Author + information
- Received January 14, 2013
- Accepted January 18, 2013
- Published online January 1, 2014.
- Mohit D. Gupta, MD, DM∗ (, )
- Girish MP, MD, DM,
- Bhagya N. Pandit, MD and
- Sanjay Tyagi, MD, DM
- Department of Cardiology, GB Pant Hospital and associated Maulana Azad Medical College, New Delhi, India
- ↵∗Reprint requests and correspondence:
Dr. Mohit D. Gupta, MD, DM, Department of Cardiology, Academic Block, First Floor, Room 125, GB Pant Hospital, New Delhi-110002, India.
A 40-year-old male smoker presented with acute myocardial infarction involving the anterior and inferior walls. Electrocardiography showed ST-segment elevation in the anterior leads and the inferior leads, suggesting a probable occlusion of a type III left anterior descending coronary artery (LAD). Coronary angiography showed a single coronary artery originating from the left sinus of Valsalva. The LAD showed thrombus containing 95% long-segment stenosis after the first diagonal with Thrombolysis In Myocardial Infarction (TIMI) flow grade 2 (Fig. 1). A large vessel originating from the mid-LAD just after the stenosis and following the course of the right coronary artery (RCA) had a TIMI flow grade 2 (Fig. 1A). Percutaneous coronary intervention (PCI) of the LAD was carried out by implanting a drug-eluting stent. TIMI flow grade 3 was achieved in both the anomalous RCA and the LAD (Fig. 1B). A computed tomography coronary angiogram done later revealed the anomalous RCA originating from the mid-LAD that coursed to the right, anterior to the pulmonary artery and the right ventricular outflow tract (Fig. 2). The anomalous origin of the RCA from the mid-LAD is one of the rarest coronary anomalies reported to date (1,2). Most of the anomalies of the RCA originating from the LAD are generally considered benign (3). However, ischemia because of this anomaly may be caused by the acute angle made by the anomalous RCA to turn towards the right atrioventricular groove, thereby causing reduced flow velocity (2). The course between the great arteries leading to compression of anomalous artery and atherosclerotic involvement of the vessels (jeopardizing a large amount of myocardium, as in the present case) may also cause angina or infarction (2). While doing primary PCI in such an anomaly, certain technical considerations such as protection of the anomalous RCA with a wire, use of a flexible and steerable wire (keeping in mind the angulated origin of the RCA) and mandatory kissing balloon technique despite having good flow in the RCA (this being a major epicardial artery and not a branch) should be kept in mind. This variant has not been listed in the classification of such an anomaly, but it resembles the IB1 type of Shirani and Roberts’ classification (3).
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 14, 2013.
- Accepted January 18, 2013.
- American College of Cardiology Foundation