Author + information
- Received October 13, 2017
- Revision received October 30, 2017
- Accepted November 7, 2017
- Published online February 14, 2018.
- Pankaj Jariwala, MD, DNBa,∗ (, )
- Hemanshu Bhatia, MDa,
- R.C. Kesava Rao, MDb and
- E.A. Padma Kumar, MD, DMa
- aDepartment of Cardiology, Maxcure–Mediciti Hospitals, Hyderabad, India
- bDepartment of Radiology, Maxcure–Mediciti Hospitals, Hyderabad, India
- ↵∗Address for correspondence:
Dr. Pankaj Jariwala, Maxcure–Mediciti Hospitals, Opposite Secretariat, Hyderabad 500063, Telangana, India.
- angiography coronary
- anomalous coronaries
- imaging (computed tomography/magnetic resonance)
- right coronary sinus
A 56-year-old hypertensive woman presented with symptoms of typical chest pain with onset 24 h before. Electrocardiography showed inferior wall myocardial infarction. Echocardiography revealed hypokinesia of inferior wall with mild mitral regurgitation (ejection fraction 48%).
Coronary angiography could not engage left coronary artery selectively. Right coronary sinus (RCS) cannulation opacified 4 coronary arteries (left anterior descending artery [LAD], left circumflex artery [LCX], ramus intermediate artery, and right coronary artery [RCA]) arising distinctively from the 4 separate ostial origins (Figure 1A). The RCA had a significant lesion in the proximal and distal segments. The LAD was normal whereas the LCX and ramus intermediate artery had nonobstructive lesions. Coronary computed tomography angiography confirmed that the anomalous separate origin of 4 coronary arteries from the RCS with nondominant LCX has a retroaortic course (Figures 1B–D). The patient underwent percutaneous transluminal coronary angioplasty to the RCA using 2 drug-eluting stents.
Patel et al. (1) described a series of 7 cases of separate ostial origin of all 3 coronary arteries from the RCS, with the LCX and LAD coursing separately to the left side of the heart as in our case. The LCX has a retroaortic course that is benign whereas the LAD has a course anterior to the pulmonary artery. Beach et al. (2) described a case similar to our case in an autopsy of a patient who had hypertrophic cardiomyopathy upon evaluation for sudden cardiac death. The other 2 cases of such an anomaly had the fourth artery as a large conus branch (3,4).
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 13, 2017.
- Revision received October 30, 2017.
- Accepted November 7, 2017.
- 2018 American College of Cardiology Foundation