Download Anomalous origin of the left anterior descending coronary artery

December 2013 - Issue 2
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101
Case studies
Anomalous origin of the left anterior descending
coronary artery from the right coronary artery
Kyriacos Papadopoulos MD, Georgios M. Georgiou MD, Evagoras Nicolaides MD
Cardiology Department, Nicosia General Hospital, Nicosia, Cyprus
Abstract
Dual left anterior descending coronary artery (LAD) originating from the left main stem and the right coronary artery (RCA)
(Type IV dual LAD) is a very rare coronary artery anomaly. In this report, we describe a 49 year old woman presenting with
unstable angina and positive for myocardial ischemia exercise tolerance test who subsequently was found to have this
coronary anomaly.The diagnosis was made with coronary angiography.This anomaly has been reported to occur in 0.01 –
0.7% of patients under going cardiac catheterization.To our knowledge, only a few such cases have been published in the
literature so far.
Key words: Coronary artery anomaly, double left anterior descending artery, cardiac catheterization, exercise tolerance test,
unstable angina
Introduction
Arterial hypertension and diabetes mellitus were present as risk
factors for coronary atherosclerosis. Physical examination and
laboratory tests revealed no significant pathology.
We report a case of a left anterior descending artery originating
from both right and left sinus of valsava, which is classified
among rare coronary anomalies.The anomaly was discovered
incidentally during cardiac catheterization.
Coronary angiography was performed via the radial approach.
Initially the right coronary angiography revealed additional
longer artery originating from the conus branch of the right
coronary artery (RCA) (figure 1).
Case Report
A 49 years old woman was admitted to the Cardiology
Department of Nicosia General Hospital for scheduled cardiac
catheterization because of angina on exertion and positive for
myocardial ischemia exercise tolerance test (Treadmill Stress
Test).
Figure 1: Selective coronary angiography of RCA (RAO 30°)
demonstrating that the LAD arose aberrantly from the right sinus of
valsalva and the proximal part of RCA (conus branch) supplying the
area abandoned by the main LAD.
Contrast injection in the left coronary artery showed a small
left circumflex without significant stenosis and the short left
anterior descending artery (LAD) originating from the left
coronary sinus,and terminating in the proximal interventricular
groove,giving off two diagonal branches (figure 2).
Figure 2: Left coronary angiography (RAO, Cranial) showing the LAD
ending at mid segment without reaching the apex of the heart.
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We realized that this coronary anomaly was a rare IV type
double LAD coronary artery.
Discussion
The incidence of coronary artery anomalies ranges from 0.6 –
1.3 % of patients undergoing coronary angiography (2).
The double LAD is a rare form of coronary artery anomaly.
Spindola – Franco described four types of double LAD (1,3):
Type I – III arises from the left side and the last type (type IV)
emerges from the right coronary sinus.
Our case resembles type IV of dual LAD.
This anomaly has been reported to occur in 0.01 – 0.7% of
patients under going cardiac catheterization and is occasionally
seen in the tetralogy of Fallot (4).
There are three variations in the initial course of LAD (4):
1.Anterior to the right ventricular infundibulum (anterior type)
2. Between the aorta and the pulmonary trunk (intra-arterial
type)
3. Within the ventricular septum beneath the right ventricular
infudibulum (septal type)
According to this classification, our case is consistent with
septal type.Systolic compression of the intraseptal segment
that could account for our patient’s symptoms and abnormal
exercise stress test was not evident.
Multidetector row CT allows 3D comprehension of the coronary
artery system and it is extremely useful to identify congenital
coronary artery anomalies, regarding both their origins, courses
and also relationships with other cardiac structures.
Consequently, we arranged a CT-angiography in order to have
a more accurate view of the course of the coronaries and their
relationship with other structures.
Beside the clinical consequences of anomalous vessels,
knowing the anatomical variation is crucial at the time of
surgery. Grave surgical complications may occur by causing a
trauma on the aberrant vessel (5).
In conclusion we presented a rare coronary anomaly known as
double LAD type IV.The LAD arose aberrantly from the conus
branch of RCA and supplied the area abandoned by the main
LAD.
Correspondence to:
Kyriacos Papadopoulose
Nycosia Hospital, Cyprus
[email protected]
Case studies
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December 2013 - Issue 2
References
1. Jalal Kheirkhah, MD, Parham Sadeghipour, MD,* and Ali Kouchaki, An
Anomalous Origin of Left Anterior Descending Coronary Artery from Right
Coronary Artery in a Patient with Acute Coronary Syndrome Tehran Heart
Cent. 2011 November; 6(4): 217–219
2. Talanas G, Delpini A, Casu G, Bilotta F, Pes R, Terrosu P A double left
anterior descending coronary artery emerging from the right Valsalva
sinus: a case report and a brief literature review. J Cardiovasc Med
(Hagerstown). 2009 Jan;0(1):64-7.
3. Spindola-Franco H, Grose R, Solomon N. Dual left anterior descending
coronary artery: angiographic description of important variants and surgical
implications. Am Heart J 1983;105:445-55.
4. M. Ebrahimi, M. Dargahy and S. Bajouri Anomalous Origin of Left Anterior
Descending Coronary Artery from Right Coronary Artery Associated with
Hypertrophic Cardiomyopathy Iranian Heart Journal 2008; 9 (2):59-61.
5. Kosar F. An unusual case of double anterior descending artery originating
from the left and right coronary arteries. Heart Vessels. 2006;21:385–37.