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Scott Med J OnlineFirst, published on January 27, 2015 as doi:10.1177/0036933014567599
Case Report
Anomalous origin of the right coronary artery from the left circumflex coronary artery: an extremely rare coronary anomaly
Scottish Medical Journal 0(0) 1–3 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933014567599 scm.sagepub.com
Babak Bagheri1, Razhan Piran2, Maryam Nabati3, Rozita Jalalian3 and Mozhdeh Dabirian3
Abstract Isolated single coronary artery is an extremely rare anomaly with an incidence of 0.024% to 0.066% which may be associated with other congenital anomalies. This report describes a 50-year-old woman who was referred with recurrent chest discomfort and was diagnosed with anomalous origin of the right coronary artery from the left circumflex coronary artery.
Keywords Anomalous coronary artery, right coronary artery, left circumflex artery
Introduction This report describes a 50-year-old woman who was referred with recurrent chest discomfort and was diagnosed with anomalous origin of the right coronary artery (RCA) from the left circumflex (LCX) coronary artery. Isolated single coronary artery is an extremely rare anomaly with an incidence of 0.024% to 0.066% which may be associated with other congenital anomalies.1 Single coronary anomalies usually are asymptomatic although they may present with typical chest pain, myocardial infarction or sudden cardiac death.2
Case presentation A 50-year-old woman with systemic hypertension was evaluated for coronary artery disease because of recurrent chest discomfort. A resting electrocardiogram showed normal sinus rhythm, normal axis, normal PR and QT intervals, no ST segment change and intraventricular conduction defect (QRS duration ¼ 100 ms). Exercise stress test showed horizontal ST segment depression for 2 ms in leads V5 and V6, after 6 min of exercise. Transthoracic echocardiography showed a left ventricular ejection fraction of 55% without regional wall motion abnormalities. Mild mitral regurgitation and mitral valve billowing were noted.
Cardiac catheterisation demonstrated that the left main was very short without any stenosis. There was no stenosis in left anterior descending and LCX arteries. LCX was very large. RCA could not be found with right Judkins catheter selectively. There was a medium size vessel originating from distal of LCX extending to the RCA course toward the right sinus of valsalva (Figure 1). This anomalous RCA was terminated near the right sinus of valsalva. Nonselective aortic root contrast injection demonstrated that there was no origin of RCA in the right sinus of valsalva (Figure 2). A 64-slice coronary computed tomography (CT) angiogram was performed to confirm that the course of anomalous RCA was not malignant and also it does not have intramuscular course (Figures 3 and 4). 1
Interventionist, Mazandaran Heart Center, Mazandaran University of Medical Sciences, Iran 2 General Cardiologist, Mazandaran Heart Center, Mazandaran University of Medical Sciences, Iran 3 Echocardiography Fellow, Mazandaran Heart Center, Mazandaran University of Medical Sciences, Iran Corresponding author: Babak Bagheri, Mazandaran Heart Center, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran. Email: [email protected]
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Figure 1. Coronary angiography, right anterior oblique (RAO) caudal view demonstrated anomalous RCA originating from distal of LCX.
Figure 2. Aortogram showed absent origin of RCA in right sinus of valsalva.
The coronary CT angiogram showed the RCA was originated from the distal of the large LCX and terminated near the right sinus of valsalva. It does not have malignant course.
Discussion The incidence of coronary artery anomalies is between 0.6% and 1.3% during coronary angiography and 0.3% in autopsies.2 Isolated single coronary artery is an extremely rare anomaly with an incidence of 0.024% to 0.066% which may be associated with other congenital anomalies.1 Single coronary anomalies usually are
Figure 3. Three-dimensional reconstructed coronary CT angiogram showed RCA originating from distal of LCX and terminated near the right sinus of valsalva.
Figure 4. Coronary CT angiogram showed that there was no origin of RCA in the right sinus of valsalva.
asymptomatic although they may present with typical chest pain, myocardial infarction or sudden cardiac death. The incidence of sudden cardiac death will increase in patients with a single coronary artery and left main coronary artery which courses between the aorta and pulmonary artery.2 Multi-slice CT angiography and cardiac magnetic resonance angiography are noninvasive, threedimensional imaging modalities with good diagnostic accuracy for coronary artery anomalies.3,4 The present study describes a patient with a single coronary anomaly in which the RCA originating from the distal of the LCX. This is a rather rare anomaly
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with the incidence of 0.00% to 0.35%.5 Although isolated congenital coronary anomalies are not risk factors for development of coronary artery stenosis,1,6 if the anomalous artery traverses within the aortic wall or between the aorta and pulmonary artery, the risk of myocardial ischemia and sudden cardiac death will increase.6 In our case, the anomalous RCA does not have intramuscular course and terminated near the right sinus of valsalva. In 1976, Chaitman et al.7 studied 3750 cases who were undergoing coronary angiography. They have reported that the incidence of the anomalous LCX artery originating from the RCA was 0.45%, but they found only one case of the anomalous origin of RCA from the LCX artery. In a large study in 1980, Sheldon et al.8 studied 38,703 patients who were undergoing coronary angiography. They reported an incidence of 0.45% (176 cases) of anomalous LCX artery originating from the RCA, but they found no case of anomalous origin of RCA from the LCX artery. In 1986, Tavernarakis et al.9 reported a case of anomalous origin of the RCA from LCX discovered among 3100 coronary angiographies. They suggested that this coronary anomaly did not have any clinical significance. In 2010, Sudip et al.1 reported a case of the anomalous origin of RCA from the distal LCX artery that had a benign course. Coronary angioplasty, surgery and medical treatment are therapeutic choices for the management of single coronary artery anomalies. The selection of the therapeutic option depends on the origin of the anomalous artery, its course and termination.2,6 The case presented here is a very rare and mostly benign form of coronary anomalies. According to the benign course of RCA and absence of stenosis, no invasive intervention was performed for the patient. Medical treatment for systemic hypertension and risk factors modification
was planned. After six months, she was well and asymptomatic. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of conflicting interests None declared.
References 1. Sudip D, Tarek M and Farrukh H. Anomalous right coronary artery originating from the distal left circumfelex artery: a novel coronary artery anomaly viewed by computed tomography and invasive angiography. Can J Cardiol 2010; 26: e213. 2. Chen HY. Anomalous origin of coronary arteries from a single sinus if Valsalva. Exp Clin Cardiol 2012; 17: 150–151. 3. Angelini P, Velasco JA and Flamm S. Coronary anomalies: incidence, pathophysiology, and clinical relevance. Circulation 2002; 105: 2449–2454. 4. Gilmour J, Kafka H, Ropchan G, et al. Anomalous right coronary artery: a multimodality hunt for the origin. Case Rep Cardiol 2011; 2011: 4. 5. Yamanaka O and Hobbs R. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990; 21: 28–40. 6. Angelini P. Coronary artery anomalies: an entity in search of an identity. Circulation 2007; 115: 1296–1305. 7. Chaitman BR, Lesperance J, Saltiel J, et al. Clinical angiographic and hemodynamic findings in patients with anomalous origin of the coronary arteries. Circulation 1976; 53: 122–131. 8. Sheldon W, Hobbs ER, Millit D, et al. Congenital variation of coronary artery anatomy. Cleve Clin Q 1980; 47: 126–130. 9. Tavernarakis A, Voudris V, Ifantis G, et al. Anomalous origin of the right coronary artery arising from the circumflex artery. Clin Cardiol 1986; 9: 230–232.
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Scott Med J OnlineFirst, published on January 27, 2015 as doi:10.1177/0036933014567599
Case Report
Anomalous origin of the right coronary artery from the left circumflex coronary artery: an extremely rare coronary anomaly
Scottish Medical Journal 0(0) 1–3 ! The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933014567599 scm.sagepub.com
Babak Bagheri1, Razhan Piran2, Maryam Nabati3, Rozita Jalalian3 and Mozhdeh Dabirian3
Abstract Isolated single coronary artery is an extremely rare anomaly with an incidence of 0.024% to 0.066% which may be associated with other congenital anomalies. This report describes a 50-year-old woman who was referred with recurrent chest discomfort and was diagnosed with anomalous origin of the right coronary artery from the left circumflex coronary artery.
Keywords Anomalous coronary artery, right coronary artery, left circumflex artery
Introduction This report describes a 50-year-old woman who was referred with recurrent chest discomfort and was diagnosed with anomalous origin of the right coronary artery (RCA) from the left circumflex (LCX) coronary artery. Isolated single coronary artery is an extremely rare anomaly with an incidence of 0.024% to 0.066% which may be associated with other congenital anomalies.1 Single coronary anomalies usually are asymptomatic although they may present with typical chest pain, myocardial infarction or sudden cardiac death.2
Case presentation A 50-year-old woman with systemic hypertension was evaluated for coronary artery disease because of recurrent chest discomfort. A resting electrocardiogram showed normal sinus rhythm, normal axis, normal PR and QT intervals, no ST segment change and intraventricular conduction defect (QRS duration ¼ 100 ms). Exercise stress test showed horizontal ST segment depression for 2 ms in leads V5 and V6, after 6 min of exercise. Transthoracic echocardiography showed a left ventricular ejection fraction of 55% without regional wall motion abnormalities. Mild mitral regurgitation and mitral valve billowing were noted.
Cardiac catheterisation demonstrated that the left main was very short without any stenosis. There was no stenosis in left anterior descending and LCX arteries. LCX was very large. RCA could not be found with right Judkins catheter selectively. There was a medium size vessel originating from distal of LCX extending to the RCA course toward the right sinus of valsalva (Figure 1). This anomalous RCA was terminated near the right sinus of valsalva. Nonselective aortic root contrast injection demonstrated that there was no origin of RCA in the right sinus of valsalva (Figure 2). A 64-slice coronary computed tomography (CT) angiogram was performed to confirm that the course of anomalous RCA was not malignant and also it does not have intramuscular course (Figures 3 and 4). 1
Interventionist, Mazandaran Heart Center, Mazandaran University of Medical Sciences, Iran 2 General Cardiologist, Mazandaran Heart Center, Mazandaran University of Medical Sciences, Iran 3 Echocardiography Fellow, Mazandaran Heart Center, Mazandaran University of Medical Sciences, Iran Corresponding author: Babak Bagheri, Mazandaran Heart Center, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran. Email: [email protected]
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Figure 1. Coronary angiography, right anterior oblique (RAO) caudal view demonstrated anomalous RCA originating from distal of LCX.
Figure 2. Aortogram showed absent origin of RCA in right sinus of valsalva.
The coronary CT angiogram showed the RCA was originated from the distal of the large LCX and terminated near the right sinus of valsalva. It does not have malignant course.
Discussion The incidence of coronary artery anomalies is between 0.6% and 1.3% during coronary angiography and 0.3% in autopsies.2 Isolated single coronary artery is an extremely rare anomaly with an incidence of 0.024% to 0.066% which may be associated with other congenital anomalies.1 Single coronary anomalies usually are
Figure 3. Three-dimensional reconstructed coronary CT angiogram showed RCA originating from distal of LCX and terminated near the right sinus of valsalva.
Figure 4. Coronary CT angiogram showed that there was no origin of RCA in the right sinus of valsalva.
asymptomatic although they may present with typical chest pain, myocardial infarction or sudden cardiac death. The incidence of sudden cardiac death will increase in patients with a single coronary artery and left main coronary artery which courses between the aorta and pulmonary artery.2 Multi-slice CT angiography and cardiac magnetic resonance angiography are noninvasive, threedimensional imaging modalities with good diagnostic accuracy for coronary artery anomalies.3,4 The present study describes a patient with a single coronary anomaly in which the RCA originating from the distal of the LCX. This is a rather rare anomaly
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with the incidence of 0.00% to 0.35%.5 Although isolated congenital coronary anomalies are not risk factors for development of coronary artery stenosis,1,6 if the anomalous artery traverses within the aortic wall or between the aorta and pulmonary artery, the risk of myocardial ischemia and sudden cardiac death will increase.6 In our case, the anomalous RCA does not have intramuscular course and terminated near the right sinus of valsalva. In 1976, Chaitman et al.7 studied 3750 cases who were undergoing coronary angiography. They have reported that the incidence of the anomalous LCX artery originating from the RCA was 0.45%, but they found only one case of the anomalous origin of RCA from the LCX artery. In a large study in 1980, Sheldon et al.8 studied 38,703 patients who were undergoing coronary angiography. They reported an incidence of 0.45% (176 cases) of anomalous LCX artery originating from the RCA, but they found no case of anomalous origin of RCA from the LCX artery. In 1986, Tavernarakis et al.9 reported a case of anomalous origin of the RCA from LCX discovered among 3100 coronary angiographies. They suggested that this coronary anomaly did not have any clinical significance. In 2010, Sudip et al.1 reported a case of the anomalous origin of RCA from the distal LCX artery that had a benign course. Coronary angioplasty, surgery and medical treatment are therapeutic choices for the management of single coronary artery anomalies. The selection of the therapeutic option depends on the origin of the anomalous artery, its course and termination.2,6 The case presented here is a very rare and mostly benign form of coronary anomalies. According to the benign course of RCA and absence of stenosis, no invasive intervention was performed for the patient. Medical treatment for systemic hypertension and risk factors modification
was planned. After six months, she was well and asymptomatic. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Declaration of conflicting interests None declared.
References 1. Sudip D, Tarek M and Farrukh H. Anomalous right coronary artery originating from the distal left circumfelex artery: a novel coronary artery anomaly viewed by computed tomography and invasive angiography. Can J Cardiol 2010; 26: e213. 2. Chen HY. Anomalous origin of coronary arteries from a single sinus if Valsalva. Exp Clin Cardiol 2012; 17: 150–151. 3. Angelini P, Velasco JA and Flamm S. Coronary anomalies: incidence, pathophysiology, and clinical relevance. Circulation 2002; 105: 2449–2454. 4. Gilmour J, Kafka H, Ropchan G, et al. Anomalous right coronary artery: a multimodality hunt for the origin. Case Rep Cardiol 2011; 2011: 4. 5. Yamanaka O and Hobbs R. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990; 21: 28–40. 6. Angelini P. Coronary artery anomalies: an entity in search of an identity. Circulation 2007; 115: 1296–1305. 7. Chaitman BR, Lesperance J, Saltiel J, et al. Clinical angiographic and hemodynamic findings in patients with anomalous origin of the coronary arteries. Circulation 1976; 53: 122–131. 8. Sheldon W, Hobbs ER, Millit D, et al. Congenital variation of coronary artery anatomy. Cleve Clin Q 1980; 47: 126–130. 9. Tavernarakis A, Voudris V, Ifantis G, et al. Anomalous origin of the right coronary artery arising from the circumflex artery. Clin Cardiol 1986; 9: 230–232.
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