While this organism is usually considered opportunistic and causes benign infection usually confined to the intestinal tract, it can lead to a life-threatening situation when it extends outside this structure. Since the organism is becoming more prevalent, it is important to recognize its role in a variety of diseases where the exact cause often remains obscure. REFERENCES

1 Toivanen P, Toivanen A, Olkkonen L, et al: Hospital outbreak of Yersinia enterocolitica infection. Lancet 1:801803, 1973 2 Hewstone AS, Davidson GP: Yersinia enterocolitica septicemia with enteritis in a thalassaemic child. Med J Aust 1:1035-1038, 1972 3 Asakawa Y, Akahane S, Kagata N, et al: Two community outbreaks of human infection with Yersinia enterocolitica. J Hyg 71:715-723, 1973 4 Toma S: Survey on the incidence of Yersinia enterocoliuca in the province of Ontario. Can J Public Health 64:477-487, 1973 5 Abramovitch H, Butas A: Septicemia due to Yersinia enterocolitica. Can Med Assoc 109:1112-1115, 1973 6 Gutman LT, Ottessen EA, Quan TJ, et al: An interfamilial outbreak of Yerslnia enterocolitica enteritis. N Engl J Med 288: 1372-1376, 1973 7 Hannuksela M, Ahvonen P: Erythema nodosum due to Yersinia enterocolitica. Scand J Infect Dis 1: 17-19, 1969 8 Solem JH, Lassen J: Reiter's disease following Yersinla enterocolitica infection. Scand J Infect Dis 3:83-&5, 1971 9 Laitinen 0, Tuuhea J, Ahvonen P: Polyarthritis associated with Yersinia enterocoUtica infection. Ann Rheum Dis 31 :34-39, 1972 10 Rabson AR, Koomhof HJ, Notman J, et al: Hepatosplenic abscess due to Yersinia enterocolitica. Br Moo J 4:341, 1972 11 Winblad S: Erythema nodosum associated with infection with Yersinia enterocolitica. Scand J Infect Dis 1: 11-16, 1969 12 Chessum B, Frengey JD, Fleck DG, et al: Case of septicemia due to Yersinia enterocolitica. Br Med J 3: 466, 1971 13 Mollaret HH: Human Yersinia enterocolitica infections in 1970: Report of 642 recent cases: Clinical and epidemiological aspects. Pathol BioI 19: 189, 1970

Ectopic Origin of the Left Anterior Descending Coronary Artery from the Right Coronary Sinus" Report of a Case Simulating Anterior Descending Obstruction HectM Lardani, M.D., and William C. Sheldon, M.D.,

F.C.C.P. o From.

the Department of Cardiology, Cleveland Clinic Foundation and Cleveland Clinic Educational Foundation, Cleveland. Reprint requests: Dr. Lardani, 2020 East 93rd, Cleveland 44106

548 LAIDANI, SHELDON

w.

A patient with anomalous aortic origin of the left anterior descending coronary artery studied. The clinieal picture and the preUminary angIograpblc findings simulated obstruction of the left anterior descending coronary artery near its origin. Careful catheter exploration of the right coronary sinus led to the correct diagnosis, emphasizing the importance of complete visualization of all branches of the coronary tree, including d.istaI radicles of a supposedly occluded vesseL aortic origin of the left anterior descending A nomalous (LAO) bra-ch of the left coronary artery from the

right coronary sinus is infrequent. In a review of the literature up to May 1974, only four cases of this anomaly among 36 cases of anomalous aortic origin of the left coronary artery or its branches, were reported.l-" In six additional cases, the LAD originated from the proximal right- coronary artery. None of these patients had concomitant cardiac defects. CASE REPORT

On March 18, 1974, a 44-year-old white man noticed retrosternal burning pain during emotional stress; the pain lasted for approximately 30 minutes. An electrocardiogram showed inverted T waves in leads 2, 3, aVF, and Va to V6Subsequent ECGs showed persistent low-voltage T waves in leads V 4 to V6 and a Q wave in lead aVL. The patient was then referred to the Cleveland Clinic Foundation for further studies. The patient had no family or personal history of cardiovascular disease. Findings from the physical examination were unremarkable. The laboratory data were normal, except for hypertriglyceridemia (305 mg/l00 ml) and an elevated fasting glucose level (1C)5 mg/l00 ml). A cine coronary arteriogram performed by the Sones technique was interpreted as showing a dominant right coronary artery with minor luminal irregularities and total occlusion of the LAD near its origin, without anterograde or retrograde visualization of its distal radicles. The circumflex artery was normal, and the left ventricle was normal (Fig lA and IB). Observation of normal contractions of the left ventricle, particularly in the anterior aspect, despite total occlusion of the LAD and no evidence of intercoronary collaterals, led to a repeat study to define the source of eollaterals for the distal LAD. Catheter exploration of the right coronary sinus on the same day demonstrated an anomalous origin of the entire LAD system (Fig lC), with only minor luminal irregularities. The LAD arose slightly anterior to the ostium of the right coronary artery, passed behind the pulmonary artery, and reached the anterior interventricular groove, where it followed a normal course and gave origin to a large diagonal branch. Reevaluation of the vessel arising from the left coronary sinus revealed that the arterial remnant, previously thought to be the proximal segment of the LAD, was a high lateral branch of the circumflex artery occluded in its proximal portion. At the Cleveland Clinic, we have seen at least six patients, ranging in age from seven months to 58 years, with isolated anomalous aortic origin of the LAD. In three of these patients (ages 58, 48, and 42 years), the LAD arose separately from the right coronary sinus, with the circumflex artery having a normal origin from the left coronary sinus. There were no associated anomalies of the heart. In the remaining

CHEST, 69: 4, APRil, 1976

patients the LAD originated from the proximal right coronary artery in two patients, and from a common orifice with the right coronary artery in one patient. Interestingly, these three patients had large ventricular septal defects (ages, seven months, 15 years, and 20 years) . The three required surgery because of the large left-to-right shunts. Berry and McGoon3 reported 23 cases of the LAD arising from the right coronary artery in approximately 1,400 patients operated upon for repair of tetralogy of Fallot. Five deaths in this group were attributed to division of the anomalous artery within the muscle of the right ventricular outflowtract. DISCUSSION

Anomalous isolated aortic origin of the LAD is an unusual anomaly of the coronary arteries. In this patient the history of chest pain and the appearance of a Q wave in lead aVL, plus the inverted T waves over the precordial leads, were suggestive of anterior ischemia. The stump shown in the left coronary arteriogram without visualization of the distal LAD and the presence of a norrnalleft ventricle suggested that total occlusion of the LAD had occurred, with excellent protection of the myocardium by collaterals of an unidentified source; however, this misinterpretation was clarified with the demonstration of the anomalous origin of the LAD . In retrospect, the remnant observed was an obstructed high lateral branch of the circumflex artery. This alternative hypothesis was also compatible with the electrocardiographic changes. The final angiographic interpretation allowed us to reassure the patient regarding the localized nature of his coronary arterial disease. This case emphasizes the importance of complete visualization of all the branches of the coronary tree, including the distal radicles of a vessel supposedly occluded, especially when there is no evidence of impaired wall motion in the ventriculogram. Visualization of an anomalous source of collaterals may be helpful in identifying the distal radicles of an obstructed vessel and in judging its quality for possible surgical intervention. In our patient the inconvenience of a repeat catheterization was rewarded by the unusual finding described herein. In patients with tetralogy of Fallot, a careful evaluation of the origin and distribution of the major trunks of the coronary tree is of utmost importance if surgery is under consideration. The finding of associated ventricular septal defects in our three cases of LAD arising from the right coronary artery has not been reported previously and may indicate a need for further investigation in a larger series . FIGURE 1. A (top). Dominant right coronary artery in left anterior oblique projection. Note minor luminal changes. B (middle). Left coronary artery in left anterior oblique projection. This was interpreted as being stump of occlusion of proximal LAD (arrow). There was no visualization of distal radicles of LAD. Circumflex artery shows mild irregularities. C (bottom). Opacification of anomalous LAD in right anterior oblique projection. Large septal branch can be seen in center of frame; to its right, interventricular trunk and its diagonal branch can be seen. There are mild luminal irregularities.

CHEST, 69: 4, APRIL, 1976

1 Ogden JA: Anomalous aortic origin: Circumflex, anterior descending, or main left coronary arteries. Arch Pathol 88:323-328, 1969 2 Ogden JA, Kabemba JA: Les variation des arteres coronaires: Revue de 224 cas. Acta Cardiol25:487-500, 1970 3 Berry EB, McGoon DC: Total correction for tetralogy of Fallot with anomalous coronary artery. Surgery 74:894898, 1973

ECTOPIC ORIGIN OF LEFT ANTERIOR DESCENDING CORONARY ARTERY 549

Ectopic origin of the left anterior descending coronary artery from the right coronary sinus. Report of a case simulating anterior descending obstruction.

A patient with anomalous aortic origin of the left anterior descending coronary artery was studied. The clinical picture and the preliminary angiograp...
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