Author + information
- Received March 19, 2014
- Accepted March 27, 2014
- Published online October 1, 2014.
- ∗Indo-US Superspeciality Hospitals, Ameerpet, Hyderabad, India
- †Lucid Diagnostics, Banjara Hills, Hyderabad, India
- ↵∗Reprint requests and correspondence:
Dr. Pankaj Jariwala, Indo-US Superspeciality Hospitals, Shyam Karan Road, Anand Bagh, Ameerpet, Hyderabad, India, 500016.
A 56-year-old male patient who was hypertensive and nondiabetic presented with chest discomfort on exertion for the last 3 months. The electrocardiogram was normal, and 2-dimensional echocardiography revealed normal left ventricular function, no left ventricular regional wall motion abnormalities. Hence, he was given a stress test, which was positive for inducible ischemia at low workload.
Coronary angiography showed a small rudimentary left coronary artery; while searching for the left coronary artery, to our surprise, the origin of the left coronary artery was found to be from the right coronary sinus. It had a main stem artery giving separate origins to the left anterior descending, diagonal, and obtuse marginal (first to fifth) coronary arteries. There was an eccentric 80% stenosis of the main stem of the left coronary artery before the origin of the first obtuse marginal artery. The right coronary artery had a normal course, and the posterior descending artery showed 99% stenosis of the proximal segment (Figures 1A to 1D).
Before planning his revascularization strategy, we performed computed tomography (CT) coronary angiography on the patient for better delineation of the anatomy of the coronary arteries.
CT coronary angiography determined the coursing of the anomalous left coronary artery and showed no interarterial or intramyocardial course of the coronary arteries (Figures 2A to 2D).
Percutaneous transluminal coronary angioplasty was done using 2 drug-eluting stents to the main stem left coronary artery and posterior descending artery stenoses.
The origin of the left main coronary artery in the right coronary sinus has been described in 0.02% of autopsy series (1) and from 0.05% to 0.19% in angiographic series (2). A main stem of the left coronary artery arising from the right sinus of Valsalva has 4 anatomical courses (3):
1. Anterior course: turns anterior in front of right ventricular outflow tract, as in our case.
2. Interarterial course: between the great vessels, aorta, and pulmonary artery.
3. Septal course: intramyocardial septal continuation.
4. Posterior course: turns posterior behind the aorta.
Percutaneous angioplasty was done in view of no interarterial course of the coronary arteries.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 19, 2014.
- Accepted March 27, 2014.
- American College of Cardiology Foundation