Kyriacos , Georgios M , and Evagoras: Anomalous origin of the left anterior descending coronary artery from the right coronary artery.

Introduction

We report a case of a left anterior descending artery originating from both right and left sinus of valsava, which is classified among rare coronary anomalies.The anomaly was discovered incidentally during cardiac catheterization.

Case Report

A 49 years old woman was admitted to the Cardiology Department of Nicosia General Hospital for scheduled cardiac catheterization because of angina on exertion and positive for myocardial ischemia exercise tolerance test (Treadmill Stress Test).

Arterial hypertension and diabetes mellitus were present as risk factors for coronary atherosclerosis. Physical examination and laboratory tests revealed no significant pathology.

Coronary angiography was performed via the radial approach. Initially the right coronary angiography revealed additional longer artery originating from the conus branch of the right coronary artery (RCA) (figure 1).

Contrast injection in the left coronary artery showed a small left circumflex without significant stenosis and the short left anterior descending artery (LAD) originating from the left coronary sinus,and terminating in the proximal interventricular groove,giving off two diagonal branches (figure 2).

Figure 1:

Selective coronary angiography of RCA (RAO 30°) demonstrating that the LAD arose aberrantly from the right sinus of valsalva and the proximal part of RCA (conus branch) supplying the area abandoned by the main LAD.

icfj.2013.1.2.101-g001.jpg

Figure 2:

Left coronary angiography (RAO, Cranial) showing the LAD ending at mid segment without reaching the apex of the heart.

icfj.2013.1.2.101-g002.jpg

Discussion

The incidence of coronary artery anomalies ranges from 0.6 – 1.3 % of patients undergoing coronary angiography (2). The double LAD is a rare form of coronary artery anomaly.

Spindola – Franco described four types of double LAD (1,3): Type I – III arises from the left side and the last type (type IV) emerges from the right coronary sinus. Our case resembles type IV of dual LAD.

This anomaly has been reported to occur in 0.01 – 0.7% of patients under going cardiac catheterization and is occasionally seen in the tetralogy of Fallot (4).

There are three variations in the initial course of LAD (4):

  1. Anterior to the right ventricular infundibulum (anterior type)

  2. Between the aorta and the pulmonary trunk (intra-arterial type)

  3. Within the ventricular septum beneath the right ventricular infudibulum (septal type)

According to this classification, our case is consistent with septal type.Systolic compression of the intraseptal segment that could account for our patient’s symptoms and abnormal exercise stress test was not evident.

Multidetector row CT allows 3D comprehension of the coronary artery system and it is extremely useful to identify congenital coronary artery anomalies, regarding both their origins, courses and also relationships with other cardiac structures.

Consequently, we arranged a CT-angiography in order to have a more accurate view of the course of the coronaries and their relationship with other structures.

Beside the clinical consequences of anomalous vessels, knowing the anatomical variation is crucial at the time of surgery. Grave surgical complications may occur by causing a trauma on the aberrant vessel (5).

In conclusion we presented a rare coronary anomaly known as double LAD type IV.The LAD arose aberrantly from the conus branch of RCA and supplied the area abandoned by the main LAD.

References

1. 

Jalal Kheirkhah, MDParham Sadeghipour, MD*Ali Kouchaki An Anomalous Origin of Left Anterior Descending Coronary Artery from Right Coronary Artery in a Patient with Acute Coronary Syndrome Tehran Heart Cent. 2011; November6(4)217–219

2. 

Talanas G, Delpini A, Casu G, Bilotta F, Pes R, Terrosu P A double left anterior descending coronary artery emerging from the right Valsalva sinus: a case report and a brief literature review. J Cardiovasc Med (Hagerstown). 2009; Jan0(1)64–7

3. 

Spindola-Franco H, Grose R, Solomon N Dual left anterior descending coronary artery: angiographic description of important variants and surgical implications. Am Heart J. 1983; 105: 445–55

4. 

M Ebrahimi, M Dargahy, S Bajouri Anomalous Origin of Left Anterior Descending Coronary Artery from Right Coronary Artery Associated with Hypertrophic Cardiomyopathy Iranian Heart Journal. 2008; 9: (2)59–61

5. 

Kosar F An unusual case of double anterior descending artery originating from the left and right coronary arteries. Heart Vessels. 2006; 21: 385–37



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