Superdominant Right Coronary Artery Research Articles

Hyperdominant Right Coronary Artery Occlusion Presenting with Acute Anterior Wall Myocardial Infarction

This case report describes a 69-year-old male who presented with acute anterior myocardial infarction and was detected to have a hyperdominant right coronary artery (RCA) with a large posterior descending branch coursing from the posterior interventricular groove into the apical part of the anterior interventricular space and posterior left ventricular branch coursing in the left atrioventricular groove and supplying the entire free wall. Primary percutaneous intervention of the proximally occluded posterior descending artery resulted in resolution of ST-segment elevation in anterior and inferior leads and also revealed the large vascular territory of the RCA. The occurrence of superdominant RCA and intact left circumflex artery presenting with acute anterior wall myocardial infarction has not been described earlier. Precise morphological and physiological knowledge and evaluation of such a variation assists in opting for the best available therapeutic modality and prognosis.

What does one need to survive with Anomalous origin of left coronary artery from pulmonary trunk (ALCAPA) beyond infancy.

A 53-year old man presented with sustained monomorphic ventricular tachycardia which was restored with 200 joules of direct current cardioversion. Complete haemogram, liver, and kidney function tests, and serum electrolytes were within normal limit. His past history was insignificant except exertional dyspnoea NYHA class-I for last one year. Transrthoracic echocardiography revealed dilated left ventricle and atrium with severe systolic dysfunction (EF=28%). There was continous flow entering the pulmonary trunk. Origin of right coronary artery was dilated and left coronary artery was originating from main pulmonary artery suggestive of anomalous origin of left coronary artery from pulmonary trunk (ALCAPA). Coronary angiogram showed dilated and tortuous right coronary artery (RCA) with absence of a left coronary ostium in aortic sinus. During the delayed filling phase, abundant intercoronary anastomoses (Rentrop grade 3) were seen, communicating with left coronary artery which was later opacifying the main pulmonary artery thus establishing diagnosis of ALCAPA. Multidetector computed tomography angiography confirmed its diagnosis. Implantable cardioverter defibrillator was implanted. ALCAPA is a rare congenital cardiovascular anomaly which occurs 1 in 300,000 live births with rare survival to adulthood as 90% succumbs by third decade.Those with this syndrome who manages to survive beyond childhood are often incapacitated by myocardial ischemia, arrhythmias and severe ischemic cardiomyopathy. Survival beyond fourth or fifth decade with ALCAPA without surgical intervention is exceedingly rare as low pulmonary artery pressure results in coronary steal phenomenon. Rarely some remain asymptomatic until adulthood due to superdominant RCA, although they generally become symptomatic in early adulthood due to fixed myocardial ischemia and coronary steal phenomenon. In utero, as the systemic and pulmonary arterial pressures are equal, there is anterograde flow in both the left and the right coronary. In the neonatal period as the pulmonary artery pressure falls and ductus arteriosus closes, the flow in the left coronary artery reverses. The more collateral channels exist between RCA and anomalous left coronary system (ALCA), the longer the patient may survive. Another contributing factor may be the area supplied by the ALCA as the smaller the area supplied by the ALCA, the less extensive the myocardial ischemia is likely to be. In few adult cases, RCA supplies not only the posterior wall of the left ventricle but also its lateral wall. May be this reduction in the area of the myocardium supplied by the ALCA would favour survival. However, even extensive collateral circulation may not totally prevent ischemic damage though can delay it as low pulmonary artery pressure may still result in coronary steal phenomenon, which may cause sudden deaths. We believe right coronary artery may have “supernormal” flow reserve to account for his survival. Surgical correction such as direct transfer of the left coronary artery from pulmonary artery (like in arterial switch operation), Takeuchi repair (creating aorto-pulmonary window), and bypass graft when these two are not possible, it is one of the coronary anomalies not compatible to life. In our case, it was decided not to intervene surgically as risk of cardiac surgery was outweighing the benefit.

A Rare Case of Single Right Coronary Artery with Absent Left Main Coronary Artery

A 54-year-old woman presented with abdominal pain and diarrhoea, and had new T-wave inversion on electrocardiogram in leads V2–V6. Past history included recurrent deep vein thrombosis/pulmonary embolism and a recent subtotal colectomy for ulcerative colitis. The patient denied chest pain and serial troponin I measurements were normal (<0.040 μg/L). Postoperative ileus was the likely cause of abdominal pain. Echocardiography revealed impaired left ventricular (LV) systolic function (LV ejection fraction 35–40%). Coronary angiography was performed and the left main coronary artery (LMCA) could not be located despite cuspal injections, ascending aortogram, and left ventriculogram. A dominant right coronary artery (RCA) was visualised, which passed around the left ventricular apex to the area normally supplied by the obtuse marginal, diagonal, and distal left anterior descending arteries. Computed tomography coronary angiography (CTCA) revealed a superdominant RCA supplying the LV apex and lateral wall with no LMCA coming off the left coronary cusp. The left circumflex was small and arose from a conus branch separate to the RCA. No significant stenosis was visualised on CTCA. The T-wave changes on electrocardiogram and subtle subendocardial enhancement/fibrosis in the anterior wall on cardiac magnetic resonance imaging were deemed to be secondary to supply–demand ischaemia, particularly at the distal end of the RCA, where it supplied the left anterior descending artery territory. The patient was discharged on metoprolol 25 mg twice daily and her usual warfarin. Single RCA with absent LMCA is extremely rare with only few isolated cases in the literature. Use of CTCA in combination with coronary angiography was useful in defining this unusual anatomy.

Do we need three coronary arteries?

Normal myocardium is usually perfused by three coronary arteries- a left main system bifurcating into left anterior descending artery (LAD), and left circumflex artery (LCx), and right coronary artery (RCA). Coronary artery anomalies are congenital changes in their origin, course, and/or structure, which are usually discovered as incidental findings during coronary angiographic studies. Here, we report a case of 56-year-old hypertensive, and diabetic male who was being evaluated for exertional angina and dyspnoea whose coronary angiogram revealed a rare coronary anomaly: normal LAD, absent LCx, and superdominant RCA which was better delineated on Multidetector coronary angiography (MDCT). Multislice CT is the non-invasive modality of choice for imaging anomalies of coronary arteries and provides high speed with excellent spatial resolution.

Septal fluttering- an important echocardiographic diagnostic sign of anomalous origin of left coronary artery from pulmonary trunk (ALCAPA)

A 49-year old woman presented with exertional dyspnoea NYHA class-II for last three year, with recent worsening in the past six months. Transrthoracic echocardiography (TTE) revealed dilated left ventricle and atrium with systolic dysfunction (EF=35%). Apical 4-chamber view showed continous low flow signals (diastolic more than systolic) in the interventricular septum detected by continous Doppler interrogation (Fig.1, 2). Beside mild mitral regurgitation, and dilated ostium of right coronary artery (RCA), other abnormalities could not be detected. Coronary angiogram showed absent left coronary ostium in aortic sinus, dilated and tortuous right coronary artery (RCA) giving abundant intercoronary anastomoses to left coronary artery (LCA) which was later opacifying the main pulmonary artery in the delayed filling phase thus establishing diagnosis of ALCAPA (Fig. 3). The left coronary ostium arising from the pulmonary trunk, a sign qua non could not be seen on TTE because of poor parasternal short-axis echo window. ALCAPA is a rare congenital coronary anomaly with an incidence of 1 in 300,000 live births [1-3]. Angiography whether invasive or computed is its important modalities. However, they carry the disadvantage of radiation, contrast exposure, cost, and nephrotoxity. On the other hand, transrthoracic echocardiography (TTE) is an important non-invasive reliable modality which helps in its diagnosis as it gives important information regarding the anatomic, functional, and hemodynamic evaluation. Abundant intercoronary septal collaterals with continuous flow, particularly in mid-systole and more in diastole were imparting septal fluttering indicating ALCAPA which was subsequently confirmed on angiogram. Such low flow signals differentiate it from the small muscular ventricular septal defects which shunt in systole and RCA to pulmonary artery fistula where connections are epicardial and will have different angiographic appearances. Although LCA originating from the pulmonary artery in parasternal short-axis view is most diagnostic, it may not always be appreciated because of poor widow, and LCA remaining close to the aorta, and therefore septal fluttering in another pointer towards its diagnostic [4]. It suggests left-to-right shunting from RCA via LCA to main pulmonary artery through intercoronary septal collaterals, and low pulmonary vascular resistance which is in the opposite direction of normal LCA and is prominent in the diastolic phase. Adult survivors of ALCAPA are often incapacitated by myocardial ischemia, arrhythmias and cardiomyopathy. Survival without surgery (direct transfer of LCA from pulmonary artery, bypass or Takeuchi repair) is exceedingly rare beyond fourth or fifth decade as low pulmonary artery pressure results in coronary steal phenomenon [5]. Some may remain asymptomatic until adulthood due to superdominant RCA, become symptomatic due to fixed myocardial ischemia and coronary steal phenomenon [6]. The more collateral channels exist between RCA and anomalous left coronary system (ALCA), the longer the patient may survive.

Mechanical extraction of a massive intracoronary thrombus from the super-dominant right coronary artery in thrombogenic lung cancer patient.

The congenital absence of the left circumflex artery and a compensatory super-dominant right coronary artery (RCA) is a very rare benign coronary anomaly in the clinic. The presence of a massive thrombus in the super-dominant RCA can lead to fatal results in cases of acute myocardial infarction, unless the thrombus is mechanically removed. Aspiration of the thrombus using a 6 Fr right Judkins guide catheter is useful to extract a massive thrombus and is both safe and effective. We report a case of complete revascularization of the super-dominant RCA after thrombus aspiration using a 6 Fr Judkins right catheter in a patient with acute inferior and inferolateral wall myocardial infarction.

Prevalence and characteristics of coronary artery anomalies in 12401 adult patients: a coronary angiographic study from Northern Greece

Purpose: Since regional and ethnic variations of the incidence of CAA have been reported, our aim was to estimate their incidence in a population from Northern Greece, which has not been previously studied. Methods: A series of 12401 coronary angiograms, performed between January 2003 and December 2011 in a cardiac catheterization unit at our institution was retrospectively reviewed for the presence of coronary artery anomalies. Results: The overall incidence of isolated coronary artery anomalies was 1.35% (167/12401, mean age: 62.9±11.6 years, males: 74.3%). The most common coronary anomaly was separate ostia for Left Anterior Descending artery (LAD) and circumflex artery (Cx) inside the left sinus of Valsava (SoV), with an incidence of 0.48% (59/12401) or 35.3% of all coronary anomalies. The second most common anomaly was origin of Cx from the right side with an incidence of 0.35% (43/12401) or 25.7% of all coronary anomalies. Regarding the anomalous origin of the Cx from the right SoV, three distinct anatomical variants of the ostium of the anomalous left circumflex coronary artery were identified: a) separate ostia for Right Coronary Artery (RCA) and anomalous circumflex within the right sinus of Valsalva (type I, n=20, 46.5%), b) common ostia in the right sinus (type II, n=13, 30.2%), and c) Cx arising arising as a branch of the proximal RCA (type III, n=10, 23.3%). In all cases the anomalous Cx had a posterior course to the aorta. Anomalous RCA origin was found in 41 cases (0.33% or 24.6% of all coronary anomalies). It originated separately from the left sinus of Valsalva (SV) in eighteen patients (an incidence 0.14% or 10.8% of all anomalies). A single coronary artery arising from the right SoV was seen in four patients (0.03% or 2.4% of anomalies). An absent circumflex or super-dominant RCA in 2 cases (0.02% or 1.2% of anomalies). In this series we also found also seventeen cases of coronary fistulas (0.13% or 10.2% of anomalies). In one patient coronary angiography revealed congentital left main coronary artery atresia (0.008%) with a dominant RCA providing intercoronary retrograde collateral to the left anterior descending artery (LAD) and left circumflex artery (LCx). Conclisions: The incidence of coronary artery anomalies in our study population was 1.35%. The most common type was separate ostia for LAD and Cx inside the left SoV and second most common the origin of the Cx from the right sinus of Valsalva. Although geographic variations in the incidence of CAA have been reported, these results are in agreement with previously published large angiographic series.