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Asian Cardiovasc Thorac Ann 2001;9:128-129
© 2001 Asia Publishing EXchange Pte Ltd

CASE STUDY

Right Coronary Artery Origin in Stenosed Left Anterior Descending Artery

M Kamil Göl, MD, Veli Vefali, MD, Bayram Yilmazkaya, MD, Sabahattin Göksel, MD, Vedat Nisanoglu, MD, Ülkü Yildiz, MD, Ali Yener, MD, Oguz Tasdemir, MD

Cardiovascular Surgery Clinic
Çankaya Hospital
Sihhiye, Ankara, Turkey
For reprint information contact: M Kamil Göl, MD Tel: 90 312 310 3080 Fax: 90 312 309 0425 email: nkgol{at}ato.org.tr Department of Cardiovascular Surgery, Türkiye Yüksek Ihtisas Hospital, Sihhiye, Ankara 06100, Turkey.

   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
A very rare coronary artery anomaly of right coronary artery originating from the middle portion of the left anterior descending artery was discovered in a 58-year-old woman with unstable angina pectoris. Double coronary artery bypass grafting was performed successfully.


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
Anomalies of coronary artery origin are well described in the literature.1,2 Anomalies of the coronary arteries are present in 1% to 2% of the population who undergo coronary angiography and are rarely associated with myocardial ischemia.3 Single coronary artery is very seldom observed. Reported cases of the right coronary artery (RCA) originating from the left anterior descending artery (LAD), which is a variation of the single coronary artery type of malformation, is most uncommon; less than 20 cases have been reported.4–6 Probably inad-vertently, a recent article declared it was the first case report in the literature.6 A report of a large series of coronary artery anomalies failed to mention this type.2


   Case Report
TOP
 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 58-year-old white woman was admitted to hospital because of stable angina pectoris on moderate exertion, for the previous 8 months. She had been doing well on nitrates and calcium channel blockers. One month prior to admission, she developed angina at rest. Electro-cardiographic tracings were normal. Physical examination was unremarkable, blood pressure was 115/65 mm Hg, and pulse rate was 82 beats•min–1. Biochemical blood analysis and chest radiographs were normal. Left heart catheterization and selective coronary arteriography were performed. Left ventricular pressure was 130/10 mm Hg and the ejection fraction was 50% with mild hypokinesia at the inferior segment. The left main coronary artery, LAD, and the left circumflex had normal origins and courses. The LAD exhibited 75% stenosis in the proximal segment before the origin of the first diagonal branch. The RCA originated from the middle segment of the LAD, distal to the first perforating branch, with 80% stenosis at the origin. Aortic root injections confirmed the absence of the right coronary ostium (Figure 1Go). Coronary artery bypass surgery was undertaken using a left internal mammary artery graft to the LAD and a saphenous vein graft to the RCA. The distal anastomosis site for the RCA graft was on the free wall of the right ventricle where the artery passed across to reach its regular path. At operation, the aortic root was opened and all the sinuses were searched for another coronary ostium, but none was found except the ostium of the left coronary artery in the left sinus of Valsalva. The course of the RCA was anterior to the conus of the pulmonary artery to the right atrioventricular groove. Postoperative recovery was uneventful and the patient was discharged from the hospital on the 5th postoperative day. She was free of symptoms at the 6-month follow-up.



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  		Figure 1. Arteriogram showing the anomalous origin of the right coronary artery from the middle segment of the left anterior descending artery. The black arrow indicates a stenotic site on the anomalous right coronary artery (R). The white arrow with double head indicates left anterior descending artery (L) stenosis.

 

   Discussion
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 Abstract
 Introduction
 Case Report
 Discussion
References
 
Although anomalous coronary arteries are relatively uncommon, they have gained the interest of cardiologists, cardiovascular surgeons, and anatomists. Various origins of the RCA have been reported.2 Among the spectrum of anomalous coronary arteries, the RCA has been found to be the most commonly involved artery. As a variation of single coronary artery, RCA originating from the left main coronary artery may be symptomatic on exertion; or it may even cause sudden death when the course of the RCA passes between the aorta and the pulmonary artery, perhaps due to compression between the large vessels. Origin of the RCA from the LAD in patients with no other congenital malformation is a very rare variation. Previously reported cases were also asymptomatic until the development of coronary atherosclerosis. When significant atherosclerotic stenosis develops in the LAD, this anomaly may become very dangerous since any occlusion of the proximal LAD will compromise the blood supply to both ventricles. This results in extensive infarction involving the anterior, septal, and inferior segments of the left ventricle as well as the right ventricle, which would probably be fatal. The anomaly might be speculated to be a collateral vessel between the right and left coronary circulation, but this was not the case in our patient. The absence of a coronary ostium for the RCA proved that this was a case of anomalous origin of the RCA. This issue was discussed in the case report of Biffani and colleagues5 who proposed that this anomaly could cause "coronary steal" on any rise of left ventricular end-diastolic pressure, due to lower resistance in the RCA territory.

As stated by Habbab and colleagues,4 "recognition and identification of these anomalies is of clinical importance because of their possible confusion with occlusive coronary artery disease, and because they can occasionally cause symptoms. Moreover, in patients with coronary artery disease or valvular heart disease that requires operation, the surgeon must be forewarned of their presence." We would like to emphasize that the inter-ventionist should be aware of such interesting anomalies to avoid the misdiagnosis of ostial occlusion.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Ogden JA. Congenital anomalies of the coronary arteries. Am J Cardiol 1970;25:474–9.[Medline]

  2. Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986;111:941–63.[Medline]

  3. Engel HJ, Torres C, Page L Jr. Major variations in anatomical origin of the coronary arteries: angiographic observations in 4,250 patients without associated congenital heart disease. Cathet Cardiovasc Diagn 1975;1:157–69.[Medline]

  4. Habbab MA, Senft AG, Haft JI. Origin of the right coronary artery from the left anterior descending coronary artery: a very rare anomaly of the coronary arterial origin. Am Heart J 1987;114:169–70.[Medline]

  5. Biffani G, Lioy E, Loschiavo P, Parma A. Single coronary artery, anomalous origin of the right coronary artery from the left anterior descending artery. Eur Heart J 1991; 12:1326–9.[Abstract/Free Full Text]

  6. Rath S, Battler A. Anomalous origin of the right coronary artery from the left anterior descending coronary artery. Cathet Cardiovasc Diagn 1998;44:328–9.[Medline]





This Article
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M Kamil Göl
Ali Yener
Oguz Tasdemir
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Right arrow Articles by Göl, M K.
Right arrow Articles by Tasdemir, O.
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Right arrow Coronary disease

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