarterial course of the aberrant artery, between the aortic root and the pulmonary artery has been considered as a malignant variant, because of the higher risk of myocardial ischemia and sudden death. We present two rare cases of ectopic coronary origin from the opposite sinus of Valsalva.     

Anomalous left coronary artery arising from the right sinus of Valsalva: a case report

We report a case of 56-year-old man whose coronary angiography showed a single coronary artery arising from a single ostium in the right sinus of Valsalva.     

Anomalous origin of the left main coronary artery from the right sinus of Valsalva

The clinical and angiographic findings in 10 patients with anomalous origin of the left main (LM) coronary artery from the right sinus of Valsalva are presented. The initial course of the anomalous artery was between the aorta and the pulmonary trunk in 6 patients (5 men and 1 woman), and posterior to the aorta in 4 patients (3 women and 1 man). The best coronary angiographic projection to determine the course of the LM coronary artery in relation to the aorta and pulmonary trunk was the right anterior oblique and lateral projections, with a catheter in the pulmonary trunk as a guide. In the right anterior oblique projection left ventriculogram, an increased density at the base of the aorta was seen in all patients with posterior-to-aorta course of the anomalous artery. The blood supply to the first portion of the ventricular septum is provided by 1 or 2 descending septal branches from the anomalous LM artery, when the anomalous vessel is coursing between the aorta and pulmonary trunk. When the anomalous LM courses posteriorly to the aorta, it does not provide any septal branches. In patients with this anomaly, the blood supply to the first portion of the septum is usually provided by descending septal branches originating from the right sinus of Valsalva or from the first portion of the right coronary artery. Six of the 10 patients had severe obstructive coronary artery disease. Four of the 6 patients had significant LM coronary artery disease.