Anomalous right coronary artery originating from the mid left anterior descending artery

A 68-year-old male with a history of hypertension and hypercholesterolemia presented with recurrent episodes of chest discomfort. A 12-lead ECG and an echocardiogram were normal. A myocardial perfusion study could not rule out ischemia in the inferior wall. At coronary angiography using the transradial approach, the right coronary artery (RCA) could not be visualized. Angiography of the left coronary system demonstrated non-obstructive atherosclerosis involving the mid segment of the left anterior descending (LAD) artery and a normal circumflex (Cx) artery. The RCA originated from the mid LAD segment distal to the first septal perforator and the first diagonal branch and was free of atherosclerosis disease. A contrast-enhanced 64-slice multi-detector cardiac computed tomography showed that the LAD was severely calcified in the proximal part, and the RCA coursed anterior to the right ventricular outflow tract (RVOT) to reach the right atrioventricular groove. The patient was managed medically and became asymptomatic.     

Bilateral coronary artery to left ventricular fistulas

Congenital coronary artery fistulas are important coronary artery anomalies. Bilateral coronary artery fistulas are very rare and coronary artery to left ventricular communications are even more infrequent. This report describes a patient with bilateral right and left coronary artery fistulas draining into a common channel and emptying into the left ventricular cavity.     

Incidence of exertional right ventricular wall motion abnormalities in patients with coronary artery disease

To evaluate the role of analysis of right ventricular function with exercise in patients with presumed coronary artery disease referred for radionuclide ventriculography, the records of 55 patients referred to our laboratory over a 19-month period were reviewed. All underwent rest and exercise first-pass radionuclide stress testing and cardiac catheterization within a period of four months. Three groups were identified: (1) patients with normal exercise right ventricular function (n = 24); (2) patients with exercise-induced right ventricular regional wall motion abnormalities (n = 15); and, (3) patients with abnormal resting right ventricular function without new exercise abnormalities (n = 16). Patients in each group were similar in age, sex, baseline left ventricular function, medication usage, and indication for study. The incidence of right coronary artery disease was identical in the three groups, as was the incidence of left ventricular functional abnormalities with exercise. Patients with proximal right coronary artery disease were more likely to have reduced left ventricular ejection fraction and more extensive coronary artery disease than those without disease at this site. We conclude that: (1) analysis of rest and exercise right ventricular function does not allow prediction of coronary anatomy in an unselected group of patients; (2) normal right ventricular function with exercise is compatible with extensive coronary artery disease, including proximal right coronary artery disease; and (3) abnormal exercise right ventricular function may be due to exertional left ventricular dysfunction in the absence of proximal right coronary artery disease.     

Anomalous origin of the right coronary artery arising from the circumflex artery

A case of anomalous origin of the right coronary artery discovered among 3100 selective coronary arteriograms is described. This artery was arising from the circumflex artery. The position, distribution, and configuration of this coronary artery was as a normal right coronary artery, except that its origin was in the peripheral segment of the circumflex artery. This anomalous origin is very rare and seems not to give rise to any clinical significance.     

Spontaneous coronary artery dissection in a professional body builder

A 23-year-old male, a professional body builder, developed squeezing retrosternal chest pain following weight lifting. On examination, heart rate was 42 bpm and he had blood pressure of 70/50 mm Hg. An electrocardiogram was taken and showed inferior and right ventricular ST elevation myocardial infarction. Therefore, emergency coronary angiography was done and showed normal left coronaries. Right coronary artery angiogram revealed a dissection in the mid-part of the right coronary artery which was extended to the right ventricular branch.     

Echocardiographic prediction of the site of coronary artery obstruction in acute myocardial infarction

In 49 patients with acute myocardial infarction (AMI), the infarctiontopography was assessed by cross-sectional echocardiographyand the location of coronary artery obstruction were correlated.A ventricular segmentation of 5 right and 16 left ventricularsegments was used. The site of coronary obstruction was determinedin 45 patients by coronary angiography and by necropsy in 4patients. The exact location of the obstruction could not befound in 4 patients. The infarct related vessel was the leftmain artery in 1 patient, the left anterior descending artery(LAD) in 19, the left circumflex in 6 and the right coronaryartery in 24.Specific segments were identified for each of the3 coronary arteries: anteroseptal and anterior segments forLAD, right ventricular segments for the right coronary arteryand basal anterolateral segment for the left circumflex. Specificsegments (specificity 100%) were also identified for the principalcoronary branches: basal anterior for the first anterior descendingdiagonal (sensitivity 71%), basal anteroseptal for the firstseptal perforator (83%), middle anterior for the second diagonal(100%), middle anteroseptal for the second septal (89%), basalposteroseptal for a dominant right coronary artery (89%), rightventricular anterolateral segment for the right ventriclar marginalbranch (83%) Echocardiographic identification of the topography of AMI canbe useful in recognizing the infarct-related vessel and identifyingthe site of coronary artery obstruction.     

Imaging the elusive anomalous origin of left coronary artery from pulmonary artery

A 7‐year‐old girl with severe mitral regurgitation and pulmonary artery hypertension with good ventricular function was planned for mitral valve repair, but was subsequently diagnosed to have anomalous left coronary artery from pulmonary artery. We describe the pitfalls in the diagnosis of this rare anomaly, particularly in the presence of severe pulmonary artery hypertension and absence of circumstantial evidence of coronary steal and ventricular dysfunction.     

Acute coronary syndrome in a patient with a single coronary artery arising from the right sinus of Valsalva

Coronary artery anomalies are usually encountered as coincidental findings during coronary angiography or at autopsy.Life threatening symptoms,such as arrhythmias,syncope,myocardial infarction,or sudden death,can occur in up to 20% of patients.However,the majority of anomalies(80%) are benign and asymptomatic.A single coronary artery(SCA) is one of the most rarely seen coronary anomalies with an incidence of 0.05%.We report the case of a 55-year old male patient who presented with symptoms of chest pain associated with an acute myocardial infarction.Coronary angiography revealed an anomalous left main coronary artery(LMCA) originating from the right coronary ostium,and an occluded distal right coronary artery.The occluded distal right coronary artery was successfully treated by thrombosuction and stenting.In order to confirm the origin and course of the SCA,multi-slice computed tomography(MSCT) of the heart was performed after coronary angiography.MSCT showed that the anomalous LMCA originated from the right coronary artery ostium and then passed the interventricular septum,instead of being intra arterial,and under the right ventricular infundibulum.The anomalous LMCA was classified as R-Ⅱ S subtype according to Lipton’s classification.     

Survival with total occlusion of the left main coronary artery. Significance of the collateral circulation

Four patients with total occlusion of the left main coronary artery are described. Angina pectoris was severe (NYHA class 3-4) and had lasted 20 months to seven years. Three patients had experienced a myocardial infarction. All displayed large collaterals arising from a nearly normal right coronary artery and feeding both the left anterior descending and the left circumflex arteries. The left ventricular ejection fractions ranged from 20% to 65%, and all patients had varying degrees of left ventricular asynergy. Coronary artery bypass surgery resulted in a marked improvement in three patients; one patient who underwent an aneurysmectomy died two months after the operation. The data show that total occlusion of the left main coronary artery is compatible with survival if adequate collateral supply develops from the right coronary artery. In this rare angiographic subset collateral circulation is clearly functionally significant.     

Left ventriculography induced coronary artery spasm

Angiographic contrast material is generally considered a vasodilator, although in vitro experiments have documented a spasmogenic effect. In this report we describe a patient with exercise and rest angina who developed spasm of the right coronary artery immediately following left ventricular angiography. The patient was treated successfully with calcium channel blockers. This is the first reported case of left ventricular angiography-induced coronary artery spasm.     

Supernumerary right coronary artery

A rare case of a patient with supernumerary right coronary artery in whom the two vessels arose from the right coronary sinus from two separate ostia adjacent to each other is presented. The smaller vessel gave off the sinoatrial nodal branch and the posterior descending artery whereas the larger one gave off the conus branch, the right ventricular branches, and continued as acute marginal branch. This is the first case report in the English literature.     

Noninvasive assessment of significant right coronary artery stenosis based on coronary flow velocity reserve in the right coronary artery by transthoracic Doppler echocardiography

BACKGROUND: Coronary flow velocity reserve (CFVR) measured by transthoracic Doppler echocardiography (TTDE) has been reported to be useful for the noninvasive assessment of coronary stenosis in the left anterior descending artery. However, the measurement of CFVR in the right coronary artery by TTDE has not yet been validated in a clinical study. OBJECTIVE: The aim of this study was to evaluate whether CFVR by TTDE can detect significant stenosis in the right coronary artery. METHODS: We studied 50 patients who underwent coronary angiography. Coronary flow velocity in the posterior descending branch of the right coronary artery (PD) was measured by TTDE both at baseline and during hyperemia induced by the intravenous infusion of adenosine triphosphate. CFVR was calculated as the hyperemia/baseline (average diastolic peak velocity). RESULTS: Adequate spectral Doppler recordings in the PD were obtained in 36 patients including 26 patients who were given an echocardiographic contrast agent to improve Doppler spectral signals. The study population was divided into 2 groups with (Group A;n = 11) and without (Group B;n = 25) significant stenosis in the right coronary artery. CFVR in Group A was significantly smaller than that in Group B (1.6+/-0.3versus2.5+/-0.4; P < 0.0001). The sensitivity of a CFVR of <2.0 for predicting the presence of significant stenosis in the right coronary artery was 91%, and the specificity was 88%. CONCLUSIONS: The measurement of CFVR in the PD by TTDE is useful for the noninvasive assessment of significant stenosis in the right coronary artery.     

Functional assessment of anomalous right coronary artery using fractional flow reserve

Anomalous origin of a coronary artery is a recognized cause of sudden cardiac death (SCD). To date, there is no standard test to predict which patients are at increased risk for SCD. Fractional flow reserve (FFR) is an invasive technique used to qualify focal obstructive coronary lesions. We present a case where FFR was used to guide therapy in a young patient with anomalous right coronary artery (ARCA) when standard noninvasive testing showed ischemic discrepancy. © 2016 Wiley Periodicals, Inc.     

Nondominant right coronary artery occlusion and ventricular tachyarrythmias.

It is usually considered that occlusion of a nondominant right coronary artery is not associated with significant consequences. We report two cases of nondominant right coronary artery occlusion that presented with sudden cardiac death. Timely intervention resulted in complete resolution of the ventricular arrhythmias. This highlights the need for greater vigilance in the recognition and treatment of these lesions.     

Triple origin of left coronary arteries from right coronary artery: Unusual case of single coronary artery

A rare case of coronary anomaly is presented: all of the coronary arteries originated from a single ostium located in the right coronary cusp. No clinical evidence of coronary pathology was recognized until the age of 57 years when the patient was found to have coronary obstructive disease. The single coronary artery had a main branch corresponding to the usual dominant right coronary artery. Three other branches separated from this and vascularized the areas normally receiving the circumflex and ramus medianus, the left anterior descending, and a large septal branch.     

Anomalous origin of the right coronary artery from the ascending aorta above the left coronary sinus

Ectopic origin of the right coronary artery is an infrequent anomaly. We report a case in which the right coronary artery arose from the ascending aorta above the left sinus. This anomaly was associated with a bicuspid aortic valve. Techniques for delineation of the ectopic origin of the right coronary artery are discussed.     

The distribution and severity of coronary artery disease and left ventricular dysfunction among patients with single coronary artery disease and angina pectoris

The distribution and severity of coronary artery disease and left ventricular dysfunction were evaluated in 103 patients with single coronary artery disease and angina pectoris. The coronary arterial patterns were separated into right (76), mixed (18), and left (9) systems depending upon the blood supply to the inferior surface of the left ventricle. The following relationships were noted: (1) In patients with single coronary artery disease and angina pectoris, coronary arterial lesions are similar among right, mixed, and left systems. (2) In order of frequency, single coronary artery disease occurred most commonly in the left anterior descending coronary artery (55), next most commonly in the right coronary artery (36), and least commonly in the circumflex/obtuse marginal coronary artery (12). (3) Left ventricular wall motion abnormalities were seen in descending order of frequency: patients with right coronary artery (50%), left anterior descending coronary artery (36%), and circumflex/obtuse marginal coronary artery (25%) disease.     

Complete occlusion of the left main coronary artery: clinical and angiographic observations in five cases

Involvement of the left main coronary artery is observed in approximately 5 to 8% of patients with coronary artery lesions detected by coronary angiography, but occlusion of the left main artery is a very infrequent finding. Out of approximately 4000 patients undergoing coronary angiography, four men and one woman, 37 to 60 years old, showed total occlusion of this vessel. Four of them had angina pectoris and three had had a myocardial infarction. All five showed deep ST depression in V 2(or 3)-6 during bicycle exercise testing. Apart from the left main artery occlusion, all had significant obstructive lesions in other coronary vessels, including the right coronary artery or its major branches. There was collateral circulation from the right coronary artery in all patients. Left ventricular function was well preserved in three patients and markedly impaired in two. Four patients underwent bypass surgery and they have been followed for 10 to 28 months. Three are free of angina and one has only minimal angina. One patient refused surgery and he continued to have severe angina despite intense medical treatment. He died suddenly after 30 months follow-up. In patients with complete occlusion of the left main coronary artery, development of adequate collateral flow seems important in preserving left ventricular function, but collaterals are usually insufficient to prevent angina. Moreover, associated obstructive lesions in other coronary arteries constitute a potential threat to the collateral circulation. Effective symptomatic relief is obtained by coronary bypass grafting, and revascularization may also improve prognosis in this subset of patients with coronary heart disease.     

Aortic implantation of the anomalous left coronary artery from the pulmonary artery: One-year angiographic follow-up

Surgical aortic reimplantation of the anomalous origin of the left coronary artery from the pulmonary artery in a 16-year-old boy is reported. One-year angiographic follow-up showed patency of the reimplanted coronary ostium, normalization of left ventricular segmental wall motion and volume, and reduction in the caliber of the right coronary artery. This is the surgical correction procedure of choice in anatomically feasible cases.     

Ruptured aneurysm of the sinus of valsalva with single coronary artery

This paper will report the case of a patient with an aneurysm of Valsalva's sinus accompanied by single coronary artery (the presence of only a single ostium of the coronary arteries), who survived for 14 years, under conservative treatment, after a rupture of the aneurysm. In this patient the aneurysm of Valsalva's sinus ruptured from the right coronary sinus into the right ventricular outflow tract. The single coronary artery originated from the left coronary sinus, and the right coronary artery branched from the left main trunk and ran dorsally to the aorta. No case of ruptured aneurysm of Valsalva's sinus accompanied by a single coronary artery has been reported in the literature. After 14 years of conservative treatment, the patient was surgically treated by direct suture of the ruptured aneurysm and by aortic valve replacement. The postoperative course was uneventful.