Images in cardiovascular medicine. Anomalous course of the left main or left anterior descending coronary artery originating from the right sinus of valsalva: identification of four common variations by electron beam tomography.

Abstract

HomeCirculationVol. 105, No. 6Anomalous Course of the Left Main or Left Anterior Descending Coronary Artery Originating From the Right Sinus of Valsalva Free AccessOtherPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherPDF/EPUBAnomalous Course of the Left Main or Left Anterior Descending Coronary Artery Originating From the Right Sinus of ValsalvaIdentification of Four Common Variations by Electron Beam Tomography Dieter Ropers, MD, Gisbert Gehling, MD, Karsten Pohle, MD, Ralph Maeffert, MD, Matthias Regenfus, MD, Werner Moshage, MD, Peter Schuster, MD, Werner G. Daniel, MD and Stephan Achenbach, MD Dieter RopersDieter Ropers From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Gisbert GehlingGisbert Gehling From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Karsten PohleKarsten Pohle From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Ralph MaeffertRalph Maeffert From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Matthias RegenfusMatthias Regenfus From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Werner MoshageWerner Moshage From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Peter SchusterPeter Schuster From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author , Werner G. DanielWerner G. Daniel From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author and Stephan AchenbachStephan Achenbach From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany. Search for more papers by this author Originally published12 Feb 2002https://doi.org/10.1161/hc0602.102020Circulation. 2002;105:e42–e43An 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 at 4 mL/second). In addition to the original axial images, 2-dimensional multiplanar reconstructions and 3-dimensional reconstructions were rendered on an image processing workstation (NetraMD, ScImage) to display the anatomic course of the anomalous LM or LAD. In all cases, the results were confirmed by invasive coronary angiography.Posterior or Retroaortic CourseIn the nonprocessed axial image (Figure 1A) and the 3-dimensional reconstruction (Figure 1B), EBT shows the retroaortic course of the LM that originates from the right sinus of Valsalva and passes posterior and inferior to the aortic root. Download figureDownload PowerPointFigure 1. Posterior or retroaortic course of the left main coronary artery. A, Axial cross-sectional image. The arrow points at the artery posterior and inferior to aortic root. LA indicates left atrium; RA, right atrium; LV, left ventricle; MV, mitral valve. B, 3-Dimensional reconstruction (lateral view). The arrows point at the left main coronary artery. The arrowhead indicates the right coronary artery. Ao indicates ascending aorta; PA, pulmonary artery.Interarterial or Preaortic CourseThe course of the LM between the aorta and the pulmonary trunk is clearly delineated both in the original cross-section (Figure 2A) and in the 3-dimensional reconstruction (Figure 2B). Download figureDownload PowerPointFigure 2. Interarterial or preaortic course of the left main coronary artery. A, Original axial cross-section. Arrows indicate the left main taking a path between the ascending aorta and pulmonary trunk. The arrowhead points at the right coronary artery. Ao indicates ascending aorta; PA, pulmonary artery. B, 3-Dimensional reconstruction. The arrows point at the left main coronary artery. LA indicates left atrium; RA, right atrium.Anterior or Prepulmonic CourseIn a patient with a right-sided single coronary artery, the LAD originates from the proximal right coronary artery and takes a course anterior to the right ventricular outflow tract to the left anterior interventricular groove (Figures 3A and 3B). The left circumflex coronary artery (LCX) follows a retroaortic course (not displayed). Download figureDownload PowerPointFigure 3. Anterior or prepulmonic course of the left anterior descending coronary artery. A, Original axial cross-section. The arrows point at the LAD. Ao indicates ascending aorta; PA, pulmonary artery; Vcs, superior vena cava. B, 3-Dimensional reconstruction (anterior view). The arrows point at the LAD, which takes a course anterior to the right ventricular outflow tract. The arrowhead points at the orthotopic right coronary artery. The left circumflex coronary artery (which follows a retroaortic course) is not displayed.Septal or Subpulmonic CourseIn this case, the LM ostium is located adjacent to the right coronary ostium. The LCX takes a prepulmonic path, whereas the LAD follows an intramyocardial course through the interventricular septum beneath the right ventricular infundibulum (Figure 4A). The artery surfaces in the midsection of the interventricular groove, which is clearly shown in the 3-dimensional reconstruction (Figure 4B). Download figureDownload PowerPointFigure 4. Septal or subpulmonic course of the left anterior descending coronary artery. A, Curved multiplanar reconstruction. The arrows point at the LAD, which takes an intramyocardial course through the interventricular septum beneath the right ventricular infundibulum. Ao indicates ascending aorta; PA, pulmonary artery. B, 3-Dimensional reconstruction that shows the LAD surfacing in the midsection of the anterior interventricular groove (white arrow). The black arrow indicates the left circumflex coronary artery, which follows a course anterior to the pulmonary artery. Arrowhead indicate right coronary artery.These examples illustrate the potential of contrast-enhanced EBT to visualize the exact 3-dimensional course of anomalous coronary arteries.The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St.Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.Circulation encourages readers to submit cardiovascular images to the Circulation Editoral Office, St.Luke's Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MCI-267, Houston, TX 77030.FootnotesCorrespondence to Dr D. Ropers, Medizinische Klinik II mit Poliklinik, University of Erlangen-Nuernberg, Oestliche Stadtmauerstrasse 29, 91054 Erlangen, Germany. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Zahradníková S, Buděšínský T and Knot J (2020) (An anomalous origin and course of left anterior descending artery), Cor et Vasa, 10.33678/cor.2020.009, 62:5, (452-456), Online publication date: 1-Nov-2020. Agbor-Etang B, La V, Nazzal S and Pai R (2018) Implications of Anomalous Left Coronary Artery Origin, The American Journal of Medicine, 10.1016/j.amjmed.2017.09.038, 131:1, (e21-e22), Online publication date: 1-Jan-2018. Forte E, Inglese M, Infante T, Schiano C, Napoli C, Soricelli A, Salvatore M and Tedeschi C (2016) Anomalous left main coronary artery detected by CT angiography, Surgical and Radiologic Anatomy, 10.1007/s00276-016-1634-9, 38:8, (987-990), Online publication date: 1-Oct-2016. Kim S, Ko S, Choi S, Choi B and Stillman A (2016) Sudden cardiac death from structural heart diseases in adults: imaging findings with cardiovascular computed tomography and magnetic resonance, The International Journal of Cardiovascular Imaging, 10.1007/s10554-016-0891-3, 32:S1, (21-43), Online publication date: 1-Jun-2016. Green M, Sehgal S, Smukler N, Suber L and Saththasivam P (2015) Anomalous Coronary Artery, Seminars in Cardiothoracic and Vascular Anesthesia, 10.1177/1089253215605389, 20:3, (232-236), Online publication date: 1-Sep-2016. Gao X, Li H and Chen H (2015) Myocardial Ischemia due to a Type IV Dual LAD with the Long LAD Arising from the Right Sinus of Valsalva: A Case Report and Literature Review, Internal Medicine, 10.2169/internalmedicine.54.4147, 54:20, (2619-2623), . Yi B, Sun J, Yang H and Kang D (2015) Coronary Artery Anomalies: Assessment with Electrocardiography-Gated Multidetector-Row CT at a Single Center in Korea, Journal of the Korean Society of Radiology, 10.3348/jksr.2015.72.4.207, 72:4, (207), . Aiyappan S, Ranga U and Veeraiyan S (2014) Single coronary artery from right sinus of valsalva associated with atrial septal defect, Indian Journal of Thoracic and Cardiovascular Surgery, 10.1007/s12055-014-0287-8, 30:4, (314-315), Online publication date: 1-Dec-2014. Ni J, Ge C, Wang P and Zhang W (2014) Undescribed origin of the left main coronary artery from the right sinus of Valsalva: An explanation of nonexistent myocardial ischemia?, International Journal of Cardiology, 10.1016/j.ijcard.2014.03.203, 174:2, (e32-e33), Online publication date: 1-Jun-2014. Shimizu T, Iwaya S, Suzuki S, Sakamoto N, Sugimoto K, Nakazato K, Suzuki H, Nishimura T, Takahashi Y, Saito S and Takeishi Y (2014) Sudden Cardiac Arrest Associated with an Anomalous Aortic Origin of the Left Coronary Artery from the Opposite Sinus of Valsalva, Internal Medicine, 10.2169/internalmedicine.53.2676, 53:22, (2601-2604), . Türkvatan A, Güray Y and Altınsoy D (2012) Multidetector computed tomography imaging of coronary artery anomalies, Cardiology in the Young, 10.1017/S1047951112001758, 23:5, (661-674), Online publication date: 1-Oct-2013. Lee H, Hong Y, Kim H, Lee J, Hur J, Choi B, Chang H, Nam J, Choe K and Kim Y (2012) Anomalous Origin of the Right Coronary Artery from the Left Coronary Sinus with an Interarterial Course: Subtypes and Clinical Importance, Radiology, 10.1148/radiol.11110823, 262:1, (101-108), Online publication date: 1-Jan-2012. Pontone G, Andreini D, Bertella E, Cortinovis S, De Martini S, Pirondini M, Fabbiocchi F, Bartorelli A and Pepi M (2011) Detection of left main coronary artery anomalous origin with low-dose multidetector computed tomography using prospective ECG gating, Journal of Cardiovascular Medicine, 10.2459/JCM.0b013e328334f474, 12:7, (506-509), Online publication date: 1-Jul-2011. Berdajs D and Turina M (2011) Coronary Arteries Operative Anatomy of the Heart, 10.1007/978-3-540-69229-4_4, (161-243), . Fujimoto S, Kondo T, Orihara T, Sugiyama J, Kondo M, Kodama T, Fukazawa H, Nagaoka H, Oida A, Yamazaki J and Takase S (2011) Prevalence of anomalous origin of coronary artery detected by multi-detector computed tomography at one center, Journal of Cardiology, 10.1016/j.jjcc.2010.10.006, 57:1, (69-76), Online publication date: 1-Jan-2011. Erol C and Seker M (2011) Coronary Artery Anomalies, Journal of Computer Assisted Tomography, 10.1097/RCT.0b013e31822aef59, 35:5, (618-624), Online publication date: 1-Sep-2011. Matsumoto M, Yokoyama K, Yahagi T, Kikushima K, Watanabe K, Tani S, Anazawa T, Kawamata H, Nagao K and Hirayama A (2011) Double left anterior descending artery arising from right and left sinus of Valsalva in patient with acute coronary syndrome, International Journal of Cardiology, 10.1016/j.ijcard.2009.03.049, 149:1, (e40-e42), Online publication date: 1-May-2011. Said S, Dearani J, Burkhart H and Schaff H (2010) Surgical management of congenital coronary arterial anomalies in adults, Cardiology in the Young, 10.1017/S1047951110001113, 20:S3, (68-85), Online publication date: 1-Dec-2010. Cruz C, Mclean D, Janik M, Raggi P and Zafari A (2010) A Rare Coincidence of Two Coronary Anomalies in an Adult, Cardiology Research and Practice, 10.4061/2010/376067, 2010, (1-4), . Talanas G, Delpini A, Casu G, Bilotta F, Pes R and Terrosu P (2009) A double left anterior descending coronary artery emerging from the right Valsalva sinus: a case report and a brief literature review, Journal of Cardiovascular Medicine, 10.2459/JCM.0b013e3283189350, 10:1, (64-67), Online publication date: 1-Jan-2009. Herzog C, Zangos S, Zwerner P, Costello P, Vogl T and Joseph Schoepf U (2007) CT of Coronary Artery Disease, Journal of Thoracic Imaging, 10.1097/RTI.0b013e318032394f, 22:1, (40-48), Online publication date: 1-Feb-2007. Montaudon M, Latrabe V, Iriart X, Caix P and Laurent F (2007) Congenital coronary arteries anomalies: review of the literature and multidetector computed tomography (MDCT)-appearance, Surgical and Radiologic Anatomy, 10.1007/s00276-007-0217-1, 29:5, (343-355), Online publication date: 1-Jun-2007. Gerber T, Breen J, Kuzo R, Kantor B, Williamson E, Safford R and Morin R (2006) Computed Tomographic Angiography of the Coronary Arteries: Techniques and Applications, Seminars in Ultrasound, CT and MRI, 10.1053/j.sult.2005.11.005, 27:1, (42-55), Online publication date: 1-Feb-2006. Kim S, Seo J, Do K, Heo J, Lee J, Song J, Choe Y, Kim T, Yong H, Choi S, Song K and Lim T (2006) Coronary Artery Anomalies: Classification and ECG-gated Multi–Detector Row CT Findings with Angiographic Correlation, RadioGraphics, 10.1148/rg.262055068, 26:2, (317-333), Online publication date: 1-Mar-2006. Cardiac Imaging MDCT and 3D Workstations, 10.1007/0-387-31804-6_12, (213-237) Ohnesorge B, Hofmann L, Flohr T and Schoepf U (2005) CT for imaging coronary artery disease: defining the paradigm for its application, The International Journal of Cardiovascular Imaging, 10.1007/s10554-004-5346-6, 21:1, (85-104), Online publication date: 1-Feb-2005. RASHID A, SAUCEDO J and HENNEBRY T (2005) Association of Single Coronary Artery and Congenital Bicuspid Aortic Valve with Review of Literature, Journal of Interventional Cardiology, 10.1111/j.1540-8183.2005.00067.x, 18:5, (389-391), Online publication date: 1-Oct-2005. von Kodolitsch Y, Franzen O, Lund G, Koschyk D, Ito W and Meinertz T (2005) Coronary artery anomaliesAnomalien der Koronararterien Teil II: Aktuelle Erkenntnisse aus klinischen Untersuchungen, Zeitschrift für Kardiologie, 10.1007/s00392-005-0153-1, 94:1, (1-13), Online publication date: 1-Jan-2005. Memisoglu E, Ropers D, Hobikoglu G, Tepe M and Labovitz A (2005) Usefulness of Electron Beam Computed Tomography for Diagnosis of an Anomalous Origin of a Coronary Artery from the Opposite Sinus, The American Journal of Cardiology, 10.1016/j.amjcard.2005.07.048, 96:10, (1452-1455), Online publication date: 1-Nov-2005. Shi H, Aschoff A, Brambs H and Hoffmann M (2004) Multislice CT imaging of anomalous coronary arteries, European Radiology, 10.1007/s00330-004-2490-2, 14:12, (2172-2181), Online publication date: 1-Dec-2004. Schoepf U, Becker C, Ohnesorge B and Yucel E (2004) CT of Coronary Artery Disease, Radiology, 10.1148/radiol.2321030636, 232:1, (18-37), Online publication date: 1-Jul-2004. van Ooijen P, Dorgelo J, Zijlstra F and Oudkerk M (2004) Detection, visualization and evaluation of anomalous coronary anatomy on 16-slice multidetector-row CT, European Radiology, 10.1007/s00330-004-2493-z, 14:12, (2163-2171), Online publication date: 1-Dec-2004. Deibler A, Kuzo R, Vöhringer M, Page E, Safford R, Patton J, Lane G, Morin R and Gerber T (2004) Imaging of Congenital Coronary Anomalies With Multislice Computed Tomography, Mayo Clinic Proceedings, 10.4065/79.8.1017, 79:8, (1017-1023), Online publication date: 1-Aug-2004. Sinitsyn V and Achenbach S (2004) Electron Beam Computed Tomography (EBCT) Coronary Radiology, 10.1007/978-3-662-06419-1_8, (137-165), . Achenbach S, Ropers D, Pohle K, Anders K, Baum U, Hoffmann U, Moselewski F, Ferencik M and Brady T (2003) Clinical results of minimally invasive coronary angiography using computed tomography, Cardiology Clinics, 10.1016/S0733-8651(03)00090-0, 21:4, (549-559), Online publication date: 1-Nov-2003. Sevrukov A, Aker N, Sullivan C, Jelnin V and Candipan R (2002) Identifying the course of an anomalous left coronary artery using contrast-enhanced electron beam tomography and three-dimensional reconstruction, Catheterization and Cardiovascular Interventions, 10.1002/ccd.10341, 57:4, (532-536), Online publication date: 1-Dec-2002. Gać P, Żórawik A and Poręba R (2022) A Single Coronary Artery Originating from the Right Coronary Sinus with a Typical Course of the Right Coronary Artery and the Interarterial Course of the Left Main, Left Anterior Descending, and Left Circumflex as an Example of a Rare Case of High-Risk Coronary Anomaly, Diagnostics, 10.3390/diagnostics12010167, 12:1, (167) February 12, 2002Vol 105, Issue 6 Advertisement Article InformationMetrics https://doi.org/10.1161/hc0602.102020 Originally publishedFebruary 12, 2002 PDF download Advertisement