Abstract
We describe, in a 61 year old man, with coexistent aortic stenosis, the anomalous origin of posterior descending artery (PDA) from a stenotic left anterior descending (LAD) artery, as its continuation across the left ventricular apex, in the presence of a normally arising and atretic proximal right coronary artery. The patient underwent mechanical aortic valve replacement and triple coronary artery bypass grafting and made an uneventful recovery. To the best of our knowledge, origin of PDA as a continuation of LAD across the left ventricular apex in the presence of a normally arising but atretic proximal right coronary artery has never been described in literature before. There is one previous case report of continuation of LAD as PDA across the left ventricular apex in a patient with single left coronary coronary artery with an absent right coronary ostium. As the blood supply to the entire interventricular septum is derived from this "hyperdominant" LAD system, stenosis of LAD can be catastrophic. A review of literature of the anomalies of right coronary artery and, in particular, of its anomalous origin from LAD and its coexistence with aortic stenosis, is presented.
Highlights
A 61 year old current male smoker presented with moderate exertional angina and shortness of breath
left anterior descending artery (LAD) continued across the left ventricular apex as posterior descending artery (PDA), running along the posterior interventricular septum up to the atrioventricular groove
SanoFteouiegldteduactlhrct,ieovrrei2geohranitfgatahertyrtrcioaosl traiounnmda,riyaghastmngvaieollngatrtraricmeutilscahrRobCwraAinngcghiaveinsogarnomdffapSlleAytseirtiun-g Selective right coronary angiogram showing a normally situated coronary ostium, a small atretic right coronary artery (RCA) giving off SA nodal, right atrial and right ventricular branches and petering out thereafter
Summary
No two coronary anatomic patterns are alike and there is a wide range of variability within the normal distribution. Ectopic origin of RCA from posterior sinus of Valsalva, by contrast, is an extremely rare anomaly which runs a benign course with the right coronary artery having a normal distribution It is discovered accidentally and is not associated with any ischaemic symptoms [13]. In a patient requiring mitral valve replacement, the incidental discovery of an anomalous right coronary artery arising from mid LAD, which coursed along the free wall of right ventricle into the right AV groove, and continued as posterior descending artery This was associated with a separate small proximal RCA originating from right coronary sinus, with right conus, right atrial and right ventricular branches [37]. The presence of coexistent aortic stenosis in our patient, we think, was an incidental finding rather than a component of a well known syndrome, absent left main trunk [39], anomalous high origin of RCA [40] and single left coronary artery [41] have been described with aortic stenosis
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