Single
Coronary
Artery
Angiography,
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MICHAEL
from
Anatomy,
J. KELLEY,’
the
the
increasingly
arteriography heart
prominent
in the
disease, delineation will become more
origin
or the origin
of both
role
evaluation
of
STEVEN
played
by
patients
WOLFSON,2
arteries
from
the
[1, 2]. classification
initial
Perhaps as
the rarity of this a minor congenital
5],
clinical
reports
of
sociated sinus
interest
myocardial
with of
artery
was
same
entity defect
begins
which
artery
passes
This
anatomy
and clinical
and
the
significance Case
regurgitation.
Exercise but
the
rate
bicycle ergometer. The study Cardiac catheterization using left ventriculography revealed stimulation
with
paper
electrocardiographic Cine
coronary
which
until
as-
tion suggested sinus
of
that
Valsalva
in the
the left coronary (fig.
1A),
An
left
injection
arose into
I
May
Department
24. of
1976;
requests to M. J. Kelley. 2 Department of Internal Am
J Roentgenol
accepted
Diagnositc
after
Radiology. Medicine,
1 28:257-262,
Section February
recently
revision Yale
has
and The
Valsalva artery
infundibulum.
of
describes
graphy incidence
[7,
11]. Ogden 4.5% (10
at O.O1%-O.04% 9, of
congenital
the absence at the aortic
artery
is found
with
the
branch,
creating the
congenital
described
been
in its
normally
source-thus
is a rare
been
[8,
15),
patients
name
anomaly
only
seen
anomalies
while
at
autopsy
as an isolated
it is found
undergoing
coronary
[10] in
oc-
disease is estiin approx-
coronary
and Goodyer of 224 cases)
of the
of a root
coronary
vessel
in association with congenital heart incidence in the general population
0.4%
signs
75
w
arterio-
reported a survey
an of
arteries.
normal
in which
projec-
the
left
sinus
October
of Cardiology.
on
26. School
the
vessel were
of
initial
course
only
the
figure
modified
arising with
of
Type by one in the
Type
so atypical
major
their subsequent resulted in five
subtypes municate
to the
Smith
cases 2 included
ostium but distribution
3 included
that
in the
cases
it could
not
be
right or left coronary distributions. [10] proposed a classification based
artery and classification 3 in
artery,
1 included
artery. arose present
arteries. was
with either and Goodyer of
the
left coronary
and left coronary
number
coronary
Type
form.
divisions course. patterns
Using
of This and
this
from the right the left coronary
sinus
the
coronary
more detailed is presented in
classification,
subtypes arise from the left sinus of Valsalva types arise from the right sinus of Valsalva.
right of
or normal
the distribution
compared Ogden
ischemia. the right
right
of the right
or
from
of single
those in which the single divided, so that branches
a
oblique
classfication
[131 proposed three categories. which the single vessel followed
of on
symptoms
University
1977
This
imately
Valsalva revealed no coronary ostium (fig. 18), Selective coronary arteriography (fig. 2) demonstrated a branch left coronary artery which appeared to course in front Received
ventricular
of the
[1, 2, 4, 51. It has
currence [1 1-14].
right
artery.
mated
myocardial
artery
of
coronary
a complete
a single
the aorta
no at
anterior
of the impres-
Classification
showed
to suggest
performed
sinus
left
by a connecting
with
coronary
findings,
no
right
the
communicates
artery
pattern
or surgery
of
portion
and
coronary
a coronary
recent
angiographic
were
the to
and the right
absence distal
location
In an early
there
aortography
the more
expected
was stopped because of dyspnea. the brachial approach followed by significant mitral stenosis. During
changes
ascending
The
single
the
left
200
from
branch
the aorta
than
[101.
pointed artery
arterioof single
to
artery
coronary artery is defined as of one of the coronary arteries
rather
are discussed.
increased
was
sternotomy. Inspection and palpation arteries confirmed the angiographic
coronary
between
order.
commissurotomy
communicating
Single portion
Report
epinephrine
single
arising
by coronary classification
electrocardiogram
heart
the
in sequential
tract. Normal and circumflex
Discussion
K. J., a 46-year-old female, had scarlet fever as a child, At the age of 37 a murmur was heard. She was asymptomatic until 2 weeks prior to admission when she awoke with shortness of breath. Physical examination, echocardiography, and chest radiographs were consistent with mitral stenosis and aortic ischemia,
of
with
passing
has at
death
between
infundibulum.
is reviewed,
the
arose
a median coronary
sion
right ventricular outflow descending. diagonal,
a mitral
led to its of little
from
cases,
subtype identified at surgery. The
coronary
sudden
arteries
Subsequently.
through proximal
MARSHALL2
behind the left anterior
coronary
sinus
until
arising
In these
ventricular
a patient with this graphy and verified
and
subtype
[6-9J.
as a branch
and the right
stimulated
ischemia
a particular
Valsalva
not
ROBERT
aorta and appearing
artery artery
clinical significance [2, 3]. Although early reports out the surgical implications of a single coronary [4,
Significance
acquired
of Valsalva is one such anomaly which until recently been reported infrequently and usually discovered
autopsy
AND
of Valsalva:
coronary
with
of anomalies of coronary frequent. A single coronary
coronary
Sinus
and Clinical
A case of single coronary artery from the right sinus of Valsalva with a connecting branch passing between the aorta and right ventricular infundibulum is described. The anomaly was demonstrated at coronary arteriography and verified at surgery. This type of single coronary artery has been associated with sudden exertional death in young persons. The case prompted a review of the classification of single coronary artery with emphasis on clinical significance of the various subtypes and angiographic findings. With
Right
of
artery
four
and 10 subTo simplify, Valsalva in three
combasic
1976. of
Medicine.
Yale University
School
257
333
Cedar of Medicine,
Street, New
New Haven,
Haven,
Connecticut
Connecticut
06510
06510
Address
reprint
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258
KELLEY
Fig.
1.
coronary
sinus
of Valsalva
ways (figs. left anterior behind
does
aortogram from right
not give rise to left
3 and
4). The
descending
in left sinus
anterior oblique position demonstrating of Valsalva (arrows) B. Anteroposterior coronary artery RCA and LCA = right and
connecting
coronary
branch
artery
reaches
by crossing
right
R-5a,
ventricular
outflow
tract
(subtypes
the to
R-4a,
R-4b,
R-5c).
Surgical
with
the
seems
heart
right
to be benign
acquired
disease
coronary
[8,
arteries
selective
9J,
both
have
single
left
single imity
and/or
coronary
arteriography
congenital
For
valvular
example,
in types
heart
2,
encircle
the
aortic
the
of an aortic
traumatized
undergoing
root
at
the
valve
by
prosthesis
deeply
placed
right ventriculotomy valvar stenosis
or pulmonary type 4 coronary cross the line
pattern of
plating
perfusion
surgery
[18J
ation should pattern.
(fig.
resection. of
the
for would 3),
[4,
Finally, coronary
or attempting be aware
level
of the
a coronary unusual
and
disease,
3.
and
onary artery present case
sutures.
the
arteries bypass coronary
ever,
with
the the
with
primarily
selective
coronary
[ 16, 171.
The course
3),
the
by
The
patient
major
vessels contem-
during graft
ship have aorta,
sinus
addition
counterparts
in figure The three
aorta
as in the of the
present 4 have basic
which
can
oblique
of
single
are
rare
[19].
coronary
case,
the
three
Howbasic
now appeared patterns have be
in the angio-
distinguished
and
lateral
using
projections
distinction connecting
and
right
is to branch
ventricular
define and
the basic its relation-
infundibulum.
It will
a posterior course (fig. 4A) if it passes behind as in subtypes R-i, R-2a, and R-2b (fig. 3).
appear
on
endand
caudal
of
arteriograms.
most important of the aberrant
to the
cor-
be accomplished normal distribution
of Valsalva
of the
anterior
coronary
arteriosclerotic
descriptions
right
illustrated [7-9J.
single
from
though thy arise from a single helpful to further substantiate the in the “empty” coronary sinus
Angiographic
from
right
potentially
surgeon
1B).
standard
relief of infundibular be at risk with the 51, since
arteries even (fig. 2). It is also with an injection
graphic
another of these
standpoint,
distinguished
disease. This may by demonstrating
pre-
assumed may
be
of
are in close proxcoronary branches and
angiographic
the
5 (fig.
usually
the should
for
in adults
coronary artery and its branches to the aortic valve. These major seat
From artery
from right sinus of Valsalva Left confirming impression that left right and left sinus of Valsalva.
Demonstration
patterns literature
significance
to detect arteriosclerotic coronary artery disease Several subtypes of single coronary artery offer reason for evaluating the coronary anatomy patients.
Angiographic
artery
if unassociated
cardiothoracic surgeon and the angiographer. Recent reports have indicated the necessity operative
left
(fig.
anomaly
congenital
single
origin of right coronary artery injection in left sinus of Valsalva coronary arteries, RSV and LSV
coronary source findings
Implications
While
be
the either
the aorta (subtypes R-1, R-2a, R-2b); between vessels (subtypes R-3a, R-3b, R-5b); or anterior
great the
Cine ascending seems to arise
-A.
artery
ET AL.
give
loop (fig. 4B) as in subtypes R-3a,
rise
to
a left
if it passes R-3b, and
tiguous with a left coronary (fig. 4C) if it passes anterior
coronary
the 3).
between
R-bb
(fig.
artery having to the right
fundibulum, as in subtypes R-4a, 3). Our case (fig. 2) illustrates
the It will
artery
with
great It will
vessels, be con-
a cranial ventricular
R-4b, R-5a, and the R-3a single
a
loop in-
R-5c (fig. coronary
pattern.
valve oper-
distribution
Subtypes
at Risk
Recent reports variety of single
have coronary
suggested artery
that from
the
one particular right sinus of
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SINGLE
I”
259
ARTERY
,I,,,
,py.
‘ .‘.
CORONARY
‘
-
.,
.
.
V( ,
4:.
-
,
I..
,
I,.
“
Valsalva
carries
significant
illustrates
such
an anomaly.
the
anterior
branch aorta rise
sinus
which and
to
the
of
passes right
left
cases
suddenly
gives
rise
and
leftward
ventricular
were
ex
Lion.
between before
death
An
is uncertain,
Although it is thought
the
mode to
relate
to
of the connecting branch, with potential left coronary artery during increased
seven
with
the afore-
same
investi-
deaths among the left sinus
in these the
one
additional
by these
of death
giving In
artery males)
gators. There were no sudden unexplained 18 patients in whom the artery arose from of Valsalva.
4B).
the
coronary (all young
in patients
uncovered
from
a connecting
2 and
(figs.
case
vessel
to
which the single nine of 33 patients
exertional
anatomy
present
infundibulum branches
in
The coronary
Valsalva
following
of early
mentioned
17-9].
A single
posterior
coronary
autopsy series [8] arose in this manner, died
risk
acute
narrowing expansion
pulmonary our case,
artery and the aorta there was no evidence
either
by exercise
infusion
during
It can
be
subtypes Valsalva These
electrocardiography cardiac
seen
from
artery from
figure
subtypes
R-5b. Patients with myocardial ischemia
or after
epinephrine
R-3a these may
3 that
patients
with
artery from the right be prone to sudden (the
present
case),
patterns who be candidates
bypass surgery. It is hoped that the clinically insignificant variants
by coronary
181. In ischemia
catheterization.
of single coronary would potentially include
during exercise for myocardial
three sinus of death.
R-3b,
and
demonstrate for coronary
their will
differentiation be appreciated
the
coronary
angiographers.
individuals REFERENCES
angulation
of the of the
1
.
Ogden Am
JA:
J Cardiol
Congenital
25:474-479,
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1970
of
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260
KELLEY
ET AL.
RIGHT
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TYPE
I
LEFT
ARTERY
CORONARY
ARTERY
NORMAL
L1
TYPE
2
L-2 TYPE
3
L3 TYPE
4
L’4 TYPE
Fig.
3.
descending from Ogden
-
5
Normal and single coronary artery patterns seen coronary artery, LCIRC = left circumflex coronary and Goodyer [10]).
from caudal-cranial artery. AO = level
view RCA = of aortic valve,
right coronary artery. LADCA = left anterior P = right ventricular outflow tract. (Modified
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SINGLE
CORONARY
261
ARTERY
sVC.
A with
Fig. 4. - Diagrams left system A.
C
B
of heart Connecting
in right anterior oblique branch reaches left
and caudal-cranial anterior descending
views showing three basic ways that coronary artery by passing behind
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coronary
left
descending cororight ventricular
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of the
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