An Anomalous Right Coronary Artery Originating from the Left Anterior Descending Artery, a Case Report of Successful Percutaneous Coronary Intervention

Anomalous Right Coronary Artery Originating From the Left Anterior Descending Artery

Coronary anomalies are usually diagnosed incidentally during coronary angiography. Anomalous origin of the right coronary artery (RCA) from the left anterior descending (LAD) is a rare clinical entity [1, 2]. Noninvasive anatomic assessment by coronary computed tomography (CT) angiography has evolved to become a highly accurate method in the diagnosis of coronary artery disease (CAD), comparable to conventional invasive coronary angiography [3]. We report a case of anomalous RCA originating from the mid-LAD leading to exertional dyspnea. A 50-year-old woman was admitted to our cardiology outpatient clinic with the complaint of exertional dyspnea and atypical chest pain. The patient was not eligible for the treadmill stress test due to congenital hip dislocation. Therefore, we scheduled myocardial perfusion scintigraphy, and hypoperfusion was detected in the mid and basal segments of the anterior region of the heart (Figure 1). These changes were interpreted as mild ischemia. As further investigation, coronary CT angiography was scheduled for the patient. Coronary CT angiography demonstrated a single coronary artery from the left Valsalva sinus. An anomalous RCA originated from the mid-LAD, after the first diagonal branch, coursing to the right, anterior to the pulmonary artery, then trajecting downward into the right atrioventricular groove (Figures 2–4). Figure 1 Tomographic scans during stress myocardial scintigraphy. Perfusion defects in the mid and basal anterior segments in the short-axis (SAX) and vertical long-axis (VLA) views. The resting SAX and VLA views show the normal perfusion Figure 2 Coronary computed tomography angiography image showing an anomalous RCA originating from the mid-LAD and coursing anterior of the aorta and the pulmonary trunk Figure 4 Anatomical course of the anomalous RCA Figure 3 Overview of coronary vessel course in relation to the great arterial vessels aorta and pulmonary trunk Anomalies of the RCA are observed to a relatively lesser extent. Yamanaka and Hobbs [4] reported anomalous RCA at the rate of 0.26% in a series of 126,595 patients. Turkmen et al. reported the incidence of single coronary artery anomaly as 0.031% in a series of 215,140 patients who underwent routine coronary angiography [5]. Although anomalous coronary artery is considered to be a benign entity, it may cause myocardial ischemia and even sudden cardiac death. Most of these patients are asymptomatic and have normal electrocardiograms at rest. However, ischemia may be precipitated by strenuous, prolonged physical activity. Our patient's symptoms emerged only with exercise. Myocardial ischemia should be excluded before a coronary anomaly is considered as benign. Myocardial perfusion scintigraphy is a useful and widespread method for indicating the presence of ischemia. Also, coronary CT angiography may be beneficial in the diagnosis of CAD and coronary anomalies. Coronary tomputed angiography demonstrated a single coronary artery anomaly in our patient (Figures 2–4). The coronary tree was free of significant intraluminal narrowing, atherosclerosis, unusual angling or any compression sign which may explain ischemia. In our case, exertional dyspnea may be partly secondary to the myocardial ischemia, which could result from the steal phenomenon due to single coronary artery anomaly. To the best of our knowledge, this is the first case that shows myocardial ischemia in the LAD region in single coronary artery anomaly despite absence of any significant narrowing in the coronary arteries.

Type 4 dual left anterior descending coronary artery

Influence of Second- and Third-Degree Heart Block on 30-Day Outcome Following Acute Myocardial Infarction in the Drug-Eluting Stent Era

Classic Coronary Artery Disease in an Unlikely Patient

Classic Coronary Artery Disease in an Unlikely Patient

Introduction and importance: Non-dominant right coronary artery (RCA) is supposed to be benign as it does not result in large myocardial infarction. Still, in this case, non-dominant RCA from left anterior descending (LAD) artery not only produces ischemia but also results in incessant ventricular tachycardia, which is a life-threatening arrhythmia because of compromised blood flow. However, RCA is free of atherosclerotic plaque, which is the main cause of ischemia/infarction and subsequent arrhythmia. Case presentation: A 21-year-old male was admitted to the emergency cardiology ward of the National Institute of Cardiology following an episode of syncope. The patient reported a sudden loss of consciousness without preceding symptoms. Clinical discussion: The present case highlights the importance of a comprehensive evaluation and diagnosis in the management of syncope in young patients. The case presented here revealed a rare finding of a single coronary artery with a left main origin and an anomalous RCA emerging from the LAD artery. This is a very unusual presentation, with less than 50 occurrences recorded in the medical literature. This abnormality is classified as a single coronary artery anomaly (CAA), which means that the coronary arteries arise from a single coronary ostium within the aorta. Conclusion: In conclusion, CAA is an uncommon cause of SCA that can easily be overlooked without a systematic approach. In this report, we discuss the case of a patient who was discovered to have an anomalous RCA that branched off from the LAD artery.

Magnetic resonance angiography (MRA) using segmented k-space fast low-angle shot imaging has recently been used to demonstrate the proximal coronary arteries in healthy subjects and in patients with coronary artery disease. We assessed the sensitivity and specificity of coronary MRA in heart transplant recipients and investigated the feasibility of coronary MRA in patients with metallic sutures and clips in the chest. Sixteen cardiac transplant patients aged 57.2 +/- 7.9 years (mean +/- SD) were recruited. Forty-eight arterial segments were evaluated, including the left main artery (LMA), left anterior descending artery (LADA) and right coronary artery (RCA). We excluded the left circumflex artery which could not be imaged accurately. The average time between heart transplant operation and MRA was 6 years, whereas that between MRA and X-ray angiography was 4 months. The coronary MRA was interpreted by two experienced investigators who were blinded to the coronary X-ray angiography results. Similarly, the coronary X-ray angiography results were interpreted by two experienced investigators blinded to the MRA results. The coronary arterial segments were classified by MRA as being normal or as having an amount of disease that was significant (> 50% lesion) or insignificant (< 50% lesion). There were 28 true-negative, five true-positive, four false-negative and six false-positive results. Of the 28 true-negative cases, 13 were in the LMA, six in the LADA and nine in the RCA. There was one false-positive LMA, two false-positive LADA and three false-positive RCA stenoses. There were four false-negative results in the LADA and one in the RCA. Clips precluded evaluation in one LMA, one LADA and one RCA. One LMA and one LADA were not evaluated as a result of poor images. One false-positive RCA stenosis was caused by a metallic clip. Three of the false-negative LADA stenoses had lesions in the distal third of the artery. The sensitivity, specificity, negative and positive predictive values were generally poor for the left coronary artery. The best results were for the RCA (sensitivity 100%, specificity 75%, positive predictive value 50% and negative predictive value 100%). The specificity in the left coronary arteries (LMA and LADA) was 86%, but the other indicators were all poorer. For the RCA, LMA and LADA combined, the overall sensitivity was 56%, specificity 82%, predictive accuracy 45% and negative predictive value 88%. In three patients, < 50% RCA lesions were seen in the MRA data, which were all confirmed by angiography. No < 50% lesions were seen in the LMA or in the LADA by MRA or by X-ray angiography. Coronary MRA using the segmented fast low-angle shot technique is feasible in heart transplant recipients but the sensitivity and specificity of this method are limited. Further developments in coil design, rapid imaging techniques and respiratory monitoring methods are necessary to improve the accuracy of coronary MRA.

Background: A single coronary artery (SCA) is a rare anomaly encountered using conventional coronary angiography. A right coronary artery (RCA) originating from a left anterior descending artery (LAD) is a rare subtype of SCA. Only a few cases are described in published literature. Case presentation: We described this anomaly in a 55-year-old male who presented with angina pectoris. The anomalous RCA was suspected by conventional coronary angiogram and was confirmed by computed tomography (CT) coronary angiography. Using CT, we demonstrated the course of the abnormal vessel and its relation to the main vessel. We also detected the presence of plaque, which caused luminal stenosis of the proximal LAD, which may cause global ischaemia. Conclusion: We concluded that although conventional coronary angiography is an important diagnostic method, new non-invasive methods such as CT coronary angiography can be a better screening tool to detect and characterise coronary anomalies. Electronic Supplementary Materials Supplementary Material 1: Coronary angiogram demonstrates anomalous RCA originating from LAD. Supplementary Material 2: CTA coronary shows anomalous RCA originates from the mid-portion of LAD.

Anomalous right coronary artery originating from the left anterior descending artery: Case report and review of the literature

Most of current coronary CT angiography protocols are not adapted to body weight (BW) or cardiac output and no literature about influence of gender on coronary attenuation are reported with administration of a fixed iodine load per BW. To determine the influence of body mass index (BMI) and gender on coronary arterial attenuation if contrast material dose is linearly adjusted to a patient's BW at dual-source CT coronary angiography (DSCT-CA). A total of 207 consecutive patients (mean age 60.6 years) undergoing DSCT-CA were included. Contrast material (370 mg I/mL) dose calculation was randomly categorized into two groups (Group 1: 1.10 mL/kg for men and women; Group 2: men 1.10 mL/kg, women 0.99 mL/kg) and flow rate was calculated as dose was divided by scan time plus 8 s. Mean arterial attenuations between men and women were compared with respect to attenuations of ascending aorta (AA) above coronary ostia, left main coronary artery (LM), proximal segments of right coronary artery (RCA), left anterior descending (LAD), and left circumflex artery (LCX) in two groups, respectively. Attenuations of coronary arteries were correlated with BW and BMI with simple linear regression. The mean attenuations of AA, LM, RCA, LAD, and LCX were 407.8 ± 53.6 HU, 412.6 ± 55.4 HU, 411.4 ± 64.3 HU, 399.1 ± 56.7 HU, and 399.1 ± 60.2 HU, respectively, and there were no significant differences between men and women in group 1 (AA, P = 0.571; LM, P = 0.670; RCA, P = 0.737; LAD, P = 0.439, and LCX, P = 0.888). In group 2, the mean attenuations of AA, LM, RCA, LAD, and LCX in men were significantly higher than those in women (AA, P = 0.008; LM, P = 0.025; RCA, P = 0.017; LAD, P = 0.015, and LCX, P = 0.002). Positive linear regression between BW and attenuations of AA (R(2) = 0.047, P = 0.02), LM (R(2) = 0.036, P = 0.04), RCA (R(2) = 0.080, P < 0.01), LAD (R(2) = 0.078, P < 0.01), and LCX (R(2) = 0.033, P = 0.05) was found in group 1, suggesting that attenuations of coronary arteries increased in heavier patients. Similarly, there was positive linear regression between BMI and attenuations of AA (R(2) = 0.117, P < 0.01), LM (R(2) = 0.090, P < 0.01), RCA (R(2) = 0.138, P < 0.01), LAD (R(2) = 0.111, P < 0.01), and LCX (R(2) = 0.078, P < 0.01). Men and women have similar coronary attenuations with a fixed iodine load per BW. BMI has a positive linear influence on arterial attenuation at DSCT-CA involving injection protocol with dose linearly tailored to BW. Excessive contrast material may inadvertently be given in heavier patients when the dose is determined by BW only. Contrast material dose may need to be tailored individually by BW and BMI.

The appearance of single coronary artery with anomalous Right Coronary Artery (RCA) originating from left coronary artery is an extremely rare encounter. Here, the authors report one such case of a 34-year-old male, who was serendipitously encountered with a single coronary artery with anomalous RCA arising from mid Left Anterior Descending (LAD)artery. He presented with anterior wall ST-elevation Myocardial Infarction (STEMI) and developed complete heart block. His mid LAD supplying anomalous RCA was totally occluded which was successfully recanalised using drug-eluting stent. The computed tomographic angiography confirmed single coronary artery with anomalous RCA arising from mid LAD across the stent.Thus, if RCA is not seen during traditional coronary angiography, the interventionalist should keep in mind that RCA can originate from LAD.

Background: ST-segment elevation myocardial infarctions (STEMI) are uncommon presentations of coronary artery anomalies and pose challenges in the emergent setting of percutaneous coronary interventions. We describe an extremely rare case of left main coronary artery (LMCA) originating off the right coronary artery (RCA) in a patient who presents with STEMI and was found to have Medina 1,1,1 lesion at the origin of the anomalous (LMCA). Case Presentation: An 81-year old male, with a past medical history significant for aortic stenosis and hyperlipidemia, presents to the emergency room for substernal non-radiating chest pressure. His electrocardiogram showed ST segment elevations in inferior and anterior leads. He was taken emergently to the cardiac cath lab. Coronary angiogram revealed a single right coronary ostium with an anomalous LMCA to mid left anterior descending (LAD) artery via dual insertion within a myocardial bridge. There was severe 90% Medina 1,1,1 bifurcating proximal RCA stenosis and 90% proximal LMCA stenosis. The entire left coronary system was fed by the anomalous LMCA, which was inserted into the mid-LAD in a dual insertion, between which there was a myocardial bridge. Cardiothoracic surgery team was consulted, and decision was made to pursue coronary artery bypass grafting (CABG). An intra-aortic balloon pump was placed via right femoral artery and patient was taken for emergent surgery, where he underwent 3 vessel CABG (left internal mammary artery to LAD, saphenous venous graft to obtuse marginal branch and posterior descending artery). Discussion: A broad spectrum of coronary anomalies have been reported, but their incidence in STEMI is rare. We discuss a very rare anomaly in which the entire left coronary system branches off the RCA, and culprit lesion was found to be a Medina 1,1,1 lesion. We aim to add to the sparce data pool of STEMI management in patients with anomalous coronary arteries.

Improvement in Survival Following Successful Percutaneous Coronary Intervention of Coronary Chronic Total Occlusions: Variability by Target Vessel

An aberrant origin of the left main coronary artery (LM) or left anterior descending coronary artery (LAD) from the right sinus of Valsalva is a rare anomaly that has been associated with myocardial ischemia and sudden cardiac death. Depending on the anatomic relationship of the anomalous vessel to the aorta and the pulmonary trunk, the anomaly can be classified into 4 common courses: posterior, interarterial, anterior, and septal course. Contrast-enhanced electron beam tomography (EBT) has been shown to permit classification of anomalous coronary arteries. We present 4 cases that illustrate the common variations of this anomaly. In all cases, EBT was performed using a C-150 XP EBT scanner (Imatron Inc). During inspiratory breathhold, 40 to 50 axial cross-sections of the heart were acquired triggered to the ECG at 40% of the R-R interval (100 ms acquisition time, slice thickness 3 mm, table feed 2 mm, intravenous injection of 160 mL contrast agent …