Asian Cardiovasc Thorac Ann 2003;11:163-164
© 2003 Asia Publishing EXchange Ltd
Single Coronary Artery from the Left Sinus With Atherosclerosis
Mahilmaran Asha, DM,
Rajagopal Sriram, DM,
Seshadri Mukundan, MCh,
Kurudammanil A Abraham, DM
Institute for Cardiac Treatment and Research, Southern Railway Hospital, Chennai, Tamil Nadu, India
For reprint information contact: Kurudammanil A Abraham, DM Tel: 91 44 644 3051 Fax: 91 44 644 3051 email: abibaby{at}md3.vsnl.net.in Institute for Cardiac Treatment and Research, Southern Railway Hospital, Ayanavaram, Chennai, Tamil Nadu 600023, India.
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ABSTRACT
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We report a rare case of a single coronary artery originating from the left sinus of Valsalva with extensive atherosclerosis in a patient presenting with unstable angina. The distal circumflex artery continued the course of the right coronary artery.
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INTRODUCTION
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A single coronary artery (CA) occurring in isolation, without associated congenital heart disease, is a rare anomaly. The reported incidence is 0.02% to 0.04% of the general population.1 The pattern of branching and distribution differs. We report an interesting pattern in which the single left CA was seen to encircle the heart like a wreath in the left anterior oblique view of the coronary angiogram.
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CASE REPORT
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A 62-year-old male presented with features of unstable angina (Braunwald class IIIB) in April 2001 and was admitted to the intensive care unit. He had an inferolateral myocardial infarction in 1992. He had no major coronary risk factors other than his age. Coronary angiography revealed a single CA arising from the left sinus. There was no CA from the right sinus. The single CA bifurcated into the left anterior descending (LAD) and left circumflex (CX) arteries. The left CX curved around the atrioventricular groove, giving off the posterior left ventricular and posterior descending branches (PDA) and continuing the course of the right CA, finally terminating after dividing into 2 small branches (Figures 1A
and 1B). An accessory LAD (type II, which runs along the right side of the LAD) with multiple septal branches arose from the proximal LAD (Figure 1A). The LAD (type C, which curves beyond the apex) was critically narrowed in the proximal portion with delayed visualization of the mid- and distal LAD, being filled antegradely and through collaterals. The left CX had 75% stenosis after the first obtuse marginal branch and 75% narrowing at the atrioventricular groove at the origin of the PDA.
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Figure 1. (A) Left and (B) right anterior oblique views of coronary angiogram showing the single left coronary artery with the distal left circumflex (LCX) continuing as the right coronary artery (RCA). The accessory left anterior descending artery (LAD) is seen on the right of the occluded main LAD in Figure A.
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The patient underwent off-pump coronary artery bypass surgery with the left internal mammary artery grafted to the LAD and the saphenous vein to the second obtuse marginal and PDA branches. He had an uneventful recovery.
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DISCUSSION
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Isolated CA anomalies are rare in the adult population. They are usually incidentally detected during routine coronary angiography performed to evaluate coronary artery disease. The coronary vasculature embryologically begins as a proepicardial protrusion from the primordial liver. The epicardial cells undergo epithelial mesenchymal transformation and form nascent blood vessels, which mature, fuse, and penetrate the aorta, contrary to the former belief that coronary buds arise from the aorta and fuse with the coronary vessels. Multiple growth factors, adhesion molecules, and chemotactic factors are involved in the development of the coronary vasculature. Anomalies of these signaling pathways are probably responsible for CA anomalies.2 A single left CA arises as an undivided trunk from a single ostium in the left sinus with agenesis of the right coronary ostium. The description of the single CA in our report conforms to type LI (of Lipton):3 a single CA arising from the left sinus and dividing into LAD and CX, the distal CX continuing beyond the crux into the atrioventricular groove providing branches to the right ventricle. There have been very few reports describing this pattern.4–7 In type LII, the anomalous right CA arises proximally from the single undivided CA and crosses the base of the heart.8
The importance lies in the recognition of these anomalies at cardiac catheterization as these patients may present symptoms of coronary disease in a more critical manner owing to the dependence on a single CA. However, this anomaly by itself inducing myocardial ischemia is unlikely.
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REFERENCES
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ABSTRACT
INTRODUCTION
