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An Unusual Coronary Trinity: Single Left Coronary Artery with the Right Coronary Artery Originating from the Left Main Coronary Artery and Following a …
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An Unusual Coronary Trinity: Single Left Coronary Artery with the
Right Coronary Artery Originating from the Left Main Coronary
Artery and Following a Retro-Aortic Course
T uesday, 05/31/11 | 4669 reads
Author(s): Aditya Kapoor, DM1, Rajeev Agarwala, DM2, Aditya Batra, MD1
Issue Number:
Volume 23 - Issue 6 - June 2011 (/issue/2800)
ABSTRACT: All three coronary arteries originating from a single coronary ostium is a rarity. Single
coronary artery (CA) arising from the left aortic sinus is far more uncommon than one arising from the
right sinus. Usually in such cases, the right coronary artery (RCA) arises as a distal continuation of the
left circumflex artery. We describe an extremely uncommon anatomic variant, where the RCA arose from
the single undivided CA as a branch of the left main coronary artery and followed a retro-aortic course
before reaching its designated anatomic territory.
J INVASIVE CARDIOL 2011;23:E156–E157
______________________________________
(/files/CorTrinity%20Fig%201.png)Congenital anomalies of coronary arteries are
infrequent and usually incidentally detected during routine coronary angiography
performed to evaluate coronary artery disease. A single coronary artery (CA) occurring
in isolation, without associated congenital heart disease, is one of the rarest coronary
anomalies. We describe an extremely uncommon variant of a single CA, where the right
coronary artery (RCA) originated as a branch of the left main coronary artery (LMCA), and followed a
retro-aortic course, before coursing in its normal territory.
(/files/CorTrinity%20Fig%202.png)Case Report. The patient was RS, who underwent
coronary angiography for evaluation of exertional angina. Cannulation of the left aortic
sinus using a JL 4 catheter revealed a single coronary artery that divided into left
anterior descending (LAD) and left circumflex (CX) arteries, with the posterior
descending (PDA) arising from the distal CX artery. The RCA also arose from the
undivided common trunk of the LMCA, and coursed retro-aortic to the aorta, reaching the right
atrioventricular (AV) groove. The RCA gave off the marginal branches to the right ventricle as well as a
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An Unusual Coronary Trinity: Single Left Coronary Artery with the Right Coronary Artery Originating from the Left Main Coronary Artery and Following a …
few posterior left ventricular (PLV) branches (Figures 1–3). Only mild atherosclerotic changes were
noted in the coronary arteries, without any significant flow-limiting lesions. The patient was stabilized on
medical therapy and is presently well at 1-year follow-up.
(/files/CorTrinity%20Fig%203.png)Discussion. By definition, a single coronary artery
arises from the aortic trunk by a single coronary ostium and supplies the entire heart. A
single CA occurring in isolation, without associated congenital heart disease, is a rare
anomaly with a reported incidence of 0.02–0.04% of the general population.1 The
classification of single CA proposed by Shirani et al2 categorizes patterns primarily on
the basis of the location of the solitary coronary ostium (whether from the left or right aortic sinus,
respectively) and the course taken by the aberrantly coursing coronary artery. The classification
proposed by Lipton, on the other hand, categorizes patterns according to whether the aberrantly
coursing artery (RCA or LCA) originates from the single undivided CA or as a branch of the individual
coronary arteries.3
Type I pattern: The single CA may arise from the right or left aortic sinus. When the single CA arises
from the left sinus, after giving off the LAD and left CX, it continues beyond the crux into the right AV
groove, with the RCA arising as branches from the mid/distal CX. When the single CA originates from
the right sinus, it courses like a normal RCA and after giving off the PDA, it continues in the left AV
groove, giving off the PLV branches. Finally, it gives off the LAD as its terminal branch.
Type II pattern: The single CA arises from the right or left aortic sinus and the contralateral (be it the
LCA or RCA, respectively) arises proximally from the single undivided CA and crosses the base of the
heart to course in its respective territory.
Anomalously arising RCA as a branch of single CA, though very rare, has been reported in the past.
However, almost all such cases are Type I pattern, where the anomalous RCA arises either as a branch
of the LAD3–7 or from the mid or distal portion of the left CX in the AV groove.8–10
In contrast, the Type II pattern of anomalously arising RCA, where it arises proximally from the single
undivided CA or LMCA (as occurred in our case), is an extremely uncommon variant.11 Such an
anomalously arising RCA may follow any of the three anatomic courses: A (anterior to right ventricular
outflow tract); B (between the aorta and pulmonary artery); or P (posterior to aorta).2,3 Of these, the A
and B patterns are the most frequent, while pattern P, with retro-aortic course, is reported to be the
rarest. Our case conformed to Type II P, since the anomalously arising RCA followed a retro-aortic
route, before coursing in its normal territory.
By itself, a single CA (in absence of other congenital heart disease) usually does not cause symptoms
and is generally detected incidentally during coronary angiography. Though most cases are
asymptomatic, angina-like symptoms can occur due to acute takeoff angles, slit-like orifices, luminal
compression by anomalous course between aorta and pulmonary artery, or even accelerated
atherosclerosis.12–14 Our case had only mild atherosclerotic changes and was stabilized on medical
therapy. The patient is asymptomatic at a follow-up of 1 year.
Conclusion. It is important to think of and recognize anomalously arising coronary arteries whenever
one encounters difficulty while performing a coronary angiogram. Single coronary artery from the left
aortic sinus with RCA arising as a branch of the undivided LMCA is an extremely uncommon anomaly.
Cardiologists need to be aware of the various aberrant anatomic locations and courses of such arteries
to be able to adequately define coronary anatomy in each case.
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References
1. Wilkins CE, Betancourt B, Mathur VS, et al. Coronary artery anomalies. A review of more than
10,000 patients from the Clayton Cardiovascular Laboratories. Texas Heart Inst J 1988;15:166–
173.
2. Shirani J, Roberts WC. Solitary coronary ostium in the aorta in the absence of other major
congenital cardiovascular anomalies. J Am Coll Cardiol 1993;21:137–143.
3. Lipton MJ, Barry WH, Obrez I, et al. Isolated single coronary artery: Diagnosis, angiographic
classification, and clinical significance. Radiology 1979;130:39–47.
4. Ocal A, Kilci H, Altunkas F, Tumuklu MM. Successful percutaneous coronary angioplasty in a
patient with anomalous origin of the right coronary artery from the left anterior descending artery.
Int J Cardiol 2008;127:E42–E44.
5. Rath S, Battler A. Anomalous origin of the right coronary artery from the left anterior descending
coronary artery. Cathet Cardiovasc Diagn 1998;44:328–329.
6. Saravanan P, Mennim P, Hancock JE. Anomalous origin of right coronary artery from the mid left
anterior descending coronary artery. Heart 2006;92:1212.
7. Wilson J, Reda H, Gurley JC. Anomalous right coronary artery originating from the left anterior
descending artery: Case report and review of the literature. Int J Cardiol 2009;137:195–198.
8. Shammas RL, Miller MJ, Babb JD. Single left coronary artery with origin of the right coronary
artery from distal circumflex. Clin Cardiol 2001;24:90–92.
9. Vrolix MC, Geboers M, Sionis D, et al. Right coronary artery originating from distal circumflex: An
unusual feature of single coronary artery. Eur Heart J 1991;12:746–747.
10. Asha M, Sriram R, Mukundan S, Abraham KA. Single coronary artery from the left sinus with
atherosclerosis. Asian Cardiovasc Thorac Ann 2003;11:163–164.
11. Arteaga RB, Tronolone J, Mandawat M. Single coronary ostium — A right coronary artery arising
from left main coronary artery. J Invasive Cardiol 2006;18:241–243.
12. Taylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with isolated congenital
coronary artery anomalies. J Am Coll Cardiol 1992;20:640–647.
13. Belhouse BJ, Bellhouse FM, Reid KG. Fluid mechanics of the aortic root with applications to
coronary flow. Nature 1968;219:1059–1061.
14. Click RL, Holmes DR Jr, Vliestra RE, et al. 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.
_____________________________________
From 1the Departments of Cardiology, Sanjay Gandhi Post-Graduate Institute of Medical Sciences,
Lucknow and 2Jaswant Rai Specialty Hospital, Meerut, India.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted September 13, 2010, final version accepted October 4, 2010.
Address for correspondence: Dr. Aditya Kapoor, Additional Professor, Cardiology, Sanjay Gandhi
PGIMS, Rae Bareli Road, Lucknow 226014. Email: [email protected]
(mailto:[email protected])
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