Asian Cardiovasc Thorac Ann 2002;10:334-335
© 2002 Asia Publishing EXchange Pte Ltd
Anomalous Connection of Left Circumflex Artery to Pulmonary Artery
Seyed Hamid Mirkhani, MD,
Morteza Delavarkhan, MD,
Homeyra Bayat, MD,
Mahdi Sanatkar, MD
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Division of Cardiovascular Surgery Imam Khomeini Medical Center Tehran University of Medical Sciences and Health Services Tehran, Iran
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For reprint information contact: Morteza Delavarkhan, MD Tel: 98 21 692 1669 Fax: 98 21 692 9977 email: delavarkhan{at}hotmail.com Division of Cardiovascular Surgery, Imam Khomeini Medical Center, Tehran University of Medical Sciences and Health Services, End Keshavarz Boulevard, Tehran 14197-31351, Iran.
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ABSTRACT
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A 52-year-old woman was evaluated for chest discomfort and dyspnea on exertion. Coronary angiography demonstrated an anomalous connection between the left circumflex artery and the right pulmonary artery. Successful repair was achieved under cardiopulmonary bypass, and the patient became completely symptom-free.
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INTRODUCTION
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The left circumflex artery (LCx) arising from the pulmonary artery is a very rare anomaly. As an isolated lesion, anomalous origin of the LCx from the right pulmonary artery (RPA) is extremely uncommon.
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CASE REPORT
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A 52-year-old woman developed symptoms of chest discomfort, dyspnea on exertion, and palpitation one year before admission to hospital. She had no obvious risk factor for coronary artery disease. Physical examination and routine diagnostic investigations revealed no specific abnormal findings except mild cardiomegaly on chest radiography and nonspecific ST-T changes on the electrocardiogram. An exercise tolerance test was strongly positive. Coronary angiography revealed anomalous origin of the LCx from the RPA (Figures 1 and 2
), high collateral flow from the right coronary artery toward the LCx, and normal left ventricular function. There were no other abnormalities such as mitral regurgitation. Based on these findings, corrective surgery was performed under cardiopulmonary bypass. Intraoperative examination revealed normal epicardial distribution of the major coronary arteries. Dissection around the roots of the aorta and the pulmonary artery failed to reveal the anomalous origin of the LCx. Both right and left pulmonary arteries were dissected free and temporarily occluded before and during infusion of cardioplegic solution. An anterior incision in the pulmonary trunk clearly demonstrated the anomalous origin of the LCx. The anomalous ostium of the LCx was 2 cm distal from the origin of the RPA on the anteroinferior aspect, with a diameter of approximately 3.5 mm. The ostium of the LCx was closed with continuous 5/0 polypropylene suture, and the closure line was augmented with additional pledgeted mattress sutures. A saphenous vein graft was anastomosed between the ascending aorta and the obtuse marginal artery. The operation was completed in the usual manner. The postoperative course was uneventful and the patient was discharged after 7 days. At follow-up, she remained symptom-free. Coronary angiography 14 months after the operation revealed no anomalous communication between the coronary arteries and the pulmonary artery or its right and left branches, the vein graft to the obtuse marginal artery was patent, and ventriculography showed normal global and segmental left ventricular function.
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Figure 1. Angiogram (left anterior oblique view) showing retrograde filling of the anomalous left circumflex artery (LCx) from the left anterior descending coronary artery (LAD).
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Figure 2. Angiogram (right anterior oblique view) showing the appearance of the anomalous left circumflex artery (LCx) after injection into the left anterior descending artery (LAD).
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DISCUSSION
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Brooks1 described anomalous origin of a coronary artery from the pulmonary artery, apparently for the first time, in 1889. Bland and colleagues2 described the clinical syndrome associated with this anomaly. Retrograde flow from the left coronary artery to the pulmonary trunk had been suggested by Brooks,1 and Sabiston and colleagues3 verified such retrograde flow by measuring a striking increase in left coronary artery pressure when its anomalous connection from the pulmonary artery was occluded. The actual demonstration of a left-to-right shunt into the pulmonary artery was made by Augustasson and colleagues4 in 1962.
Anomalous origin of the LCx from the RPA is extremely rare, and in a review of the literature, there were only 2 reported cases of this anomaly with normal intracardiac structures. The most useful diagnostic tool was coronary angiography, with the left anterior oblique view as the best aspect for demonstrating the exact site of the anomalous connection. To avoid injury to the delicate structures around the aortic root and the origin of the pulmonary artery, we suggest dissection in this area be kept very limited. A decision regarding the corrective surgical technique in this very rare anomaly is absolutely individualized and based on intraoperative findings, clinical presentation, and the results of preoperative diagnostic investigations.
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REFERENCES
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Brooks FJ. Two cases of abnormal coronary artery of heart arising from pulmonary artery. J Anat Phys
1889;20:26–30.
Bland EF, Whight PD, Garland J. Anomalous origin of the coronary artery from pulmonary artery masquerading as mitral insufficiency. Am Heart J
1962;63:388–93.
Sabiston DC, Neill SA, Taussig HB. The direction of blood flow in anomalous left coronary artery arising from pulmonary artery. Circulation
1960;22:591–5.[Abstract/Free Full Text]
Augustasson MN, Gasul BM, Lundquist R. Anomalous origin of the left coronary artery from the pulmonary artery (adult type). Pediatrics
1962;29:274–8.[Abstract/Free Full Text]
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