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,

anomalies

1970

of

artery.

260

KELLEY

ET AL.

RIGHT

CORONARY Downloaded from www.ajronline.org by 117.253.98.201 on 10/18/15 from IP address 117.253.98.201. Copyright ARRS. For personal use only; all rights reserved

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

anterior descending branch by crossing between great vessels forming caudal loop nary artery by passing anterior to right ventricular infundibulum forming cranial infundibulum, PT pulmonary trunk, SVC superior vena cava

2. VlodaverZ, disease.

Neufield Semin

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artery

cyanotic

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17. Sos TA. Baltaxe H: The importance of coronary angiography in the evaluation of patients with aortic valvular disease. Am J Roen(genol 122:793-799, 1974 18. Lillehei CW. Bonnabeau RC. Levy JJ: Surgical correction of aortic and mitral valve disease by total valve replacement.

ET AL.

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Am

manifestations J Roentgenol

of

Single coronary artery from the right sinus of Valsalva: angiography, anatomy, and clinical significance.

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