Conventional and computed tomography angiography views of a rare type of single coronary artery anomaly: right coronary artery arising from distal left circumflex artery/Tek koroner arter anomalisinin nadir bir tipinin konvansiyonel ve cok kesitli bilgisayarli tomografi anjiyografi goruntuleri: distal circumfleks arterden cikan sag koroner arter.
Single coronary artery anomaly (SCA) is defined as the coronary artery arising from a single coronary ostium, supplying the entire heart. Although the incidence of coronary artery anomalies ranges from 0.6% to 1.3% in angiography series, the prevalence of SCA was only found to be 0.02% in the population (1). SCA anomalies are usually benign and asymptomatic; however, serious complications such as sudden cardiac death and myocardial infarction resulting from these anomalies were also reported in the literature.
Right coronary artery (RCA) originating from left coronary sinus or proximal portions of left coronary arteries or left coronary system originating from right coronary sinus constitute the major proportion of SCA anomalies. Herein, we report a case in which the RCA originates from the distal portions of left circumflex artery as a continuum of it. In addition to conventional angiography images; multi-detector computed tomography (MDCT) was used to confirm the diagnosis and determine the course of the anomalous coronary arteries in this case report.
A 52-year old woman with hypertension and dyslipidemia was admitted to our clinics with class II exertional chest pain according to Canadian Cardiovascular Society classification. After 2 mm horizontal ST depression in the lateral leads with a Duke score of -10 was revealed on stress electrocardiography, coronary angiography was performed. Single coronary artery ostium was detected in which RCA was arising as a continuum of the left circumflex coronary artery (Fig. 1). To confirm this diagnosis and search for a possible cardiac anomaly, which may explain the patient's symptoms, 64-slice MDCT (Aquilion; Toshiba Medical Systems, Tokyo; Japan) was performed thereafter (Fig. 2). With the help of this method, we confirmed the SCA originating from solitary coronary ostium without an additional cardiac anomaly. The RCA was found to be continuous with the distal portion of the left circumflex artery. We decided to continue her medical therapy and added a beta -blocker because we thought that this anomaly might directly induce myocardial ischemia. She had been asymptomatic at her last visit.
[FIGURE 1 OMITTED]
[FIGURE 2 OMITTED]
Isolated SCA anomaly is one of the rarest coronary anomalies and constitutes 24% of all the coronary artery anomalies. SCA has been reported to be seen in 0.024% to 0.066% of the patients who undergo diagnostic coronary angiography (13). Our case is a very rare type of SCA anomaly and according to the Shirani et al. (4) classification, it can be categorized into the IA group which means that a solitary ostium in the left aortic sinus (I) is unassociated with an aberrant-coursing coronary artery (anatomic SCA) (A). This type has been reported in a few numbers in the literature (5, 6).
SCA anomalies are usually found incidentally during coronary angiography. Sudden death and myocardial infarction after exercise have been reported in patients whose left main or right coronary artery goes between main pulmonary artery and aorta (7). Shirani et al. (4) demonstrated that 15% of patients with SCA might have coronary ischemia due to the relation of coronary arteries with aorta or pulmonary artery. Thus, a coronary anomaly may itself cause myocardial ischemia without contribution of significant coronary stenosis.
Myocardial ischemia has been reported in 2 cases whose RCA originates from the left anterior descending or circumflex artery (8). In these cases, thinning of coronary arteries especially RCA was supposed to be responsible for cardiac ischemia. Herein, we presented the most benign type of SCA anomaly (2, 6) which was confirmed by MDCT. In our case, atherosclerosis, presence of which is an important prognostic factor in this type of SCA anomaly (2), was not present in the coronary arteries. We thought that ischemia caused by the SCA anomaly due to the thinning of RCA, was relieved by adding a beta-blocker.
This is the first case report on both conventional angiography and the MDCT images of a RCA arising from distal left circumflex artery.
(1.) Desmet W, Vanhaecke J, Vrolix M, Van de Werf F Piessens J, Willems J, et al. Isolated single coronary artery: a review of 50.000 consecutive coronary angiographies. Eur Heart J 1992; 13: 1637-40.
(2.) Yamanaka O, Hobbs RE. Coronary artery anomalies in 126.595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990; 21: 28-40. [CrossRef]
(3.) Lipton MJ, Barry WH, Obrez I, Silverman JF Wexler L. Isolated single coronary artery: diagnosis, angiographic classification, and clinical significance. Radiology 1979; 130: 39-47.
(4.) Shirani J, Roberts WC. Solitary coronary ostium in the aorta in the absence of other congenital cardiovascular anomalies. J Am Coll Cardiol 1993; 21:137-43 [CrossRef]
(5.) Chou LP Kao C, Lee MC, Lin SL. Right coronary artery originating from distal left circumflex artery in a patient with an unusual type of isolated single coronary artery. Jpn Heart J 2004; 45: 337-42. [CrossRef]
(6.) Celik T, Iyisoy A, Yuksel C, Isik E. Anomalous right coronary artery arising from the distal left circumflex coronary artery. Anadolu Kardiyol Derg 2008; 8: 459-60.
(7.) Roberts WC, Siegel RJ, Zipes DP Origin of the right coronary artery from the sinus of Valsalva and its functional consequences: analysis of 10 necropsy patients. Am J Cardiol 1982; 49: 863-8. [CrossRef]
(8.) Yuan PJ, Wu JY, Hou CJ, Chou YS, Tsai CH. Acute coronary syndrome and single coronary artery: report of two cases and review of the literature. Acta Cardiol Sinica 2002; 18: 93-8.
Ugur Arslan, Murat Karamanlioglu, Ahmet Korkmaz
Clinic of Cardiology, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara-Turkey
Address for Correspondence/Yazisma Adresi: Dr. Ugur Arslan Turkiye Yuksek Ihtisas Egitim ve Arastirma Hastanesi, Kardiyoloji Klinigi, Ankara-Turkiye Phone: +90 312 468 66 71 Fax: +90 312 419 33 13 E-mail: email@example.com
Available Online Date/Cevrimici Yayin Tarihi: 22.06.2012
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|Title Annotation:||Case Reports/Olgu Sunumlari|
|Author:||Arslan, Ugur; Karamanlioglu, Murat; Korkmaz, Ahmet|
|Publication:||The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)|
|Date:||Sep 1, 2012|
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