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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 117-119

Left-sided anomalous origin of the coronary artery from the opposite sinus: Single anomalous left anterior descending artery originating from the right coronary artery – A rare case


1 Department of Cardiology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
2 Department of General Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Date of Submission27-Apr-2021
Date of Decision03-Jun-2021
Date of Acceptance05-Jun-2021
Date of Web Publication23-Sep-2021

Correspondence Address:
Dr. Senthilvelan Thenmozhi
Department of General Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry - 605 107
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcpc.jcpc_8_21

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  Abstract 


Anomalous origin of the coronary artery from the opposite sinus (ACAOS) is a significant subclass of coronary artery anomalies. Ischemic symptoms can develop at any age and judicious use of imaging modalities is needed to guide treatment. We present a short review of this rare coronary anomaly left-sided ACAOS diagnosed in a 42-year-old gentleman.

Keywords: Angina, anomalous origin of left coronary artery from opposite sinus, coronary angiography, coronary artery anomaly, intravascular ultrasound, myocardial ischemia


How to cite this article:
Sarojadevi AT, Thenmozhi S, Kuppuswamy BA, Somasundharam SB. Left-sided anomalous origin of the coronary artery from the opposite sinus: Single anomalous left anterior descending artery originating from the right coronary artery – A rare case. J Clin Prev Cardiol 2021;10:117-9

How to cite this URL:
Sarojadevi AT, Thenmozhi S, Kuppuswamy BA, Somasundharam SB. Left-sided anomalous origin of the coronary artery from the opposite sinus: Single anomalous left anterior descending artery originating from the right coronary artery – A rare case. J Clin Prev Cardiol [serial online] 2021 [cited 2021 Nov 30];10:117-9. Available from: https://www.jcpconline.org/text.asp?2021/10/3/117/326476




  Introduction Top


Coronary artery anomalies (CAAs) occur due to abnormalities in the development of the coronary buds or the endothelial network.[1] Anomalous origin of the coronary artery from the opposite sinus (ACAOS) is a significant subclass of CAA. ACAOS can cause sudden cardiac death (SCD) in young athletes. It can also present with clinical symptoms of myocardial ischemia. Although left-sided ACAOS (L-ACAOS) is less prevalent than right-sided ACAOS, L-ACAOS is more symptomatic. Ischemia can develop at any age and CAA should be considered in adults with cardiac symptoms. Accurate assessment by noninvasive and invasive modalities is important in guiding the management of patients with ACAOS. We highlight CAA as an important cause of ischemic etiology of cardiac symptoms in adulthood.


  Case Report Top


A 42-year-old gentleman, ex-smoker, recently diagnosed to have type-2 diabetes mellitus and systemic hypertension, presented with complaints of New York Heart Association Class-II exertional angina for 3 months, without syncope or palpitations. Electrocardiogram showed symmetric T wave inversions in leads V4–V6 [Figure 1]. Echocardiogram showed mild concentric left ventricular hypertrophy without regional wall motion abnormalities at rest. He had elevated serum triglyceride levels (219 mg/dl; normal: up to 160 mg/dl).
Figure 1: 12- lead electrocardiogram with normal standardization showing symmetric T-wave inversions in leads V4–V6, suggestive of ischemia

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Transradial (5 Fr TIG catheter) coronary angiography (CAG) revealed left main coronary artery (LMCA) arising from the left coronary sinus and bifurcating into the ramus intermedius and left circumflex artery (LCX) [Figure 2]. The ramus was a small vessel with no significant stenosis. The LCX was nondominant with major obtuse marginal branches showing 40% stenosis. Right coronary artery (RCA) and an anomalous left anterior descending (LAD) artery were seen arising from the right sinus of valsalva from a common ostium [Figure 3]. RCA was dominant and showed minimal disease. LAD gave rise to a small first septal artery at its origin and a diagonal branch before descending in the left atrioventricular groove, without stenosis.
Figure 2: Left coronary angiogram showed left main coronary artery arising from left coronary sinus and bifurcating into the ramus intermedius and left circumflex artery

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Figure 3: Right coronary angiogram showing right coronary artery and an anomalous left anterior descending artery seen arising from the right sinus of valsalva from a common ostium

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Coronary computed tomography angiogram (CTA) ruled out interarterial course (IAC) of anomalous LAD [Figure 4]. He was initiated on optimal medical management with statins, antiplatelets, and beta-blockers and was advised to restrict strenuous activities. He has been asymptomatic at follow-up for 45 months.
Figure 4: Coronary computed tomographic angiogram showing left anterior descending arising from right coronary sinus and descending in the anterior interventricular groove

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  Discussion Top


The prevalence of CAA ranges from 0.7% to 1.96%.[1] CAAs are mostly benign and are incidentally detected during CAG. CAA also Manifest as chest pain, syncope, heart failure, ventricular arrhythmias, myocardial infarction and even SCD is reported. ACAOS is seen in around 1% of the general population.[2] A single anomalous LAD artery originating from the RCA is rare; it can lead to myocardial ischemia depending on the arterial course.[3] The five different proximal coronary course of anomalous LAD are intramural or IAC (highest risk of ischemic presentation), prepulmonic or epicardial, trans-septal, retroaortic, and retrocardiac. In malignant ACAOS, IAC of the anomalous vessel courses between the pulmonary artery and the aorta. The acute angle takeoff of the intramural coronary artery, sharing a common wall with the aorta, thus results in a slit-like coronary artery ostium. Expansion of the aortic root and pulmonary trunk during exercise worsens this preexisting angulation of the coronary artery, resulting in myocardial ischemia and reduced cardiac output.[4] In the trans-septal variant, the anomalous vessel passes through the septal muscle inferior to the plane of the pulmonic valve. This was most commonly observed in patients with ectopic right-sided origin of the LMCA. Although there have been reports of myocardial ischemia (11%), arrhythmia (2%), and SCD (11%), several reports have described trans-septal course of LMCA or LAD as benign, with a mean age of 35 years (maximum: 83 years).[5],[6],[7],[8] Patients with palpitations or exercise-induced neuro-cardiogenic spells improved after coronary artery bypass graft surgery, as also observed in a man with resistant ventricular tachycardia.[8],[9] Ischemia may develop at any age and is clearly not limited only to younger patients.[9] The prevalence of ACAOS was reported to be 0.44% among children aged between 11 and 18 years, based on a cardiac magnetic resonance imaging.[10]

Noninvasive and invasive imaging modalities help in accurate delineation of the anomalous coronary anatomy. CTA offers more precise identification of the origin and course of ACAOS, due to its high spatial and temporal resolution. Recent evidence suggests that all patients with ACAOS have some degree of stenosis in the intramural segment, due to variable degrees of hypoplasia and lateral compression, which cannot be clearly identified by CAG. CTA cannot reliably identify the location (intramurality) of the proximal coronary trunk or quantify the severity of stenosis. Invasive imaging techniques such as intravascular ultrasound (IVUS) or optical coherence tomography are highly sensitive in demonstrating the intramural course, the accompanying stenosis, and its phasic change during cardiac cycle and with exercise. IVUS can reveal information on changes of stenosis severity that phasically change during the cardiac cycle and with exercise.[11],[12],[13]

Treatment options for patients with ACAOS include surgical correction, percutaneous coronary intervention, and medical management often coupled with activity restriction. Surgical or percutaneous correction is recommended in patients with ACAOS and IAC with symptoms of cardiac ischemia, SCD, or aborted SCD, and/or the presence of myocardial ischemia on stress testing. Medical management including nitrates, calcium channel blockers, beta-blockers, and exercise restriction has good results (median follow-up: 5.6 years).[14],[15] SCD directly related to anomalous origin of the coronary artery was not found despite the lack of surgical treatment in these middle-aged-to-elderly patients.[15]


  Conclusion Top


This case report illustrates a rare anomaly of a single anomalous LAD artery originating from the RCA and presenting with symptoms of myocardial ischemia in adult life. ACAOS with an IAC is associated with a high incidence of SCD. Although trans-septal course of left main (LM) or LAD was considered as benign earlier, contemporary evidence suggests that trans-septal course of LM or LAD can present with myocardial ischemia, arrhythmias, and SCD. Patients with ACAOS may develop symptoms at any age. Careful application of noninvasive anatomic and invasive imaging can identify high-risk anatomic features to guide the appropriate management strategy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yildiz A, Okcun B, Peker T, Arslan C, Olcay A, Bulent Vatan M. Prevalence of coronary artery anomalies in 12,457 adult patients who underwent coronary angiography. Clin Cardiol 2010;33:E60-4.  Back to cited text no. 1
    
2.
Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28-40.  Back to cited text no. 2
    
3.
Angelini P. Coronary artery anomalies–Current clinical issues: Definitions, classification, incidence, clinical relevance, and treatment guidelines. Tex Heart Inst J 2002;29:271-8.  Back to cited text no. 3
    
4.
Peñalver JM, Mosca RS, Weitz D, Phoon CK. Anomalous aortic origin of coronary arteries from the opposite sinus: A critical appraisal of risk. BMC Cardiovasc Disord 2012;12:83.  Back to cited text no. 4
    
5.
Agarwal PP, Dennie C, Pena E, Nguyen E, LaBounty T, Yang B, et al. Anomalous coronary arteries that need intervention: Review of pre- and postoperative imaging appearances. Radiographics 2017;37:740-57.  Back to cited text no. 5
    
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Johnson JN, Bonnichsen CR, Julsrud PR, Burkhart HM, Hagler DJ. Single coronary artery giving rise to an intraseptal left coronary artery in a patient presenting with neurocardiogenic syncope. Cardiol Young 2011;21:572-6.  Back to cited text no. 6
    
7.
Marshall ME, Headley RN. Intramural coronary artery as a cause of unstable angina pectoris. South Med J 1978;71:1304-6.  Back to cited text no. 7
    
8.
Corrado D, Thiene G, Cocco P, Frescura C. Non-atherosclerotic coronary artery disease and sudden death in the young. Br Heart J 1992;68:601-7.  Back to cited text no. 8
    
9.
Kothari SS, Talwar KK, Venugopal P. Septal course of the left main coronary artery from right aortic sinus and ventricular tachycardia. Int J Cardiol 1998;66:207-9.  Back to cited text no. 9
    
10.
Angelini P, Cheong BY, Lenge De Rosen VV, Lopez A, Uribe C, Masso AH, et al. High-risk cardiovascular conditions in sports-related sudden death: Prevalence in 5,169 schoolchildren screened via cardiac magnetic resonance. Tex Heart Inst J 2018;45:205-13.  Back to cited text no. 10
    
11.
Agrawal H, Molossi S, Alam M, Sexson-Tejtel SK, Mery CM, McKenzie ED, et al. Anomalous coronary arteries and myocardial bridges: Risk stratification in children using novel cardiac catheterization techniques. Pediatr Cardiol 2017;38:624-30.  Back to cited text no. 11
    
12.
Unzué L, García E, López-Melgar B, Agudo-Quilez P. Percutaneous treatment of an anomalous left main arising from the opposite sinus with subpulmonic course. Cardiovasc Revasc Med 2018;19:632-7.  Back to cited text no. 12
    
13.
Driesen BW, Warmerdam EG, Sieswerda GT, Schoof PH, Meijboom FJ, Haas F, et al. Anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS), fractional flow reserve- and intravascular ultrasound-guided management in adult patients. Catheter Cardiovasc Interv 2018;92:68-75.  Back to cited text no. 13
    
14.
Bixby MB. Successful medical management of a patient with an anomalous right coronary artery who declined surgery. Am J Crit Care 1998;7:393-4.  Back to cited text no. 14
    
15.
Kaku B, Shimizu M, Yoshio H, Ino H, Mizuno S, Kanaya H, et al. Clinical features of prognosis of Japanese patients with anomalous origin of the coronary artery. Jpn Circ J 1996;60:731-41.  Back to cited text no. 15
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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