Origin of all major coronary arteries from left sinus of Valsalva as a common coronary trunk: single coronary artery--a case report

Coronary anomalies are divergent and can occur in up to 1% to 2% of patients. The most common of these anomalies is separate ostia of the left anterior descending and left circumflex arteries, followed by origin of the circumflex coronary artery from the right coronary artery and the left coronary artery from the right sinus of Valsalva, either as a separate ostium or as a part of single coronary artery. Anomalous origin of right coronary artery from the left sinus of Valsalva with a separate ostium or from the left main coronary artery is very rare. These coronary anomalies may be incidentally diagnosed on routine angiography or may present with myocardial ischemia, infarction, or sudden death. A case is described in which all 3 coronary arteries were originating from the left sinus of Valsalva as a common trunk (single coronary artery), which trifurcated to left anterior descending, left circumflex, and right coronary artery.     

Right coronary artery emerging as a septal branch from the left anterior descending artery

Coronary artery anomalies are detected on approximately 1.3% of coronary angiograms. Single coronary artery anomaly (SCA) is defined as the coronary artery arising from a single coronary ostium, nourishing the entire heart. SCA anomalies are usually benign; however, serious complications such as sudden cardiac death and myocardial infarction resulting from these anomalies are also reported in the literature. We report the anomalous origin of the right coronary artery (RCA) as a continuum of the septal branch from the left anterior descending (LAD) artery, which is a very rare variation of a single coronary artery.     

Aberrant right ventricular branch of right coronary artery with mitral valve prolapse

A 37-year-old man presented with a three-week history of chest pain. Transthoracic echocardiography demonstrated a mitral valve prolapse and mild mitral insufficiency. Coronary angiography showed normal left main, circumflex, left anterior descending and right coronary arteries; however, the right ventricular branch of the right coronary artery had a separate ostium. Concomitant congenital heart abnormalities have been observed with coronary artery anomalies. Primary congenital coronary and valvular anomalies may have genetic heredity. In the present case, mitral valve prolapse was accompanied by a right ventricular coronary artery origin anomaly which, to the best of our knowledge, is the first report in the literature in which both anomalies presented together.     

Aberrant origin of the left anterior descending artery and quadrifurcation of coronary vessels associated with coronary artery disease: evaluation by computed tomographic angiography and coronary angiography

Coronary artery anomalies occur in approximately 0.2-12.2% of the adult population. Origin of left anterior descending artery and left circumflex artery from the right coronary cusp is relatively rare. The case we present is unique in that all 4 vessels (right coronary, left anterior descending, left circumflex and atrioventricular nodal branch) take off from the right coronary cusp, making a quadrifurcation. In this case, the left main artery is also absent. To our knowledge, there are few published case reports of anomalous origin of left anterior descending artery, but the total absence of a left main artery and quadrifurcation are unique to our case.     

Apport du scanner multibarrettes dans la détection des anomalies de naissance des artères coronaires avec trajet inter-aortopulmonaire : à propos de deux cas et revue de la littérature

Coronary anomalies are a rare entity. The gold standard remains the coronary angiogram. However, the identification of the origin and the course of aberrant coronary arteries using angiography may be difficult. We report two cases regarding two patients who underwent coronary angiography in order to evaluate coronary heart disease. In the first case, angiography has shown a left anterior descending artery (LAD) originating from the right anterior sinus. A multidetector CT scan (MDCT) showed an inter-aortopulmonary course of the LAD. In the second case, selective catheterization of the right coronary artery could not be done. A MDCT scan was performed. An abnormal origin of the right coronary artery was detected. It originates from the left sinus with a separate ostium of the left main coronary artery. This artery had an inter-aortopulmonary course. The 64 MDCT scan can be useful as a complementary tool for the diagnosis of coronary artery anomalies. Detection of the inter-aortopulmonary course is essential, since this situation will require surgical treatment to avoid sudden cardiac death.     

Single coronary artery from the right aortic sinus of Valsalva with anomalous prepulmonic course of the left coronary artery

Cardiac computed tomography allows for improved, noninvasive and accurate visualization of coronary artery anomalies. The case of a single coronary artery with origin from a single ostium in the right sinus of Valsalva with an anomalous course of the left coronary artery anterior to the pulmonary trunk is presented. The unusual distal reconstitution of a normal anatomical course at the junction of the mid and distal left anterior descending artery with occlusion of the proximal circumflex artery has not, to the authors’ knowledge, been previously described.     

Coronary arteries from a single coronary ostium in the right coronary sinus: a previously unreported anatomy

The coronary circulation originating from a single coronary ostium is rare. All possible anatomical variations were the basis of a recent classification. This case report describes a previously unreported IID(1) pattern, comprising a solitary coronary ostium in the right coronary sinus with an anatomical course of the right coronary artery. The left circumflex coronary artery arises from the proximal right coronary artery coursing behind the aorta to the left. The left anterior descending coronary artery arises from the proximal right coronary artery coursing to the left side anterior to the right ventricle.     

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.     

Associated coronary anomalies in 135 Iranian patients with tetralogy of Fallot

Coronary artery anomalies are common among patients with tetralogy of Fallot. One hundred and thirty-five patients (80 males and 55 females) with tetralogy of Fallot who underwent repair between 1995 and 2002 were studied to determine the incidence of coronary anomalies in Iranian patients. Eight (5.9%) patients (4 males and 4 females) had a surgically relevant coronary artery anomaly: single coronary ostium in 5, origin of the left anterior descending artery from the right coronary artery in 2, and origin of the right coronary artery from the left coronary artery in 1. The surgical technique in 3 of these patients was repair of the ventricular septal defect with a transverse incision on the right ventricle, without damage to the coronary arteries. In another patient, an allograft aortic valve cylinder was inserted. In the other 4 patients with a single coronary ostium, placement of a limited transannular patch was adequate. Consideration of these anomalies during primary repair could decrease the risk of operation in such patients. However, it seems that the presence of anomalous coronary arteries does not affect incremental risk after surgical repair.     

Coronary artery anatomy in corrected transposition of the great arteries

Congenitally corrected transposition of the great arteries is an unusual cardiac malformation with discordant atrioventricular and ventriculoarterial alignments. Because knowledge of the coronary artery anatomy is a prerequisite for successful repair of this cardiac anomaly, selective coronary arteriography was performed in 13 children (4 male and 9 female; age range 18 months to 16 years) and 1 adult (aged 59 years) with congenitally corrected transposition of the great arteries and associated intracardiac defects. The typical coronary distribution of corrected transposition (that is, coronary artery-ventricular concordance) was found in 11 patients. In one patient, a single coronary ostium was observed; the right sinus of Valsalva gave rise to a short common branch that divided into three arteries: a left circumflex artery going to the right, a well developed left anterior descending artery running into the anterior interventricular groove and a third vessel that continued on the normal course of the right coronary artery directed posteriorly. In one patient, the left circumflex artery was particularly small. In another patient, with severe hypoplasia of the left anterior descending coronary artery, the anterior ventricular wall of the heart was supplied by three small branches that ended a short distance from their origins. The adult patient had a large anterior ventricular branch arising from the morphologic left coronary ventricular as well as a large acute marginal branch, with a wide distribution, from the morphologic right coronary artery. Presurgical coronary angiographic documentation is helpful because, in congenitally corrected transposition as well as in complex congenital heart disease, coronary anomalies (in origin, course and distribution) are occasionally present and knowledge of their presence can help determine the most appropriate surgical approach.     

Left anterior descending artery of anomalous origin; Native lad arises from left internal mammarian artery. A case report and article review

Coronary artery anomalies are encountered in 2.6% of the population. Left anterior descending artery (LAD) stemming from a separate ostium is seen at a rate of 0.48%. In this case, we reported on a left internal mammarian artery (LIMA) giving rise to LAD. Coronary angiography was performed through the right radial artery in 54-year-old female patient. It did not reveal the presence of left main coronary artery in all three aortic sinuses. Pulmonary angiography also did not demonstrate LAD stemming from the pulmonary artery. Then, the LIMA was selectively visualized, and LAD originating from LIMA was observed. The PubMed database contains no reports of LIMA giving rise to LAD. This is the first case report demonstrating LAD originating from LIMA. Accordingly, if LAD cannot be visualized during angiography, an angiographic image of LIMA should be taken before a diagnosis of atresic LAD. For angiographic examination, the right radial route can be used.     

Detection of coronary artery abnormalities in tetralogy of Fallot by two-dimensional echocardiography

Patients with tetralogy of Fallot have a 5% to 19% incidence rate of abnormal distribution of coronary arteries. These abnormalities are usually detected by angiography and influence the timing and mortality rate of surgery. This study evaluates two-dimensional echocardiography as a method of assessing coronary artery distribution in tetralogy of Fallot. Forty-five consecutive patients with tetralogy of Fallot, aged 0.1 to 20.5 years (mean 5.7 +/- 4.3), had prospective two-dimensional echocardiographic studies to examine the branching patterns of the coronary arteries and to determine the presence or absence of a branch from the right or left coronary artery that crossed the right ventricular outflow tract. The first two patients had known coronary abnormalities and served as learning models. All other echocardiographic studies were performed without knowledge of angiographic or surgical findings. Twenty-two studies were completed before coronary angiography (group A) and 23 after angiography (group B). All eight patients (18%) with coronary abnormalities were correctly identified by two-dimensional echocardiography (five in group A and three in group B). Three had bilateral anterior descending coronary arteries originating from the left and right coronary arteries, two had the anterior descending artery originating from the right coronary artery, two had a large conal branch from the right coronary artery and one had origin of both left and right coronary arteries from a single left ostium. All abnormal coronary arteries were visualized crossing the right ventricular outflow tract, whereas all 21 small conal branches from the right coronary artery were not seen in the right ventricular outflow tract.(ABSTRACT TRUNCATED AT 250 WORDS)     

Single Coronary Ostium in Right Coronary Sinus: Previously Unreported “One for All” Configuration

We report our identification of a single coronary ostium arising from the right coronary sinus of Valsalva, in a 63-year-old woman who presented with chest pain atypical of angina. Coronary angiograms showed that the left anterior descending coronary artery arose from a right ventricular branch and that the left circumflex coronary artery arose from a right posterolateral branch. Both arteries reconstituted themselves in a backward fashion from the apex to the base of the heart—a configuration that to our knowledge has not been reported. The patient was treated conservatively and reported no chest pain 24 months later.     

Myocardial revascularization in a patient with situs inversus totalis

We report the case of a patient with dextrocardia and situs inversus totalis associated with obstructive coronariopathy in the anterior and posterior descending arteries, right coronary artery, first diagonal branch and left marginal branch. The patient underwent coronary artery bypass grafting surgery. This surgery has been rarely reported in literature and we found only one similar case in the national medical literature. The myocardial revascularization was carried out with the right mammary artery for the anterior descending artery. The saphenous vein anastomosed the aorta to the right coronary artery, left marginal branch, fist diagonal branch and posterior descending artery. The surgery was performed with extracorporeal circulation.     

Coronary anomalies: Incidence and importance

Most patients with coronary anomalies are asymptomatic. The knowledge of those variations could be important in regard to invasive catheter treatment or bypass surgery. In a retrospective study, the angiographic findings based on 4, 016 patients (1985-1989) were analyzed concerning coronary anomalies and malformations. Of the patients studied, 39 (0.97%) had coronary anomalies, and in 26 of these patients it was an anomalous circumflex branch. In 14 cases, the circumflex branch arose from a separate origin in the left aortic sinus. In 11 patients the origin was from the proximal segment of the right coronary artery. A singular coronary artery was found in five patients, originating from the right aortic sinus in two patients and from the left aortic sinus in three patients. An origin of the left coronary artery from the pulmonary artery, a coronary fistula, or an origin of the left anterior descending coronary artery from the RCA could be found in only one patient. Unexpected findings during invasive procedures would suggest a possibly existing coronary anomaly, especially when main branches cannot be opacified by selective contrast medium injection.     

Associated coronary and cardiac anomalies in the tetralogy of Fallot. An angiographic study

Numerous studies have pointed out the frequent association of tetralogy of Fallot (TF) with other cardiovascular defects and coronary tree anomalies. We found cardiac defects in 181 (68%) out of 265 patients with TF investigated by catheterization and selective coronary angiography. These anomalies were isolated in 88 cases (49%) and associated with others in 93 patients. In the case of an isolated anomaly associated with TF, the coronary tree was involved in 37.5% and the cardiovascular system in the remaining 62.5%; in the case of two anomalies, the coronary system was involved in 66% of the patients and the cardiovascular apparatus in 34%; in the case of three or more anomalies, the coronary arteries were involved in 71% and the cardiovascular system in 29%. Anomalies in the course and/or distribution of coronary arteries were present in 96 patients (36%): 10 had a single coronary ostium, 13 a left anterior descending artery arising from the right coronary artery, one a circumflex artery arising from the right coronary artery. Small fistulas between coronary arteries and the pulmonary artery were found in 20 cases; anastomoses between coronary and bronchial arteries or right atrium in 42. In 39 patients we observed a large conus artery or large anterior ventricular branches crossing the right ventricle. A right aortic arch was found in 56 patients (21%), a stenosis of the trunk and/or the peripheral pulmonary artery in 35 (13%) and pulmonary artery atresia in five. Four patients showed a complete atrioventricular canal, three an atrial septal defect (primum type) with cleft of the mitral valve, 61 (23%) an atrial septal defect (ostium secundum). Eleven patients had anomalies of the systemic venous return, 26 (10%) a patent ductus arteriosus. Four patients had valvular abnormalities. In our series, a large proportion of cardiac defects associated with TF consists of anomalies of coronary arteries. Our data confirm the usefulness of performing preoperatively routine coronary angiography in patients with complex congenital heart disease.     

Successful transradial intervention for two lesions with dual anomalous origins of coronary arteries

A 76-year-old male was admitted to our hospital for effort angina pectoris. His coronary computed tomography and coronary angiography revealed anomalous origins of the left anterior descending artery (LAD) from the proximal right coronary artery (RCA) and the left circumflex coronary artery (LCX) from the separate ostium in the right coronary cusp. Severe stenoses were present in the proximal segment of the LAD and in the middle segment of the LCX, which were successfully treated by 5 French (Fr) transradial approach intervention. Congenital coronary anomalies are relatively rare, with a prevalence of approximately 1.3% in a large-series study undergoing coronary angiography. Such anomalies occur in several anatomical arrangements, which have been classified in a number of research reports. Here we describe previously unreported dual anomalous origins of coronary arteries associated with significant atherosclerotic lesions, which were successfully treated by 5 Fr transradial approach intervention.     

Myocardial ischemia caused by anomaly at the origin of the left coronary artery

The case of a 68 years old man admitted because of angina "de novo" and submitted to coronariography is reported. The rest ECG showed abnormalities of the ST-T suggesting myocardial ischemia. The coronariography showed: No significant atherosclerotic lesions. The left coronary artery had an anomalous origin; the left descending coronary artery originated from an independent ostium located at the right Valsalva sinus, the circumflex artery had its origin at the same ostium as the right coronary artery.     

A case of intracoronary protruded thrombus caused after bailout stenting for side branch occlusion

A 69-year-old woman underwent percutaneous coronary intervention for a severe stenotic lesion in the bifurcation of the mid-left anterior descending artery and first diagonal branch. A single stent was implanted into the left anterior descending artery. After the stent strut was dilated by balloon inflation in the diagonal branch, dissection occurred at the ostium of the diagonal branch and resulted in side branch occlusion due to hematoma. Bailout stenting was performed in the diagonal branch, but thrombus projection occurred in the left anterior descending artery. Aspiration, balloon inflation and thrombolytic therapy were performed, but distal embolism developed. This case illustrates that thrombus projection caused by stenting in a side branch may occur as a rare complication in percutaneous coronary intervention.     

Origin and distribution anomalies of the left anterior descending artery in 70,850 adult patients: multicenter data collection.

OBJECTIVES: To present the clinical and angiographic properties of the left anterior descending artery anomalies. BACKGROUND: Coronary artery anomalies are discovered in less than 1% of angiography series. Since the number of angiographies and coronary bypass operations are increasing significantly every day, these anomalies are of clinical importance. However, data about left anterior descending artery anomalies in literature is still scarce. METHODS: We reviewed the records of 70,850 patients who had undergone coronary angiographies at 4 different cardiology center from 1999 to 2005 years. RESULTS: Major congenital coronary anomalies were discovered in 171 of these cases (0,24%). The mean age of these patients was 61 +/- 11 (18-84) years. Ninety nine patients (58%) were male. Left anterior descending artery was involved in 12 patients (0.017%). In nine patients with the anomalous LAD there were concomittant congenital coronary artery anomalies. Concurrent coronary artery anomalies encountered were double left anterior descending artery type 4 (2 cases), double left anterior descending artery type 4 with double right coronary artery (1), double right coronary artery (1), double circumflex artery with anomalous left anterior descending artery (1), circumflex artery from right sinus of Valsalva (1), separate septal perforator and myocardial bridging of posterior descending artery (1), intercoronary communication, and ostial atresia of the left anterior descending artery and anomalous circumflex artery (1). CONCLUSION: Our series is the biggest series where relatively sufficient clinical and angiographic information about the LAD anomalies were provided.