Right coronary artery originating from left anterior descending artery: a case report
© Tokmakoglu et al; licensee BioMed Central Ltd. 2010
Received: 17 April 2010
Accepted: 8 June 2010
Published: 8 June 2010
Right Coronary Artery (RCA) originating from left anterior descending artery is a very rare congenital coronary artery anomaly. A 66-year-old man presented with hypertension and complaints of exertional chest pain. The angiography was performed. Aortic root angiography showed no coronary ostium orginating from the right sinus of valsalva. Right coronary artery was vizualized as anomalously originating from the midportion of left anterior descending artery. Severe stenosis were seen in ostium of anomalous right coronary artery, in midportion of left anterior descending and in midportion of circumflex artery. The patient was referred for coronary artery bypass grafting. The patient underwent coronary artery bypass surgery for three vessels. He was discharged home on postoperative day 7 without any complication. His echocardiogram on follow-up visit revealed good biventricular function.
Congenital coronary artery anomalies are rare and usually an incidental finding during coronary angiography. Most of them have no clinical signifance. Right Coronary Artery (RCA) originating from left anterior descending artery (LAD) is a very rare congenital coronary artery anomaly. We present a patient with three vessel disease in whom the right coronary artery originated as a seperate branch from the midportion of LAD.
The most common coronary anomaly is the circumflex coronary artery arising from the right sinus or the RCA, with an incidence of 0.37%-0.6% [1, 2]. The next most common and pathologically significant anomalies are the right coronary artery from the left sinus of valsalva and the left main coronary artery arising anomalously from the right sinus of Valsalva. The combined incidence of these defects 0.17% in autopsy series and 0.1%-0.3% in patients undergoing catheterization or echocardiography [3–5]. A variety of anomalous origin of the RCA has been reported, including the left anterior sinus with variable courses, ascending aorta above the sinus level, descending thoracic aorta, left main coronary artery, circumflex coronary artery, the pulmonary arteries, or below the aortic valve [6–8]. Single coronary artery occupies approximately 0.024% of the general population . In most of the cases, aberrant RCA originates from the left main coronary artery and traverses anterior to the right ventricle or between the pulmonary trunk and ascending aorta [10, 11].
The RCA originating as a branch from the midportion of the LAD is a very rare anomaly. Six cases have been reported in the literature so far, and no patient had underlying congenital heart disease [12, 13]. In our patient RCA was stemming from the midportion of the LAD and had not congenital heart disease.
Most of the coronary anomalies remain asymptomatic and are incidental to investigations by coronary angiography. Coronary artery anomalies are classified as benign (80.6%) but potentially serious anomalies (19.4%) . However, myocardial perfusion can be affected, ranging from exertional angina to sudden death, within the different subtypes of these anomalies, such as a coronary artery arising from the pulmonary artery and a single coronary artery arising from either the left or right sinus of valsalva [6, 10].
The pathophysiology of the restricted coronary blood flow seen in the presented case anomaly is suggested to be as follows. The acute takeoff angle, slit-like orifice, and compression of the intramural segment by the aortic valve commissure. Lateral luminal compression of the intramural portion of the coronary artery and compression of the coronary artery between aorta and pulmonary artery are also other possible ischemic mechanism [14–16]. Some autopsy-based studies have shown that slit-like orifice structure and acute angle takeoff are more common in sudden cardiac death patient [14–16]. However, there is still controversy concerning the mechanism by which the interarterial course is compressed between the aorta and pulmonary artery. An intravacular ultrasound study found that luminal compression of the coronary artery was totally attributable to the aorta because the pressure of the pulmonary artery was much lower than that of the aorta . In our patient there was exertional angina. There was no surgical finding related with compression of the coronary artery between aorta and pulmonary artery.
In conclusion, RCA as a branch of LAD is very rare coronary anomaly. If RCA course is not between aorta and pulmonary artery, this anomaly is accepted as relatively benign rare anomaly. In case of classic appearence of RCA was not established during angiography physician should kept in mind that RCA can stem from LAD artery.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Click RL, Holmes DR, Vleitrstra RE, Kosinski AS, Kronmal RA: Anomalous coronary arteries: location, degree of atherosclerosis and effect on survival - a report from the coronary artery surgery study. J Am Coll Cardiol. 1989, 13: 531-537. 10.1016/0735-1097(89)90588-3.View ArticlePubMedGoogle Scholar
- Page HL, Engel HJ, Campbell WB, Thomas CS: Anomalous origin of the left circumflex coronary artery. Circulation. 1974, 50: 768-773.View ArticlePubMedGoogle Scholar
- Benson PA, Lack AR: Anomalous aortic origin of left coronary artery. Arch Pathol. 1968, 86: 214-216.PubMedGoogle Scholar
- Cheitlin MD, DeCastro CM, McAllister HA: Sudden death as the complication of anomalous left coronary origin from the anterior sinus of Valsalva. Circulation. 1974, 50: 780-787.View ArticlePubMedGoogle Scholar
- Davis JA, Cecchin F, Jones TK, Portman MA: Major coronary artery anomalies in a pediatric population: incidence and clinical importance. J Am Coll Cardiol. 2001, 37: 593-597. 10.1016/S0735-1097(00)01136-0.View ArticlePubMedGoogle Scholar
- Yamanaka O, Hobbs RE: Coronary artery anomalies in 126,595 patients undergoing coronary angiography. Cathet Cardiovasc Diagn. 1990, 21: 28-40. 10.1002/ccd.1810210110.View ArticlePubMedGoogle Scholar
- Cieslinski G, Rapparich B, Kober G: Coronary anomalies: incidence and importance. Clin Cardiol. 1993, 13: 321-4.Google Scholar
- Ho JS, Strickman NE: Anomalous origin of the right coronary artery from the left coronary sinus: case report and literature review. Tex Heart Inst J. 2002, 29: 37-9.PubMedPubMed CentralGoogle Scholar
- Lipton MJ, Barry WH, Obrez I, Silverman JF, Wexler L: Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology. 1979, 130: 39-47.View ArticlePubMedGoogle Scholar
- Kardos A, Babai L, Rudas L, Rudas L, Gaal T, Horvath T, Talosi , Toth K, Sarvary L, Szasz K, Cheng T: Epidemiology of congenital coronary artery anomalies: a coronary arteriography study on a central European population. Cathet Cardiovasc Diagn. 1997, 42: 270-5. 10.1002/(SICI)1097-0304(199711)42:3<270::AID-CCD8>3.0.CO;2-9.View ArticlePubMedGoogle Scholar
- Arteaga RB, Tronolone J, Mandawat M: Case report and brief review:Single coronary ostium-A right coronary artery arising from left main coronary artery. J Invasive Cardiol. 2006, 18 (9): 241-3.Google Scholar
- Iyisoy A, Kursaklıoğlu H, Barcin C, Barındık N, Kose S, Demirtaş E: Single coronary artery with anamolous origin of the right coronary artery as a branch from the left anterior descending artery:a very rare coronary anomaly. Heart Vessels. 2002, 16: 161-163. 10.1007/s003800200014.View ArticlePubMedGoogle Scholar
- Kamran M, oga M: Anomalous right coronary artery orginating from the left anterior descending artery. J Invasive Cardiol. 2006, 18: E221-E222.PubMedGoogle Scholar
- Kragel AH, Roberts WC: Anomalous origin of either the right or left main coronary artery from the aorta with subsequent coursing between aorta and pulmonary trunk: analysis of 32 necropsy cases. Am J Cardiol. 1988, 62: 771-7. 10.1016/0002-9149(88)91220-9.View ArticlePubMedGoogle Scholar
- Frescura C, Basso C, Thiene G: Anomalous origin of coronary arteries and risk of sudden death: a study based on an Bae Young Lee 179 autopsy population of congenital heart disease. Hum Pathol. 1998, 29: 689-95. 10.1016/S0046-8177(98)90277-5.View ArticlePubMedGoogle Scholar
- Taylor AJ, Rogan KM, Virmani R: Sudden cardiac death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol. 1992, 20: 640-7. 10.1016/0735-1097(92)90019-J.View ArticlePubMedGoogle Scholar
- Angelini P, Velasco JA, Ott D, Khoshnevis GR: Anomalous coronary artery arising from the opposite sinus: descriptive features and pathophysiologic mechanisms, as documented by intravascular ultrasonography. J Invasive Cardiol. 2003, 15: 507-14.PubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.