Prevalence of the Anomalous Aortic Origin of a Left Coronary Artery from the Right Coronary Sinus and Posterior Course: detection by Transthoracic Echocardiography in an Unselected Ambulatory Population

Giancarlo Casolo, Jacopo Del Meglio, Massimo Magnacca, Carlo Tessa, Luca Salvadori, Maria Laura Canale, Elisa Ferrali


Background:   Transthoracic echocardiography (TTE)  may detect  the origin and/or  abnormal course of  coronary epicardial  vessels.  We describe a novel TTE  pattern specific for  the anomalous origin of a left coronary vessel from the right coronary sinus and a posterior course and its prevalence in an unselected population of ambulatory patients.


Methods:  We prospectively studied 3692 consecutive patients who performed  a routine TTE.  In these subjects we looked for an abnormal finding that we found associated with the anomalous aortic origin of a coronary artery. Computed Tomography of the Coronary Arteries (CTCA)  was performed in each suspected case.


Results:  We found a TTE aspect suggestive for a coronary anomaly and a retroaortic course in 16 subjects out of the 3298 studied (0,48%).  CTCA invariably confirmed the presence of the  anomaly. In 15 out of the 16 patients the left coronary vessel originating from the right coronary sinus (RCS) was the left circumflex artery (LCX).  In  the remaining  patient  the anomalous vessel was the left main coronary artery .


Conclusions: We found a  TTE sign specific for a particular kind of  coronary anomaly.  By using TTE it is possible to detect the retroaortic course of an anomalous left coronary vessel originating from the RCS. This  pattern was found to be rare  but pathognomonic for this specific kind of congenital anomaly.  The ability to detect this specific kind of coronary anomaly by TEE may be relevant to the patient in some cases  thus representing useful clinical  information.


“Coronary anomalies”, “Coronary anatomy” , “Transthoracic echocardiography”, “CT coronary angiography”, “Non invasive Coronary Angiography”


Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary angiography. Cathet Cardiovasc Diagn. 1990; 21:28-40. doi: 10.1002/ccd.1810210110

Kimbiris D, Iskandrian AS, Segal BL, Bemis CE.Anomalous aortic origin of coronary arteries. Circulation. 1978 ; 58:606-15.

Angelini P. Coronary artery anomalies. An entity in search of an identity. Circulation 2007; 115:1296-1305. doi: 10.1161/CIRCULATIONAHA.106.618082

Angelini P, Velasco JA, Flamm S. Coronary anomalies. Incidence, pathophysiology, and clinical relevance. Circulation 2002; 105: 2449 – 2454. doi: 10.1161/01.CIR.0000016175.49835.57

Basso C, Maron BJ, Corrado D, Tiene G. Clinical profile of congenital coronary artery anomalies with origin from the wrong aortic sinus leading to sudden death in young competitive athletes. J Am Coll Cardiol. 2000; 35:1493–1501. doi:10.1016/S0735-1097(00)00566-0

Cheitlin MD, De Castro CM, McAllister HA. Sudden death as a complication of anomalous left coronary origin from the anterior sinus of Valsalva. Circulation 1974; 50:780– 7. doi: 10.1161/01.CIR.50.4.780

Weyman A, Feigenbaum H, Dillon JC, Johnston KW, Eggleton RC. Non-invasive visualization of the left main coronary artery by cross-sectional echocardiography. Circulation 1976; 54: 169-174. doi: 10.1161/01.CIR.54.2.169

Presti CF, Feigenbaum H, Armstrong WF, Ryan T, Dillon JC. Digital two-dimensional echocardiographic imaging of the proximal left anterior descending coronary artery. Am J Cardiol 1987; 60:1254-1259. doi:10.1016/0002-9149(87)90603-5

Douglas PS, Fiolkoski J, Berko B, Reichek N. Echocardiographic visualization of coronary artery anatomy in the adult. J Am Coll Cardiol 1988; 11:565-571. doi:10.1016/0735-1097(88)91532-X

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. doi:10.1016/S0735-1097(00)01136-0

Fernandes F, Alam M, Smith S, Khaja F. The role of transesophageal echocardiography in identifying anomalous coronary arteries. Circulation 1993; 88: 2532–2540. doi: 10.1161/01.CIR.88.6.2532

Giannoccaro PJ, Sochowski RA, Morton BC, Chan KL. Complementary role of transoesophageal echocardiography to coronary angiography in the assessment of coronary artery anomalies. Br Heart J 1993;70:70– 74. doi:10.1136/hrt.70.1.70

Ropers D, Moshage W, Daniel WG, Jessl J, Gottwik M, Achenbach S. Visualization of coronary artery anomalies and their anatomic course by contrast-enhanced electron beam tomography and three-dimensional reconstruction. Am J Cardiol 2001;87:193– 197. doi:10.1016/S0002-9149(00)01315-1

McConnell MV, Ganz P, Selwyn AP, Li W, Edelman RR, Manning WJ. Identification of anomalous coronary arteries and their anatomic course by magnetic resonance coronary angiography. Circulation 1995; 92:3158–3162. doi: 10.1161/01.CIR.92.11.3158

Hendel RC, Patel MR , Kramer CM, et Al. ACCF/ ACR/ SCCT/ SCMR/ ASNC/ NASCI/SCAI/SIR 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging: A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American College of Radiology, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, American Society of Nuclear Cardiology, North American Society for Cardiac Imaging, Society for Cardiovascular Angiography and Interventions, and Society of Interventional Radiology. J Am Coll Cardiol. 2006; 48:1475-1497. doi:10.1016/j.jacc.2006.07.003

Taylor AJ, Cerqueira M, Hodgson JM, et Al. ACCF/ SCCT/ ACR/ AHA/ ASE/ ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2010;56(22):1864-1894. doi:10.1016/j.jacc.2010.07.005

Zeppilli P, dello Russo A , Santini C , et Al. In Vivo Detection of Coronary Artery Anomalies in Asymptomatic Athletes by Echocardiographic Screening. Chest. 1998; 114:89-93. doi:10.1378/chest.114.1.89

Labombarda F, Coutance G, Pellissier A, et Al. Major congenital coronary artery anomalies in a paediatric and adult population: a prospective echocardiographic study. Eur Heart J Cardiovasc Imaging 2014;15:761-768. DOI:

Page HL, Engel HJ, Campbell WB, Thomas CS. Anomalous origin of the left coronary artery: recognition, angiographic demonstration and clinical significance. Circulation 1974; 50:768–73. doi: 10.1161/01.CIR.50.4.768

Click RL, Holmes Jr , Vlietstra 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. doi:10.1016/0735-1097(89)90588-3

Kejriwal NK , Tan J, Gordon SP, Newman MA. Retroaortic course of the anomalous left main coronary artery: is it a benign anomaly? A case report and review of literature. Heart Lung Circ. 2004 ; 13: 97-100. doi:10.1016/j.hlc.2004.01.013

Lorber R, Srivastava S, Wilder TJ, McIntyre S, De Campli WM, Williams WG. Anomalous aortic origin of coronary arteries in the young. Echocardiographic evaluation with surgical correlation. J Am Coll Cardiol Img. 2015;8(11):1239-1249. doi:10.1016/j.jcmg.2015.04.027

Shewan LG, Coats AJS, Henein M. Requirements for ethical publishing in biomedical journals. International Cardiovascular Forum Journal 2015;2:2 DOI: 10.17987/icfj.v2i1.4


Copyright (c) 2016 Giancarlo Casolo, Jacopo Del Meglio, Massimo Magnacca, Carlo Tessa, Luca Salvadori, Maria Laura Canale, Elisa Ferrali

Creative Commons License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.