Cardiovascular Diseases

B 2296

HerzHerz 2012 · 37:432–436 · DOI 10.1007/s00059-011-3529-1 © Urban & Vogel 2011

A.Y. Andreou · A. Tryfonos · C. Christodoulou · S. Theodorou · P.C. Avraamides

Isolierte einzelne Koronararterie mit Aufzweigung in 2 rechte KoronararterienEine seltene anatomische Variante

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A.Y. Andreou

Herz 2012 · 37:432–436DOI 10.1007/s00059-011-3529-1Received: 18 August 2011Accepted: 19 August 2011Published online: 13 October 2011© Urban & Vogel 2011

A.Y. Andreou · A. Tryfonos · C. Christodoulou · S. Theodorou · P.C. AvraamidesDepartment of Cardiology, Limassol General Hospital, Limassol

Isolated single coronary artery with dual right coronary artery distributionA rare anatomical variation

A 76-year-old man with a past medical history of hypertension, hyperlipidemia, and implantation of a ventricular de-mand pacemaker was referred to our de-partment for coronary angiography be-cause of non-ST-segment elevation myo-cardial infarction. On angiography, a ste-nosis-free left main coronary artery orig-inated normally from the left aortic sinus and bifurcated into the left anterior de-scending (LAD) and the left circumflex (LCx) arteries. The LCx artery showed a total occlusion in the mid segment be-yond which the major obtuse margin-al branch, several posterior left ventricu-lar branches, and the posterior descend-ing artery were visualized via collaterals from the LAD artery (Rentrop grade 2) (. Fig. 1a). Furthermore, the distal LCx ar-tery coursed beyond the crux cordis along the right atrioventricular (AV) groove as an aberrant right coronary artery (RCA 2) supplying a limited area to the postero-inferior right ventricular (RV) free wall (. Fig. 1b). The LAD artery contained moderate mid segment disease and gave rise to another RCA (RCA 1) (. Fig. 1c) from its segment encompassed by an early arising first diagonal branch and the first septal branch. The RCA 1 coursed anteri-or to the RV outflow tract toward the right AV groove along which it descended to the acute margin supplying the lateral RV free wall (. Fig. 1d, e). Shortly after its or-igin, it supplied a branch that coursed over the anterior RV free wall, parallel to the LAD artery eventually ramifying over the acute margin (. Fig. 1e). Furthermore,

before entering the right AV groove, the RCA 1 supplied a second branch which coursed posteriorly between the right atrial appendage and the aorta (. Fig. 1f). This branch bifurcated into a vessel which coursed leftward and posteriorly to pass onto the superior surface of the left atrium and another vessel that formed an anteri-or and rightward loop presumably passing over the crest of the right atrial appendage to descend over the lateral right atrial wall. The latter branch very likely supplied the sinus node, while an LCx artery-derived branch extending to that area was not not-ed. Neither aberrant RCA contained sig-nificant disease. A normally arising RCA could not be identified and subsequent aortic root angiography revealed that the right aortic sinus was devoid of any os-tium. The patient underwent successful recanalization of the LCx artery occlu-sion with two overlapped paclitaxel-elut-ing stents (2.75 mm x 28 mm distally and 2.75 x 16 mm proximally) (. Fig. 2).

Discussion

This case was recognized as one of isolat-ed single coronary (SCA) artery with du-al RCA which comprised a LAD artery-derived branch and another branch that coursed as the terminal extension of the LCx artery. The reported prevalence of origination of the RCA as the continu-ation of the LCx artery beyond the crux cordis (L-I type SCA) is 0.003–0.035% [1, 2]. The true prevalence of anomalous ori-gin of the RCA from the LAD artery is un-

known; however, a recent review reported at least 36 such cases [3]. There is a single report of dual blood supply to the RV via three anomalous branches which arose independently from the mid LAD artery and another anomalous branch that arose as a continuity of the LCx artery [1]. Sim-ilar to the majority of reported cases, the LAD-derived RCA presented herein orig-inated from the mid segment of this artery and followed a prepulmonic course to the right. Thus far, only two case reports de-scribed a different course of such an aber-rant RCA that is the retroaortic [3, 4]. The prepulmonic and retroaortic courses are considered benign.

The pattern of coronary artery anat-omy described herein has several clini-cal implications. Because of biventricular distribution of the LAD and LCx arteries, significant atherosclerotic disease located proximal to the branches distributed to the RV or at the bifurcation between the aberrant RCA and the LAD artery may lead to biventricular ischemia. Indeed, given the susceptibility of coronary bi-furcations for atherosclerotic build-up, it has been suggested that the presence of an additional major branch in the vicinity of the major side branches of the LAD artery may exacerbate this tendency [3]. Stent angioplasty of such lesions constitutes a high-risk procedure because it may jeop-ardize a large amount of myocardium in both ventricles should complications oc-cur. This is particularly true in cases of a dominant LAD-derived RCA and when such a vessel is involved in bifurcation dis-

432 |  Herz 4 · 2012

Image of the month

Fig. 1 8 Coronary artery angiograms: a Right anterior oblique (RAO) view demonstrating a normally arising left main coro-nary artery (LMCA) that bifurcates into the left anterior descending (LAD) artery and the left circumflex (LCx) artery. The LCx artery is dominant and appears occluded and collateralized. Note the aberrant vessel that arises from the LAD artery which was recognized as a right coronary artery (RCA 1); it supplies a right ventricular (RVB) and an atrial branch (Ab). b Left anteri-or oblique (LAO) view demonstrating the continuation of the LCx artery beyond the crux cordis along the right atrioventricu-lar groove as a second RCA (RCA 2). c LAO cranial view demonstrating the origin of the RCA 1 from the mid LAD artery; it is lo-cated between the first (D1) and second (D2) diagonal branches and adjacent to the origin of the major septal branch (S). d Lateral view demonstrating anterior course of the RCA 1. e RAO cranial view demonstrating the RCA 1 passing anterior to the right ventricular outflow tract and then along the right atrioventricular groove to supply the lateral RV free wall. f Anteropos-terior caudal view demonstrating the Ab of the RCA 1 that supplies a branch to the left atrium (LAb) and the sinus node artery (SNA); the latter follows an anterior and rightward course looping over the crest of the right atrial appendage to reach the lat-eral right atrial wall

Fig. 2 9 Coronary artery angiograms after stent angioplasty of the left circumflex (LCx) artery: a An-teroposterior caudal view demonstrating the right coronary artery 2 (RCA2) coursing as the terminal extension of the LCx artery. b Left anterior oblique view demonstrating the RCA 1 and RCA 2. The right ventricular branch (RVB) stemming from the RCA 1 and the left anterior descending (LAD) ar-tery are also shown

433Herz 4 · 2012  | 

ease; complex bifurcation techniques may be required to achieve an optimal result in both bifurcation branches. Consequently, consideration should be given to bypass surgery in the above mentioned instances.

Cardiac surgeons should be informed about the presence, course, and branching pattern of an anomalous RCA with origin from the LAD artery. Failure to recognize this vessel during its course anterior to the right ventricular outflow tract/pulmonary artery or posterior to the aorta may lead to its inadvertent damage during vent placement or aortic valve replacement, respectively. Furthermore, when surgi-cal revascularization of the LAD artery is contemplated, the potential exists of a RV branch coursing on the RV wall parallel to the anterior interventricular groove to be mistakenly regarded as the LAD artery with risk of leaving the LAD artery un-grafted. There is a single report of inferi-or wall myocardial infarction due to iso-lated ostial occlusion of an aberrant RCA stemming from the LAD artery [5]. Inter-ventional cardiologists need to be aware of this scenario to search for a stump-like thrombotic occlusion of the RCA across the LAD artery, if a right aortic sinus-con-nected RCA cannot be found. Therefore, incorrect diagnosis of ostial occlusion of a normally arising RCA can be avoided. Right ventricular “steal” is the phenome-non of interventricular redistribution of blood flow with increased RV flow at the expense of left ventricular subendocardi-al flow [6, 7]. It may occur during acute ischemia caused by a stenosis in the LAD artery in cases where this artery supplies areas of both the left and the right ven-tricles. Consequently, acute biventricular ischemia in the setting of anomalous RCA origin from the LAD artery may well in-duce RV “steal” by virtue of which the left ventricular ischemic burden may increase. Anatomic studies have shown that the AV node and bundle of His are usually sup-plied by the AV node artery together with the first septal branch of the LAD artery, while angiographic studies revealed a sig-nificant association between the combi-nation of lesions in the LAD artery and RCA, compromising the aforementioned branches with severe AV conduction dis-turbances and the need for pacemaker implantation [3, 8, 9, 10]. Patients with an

aberrant dominant RCA arising from the LAD artery and supplying the AV node artery may be at high risk of such compli-cations in case of significant LAD artery disease proximal to the first septal branch and the origin of the RCA [3]. Further-more, the LAD-derived RCA presented herein supplied branches to the atria in-cluding the sinus node area; hence, such patients may be susceptible to ischemic sinus node dysfunction or atrial arrhyth-mias in case of significant proximal LAD artery disease.

Conclusion

A case of isolated SCA comprising a LAD artery-derived RCA and a second RCA which arose as the terminal extension of the LCx artery is presented. To the best of our knowledge, this is the second report-ed case of the combination of these two variants of SCA and the first such case in which the LAD-derived RCA originated as a single branch. Furthermore, origina-tion of the sinus node artery from an ab-errant LAD-connected RCA is presented for the first time. Such variant anatomy is clinically relevant and deserves awareness by cardiac surgeons and cardiologists.

Abstract · Zusammenfassung

Herz 2012 · 37:432–436   DOI 10.1007/s00059-011-3529-1© Urban & Vogel 2011

A.Y. Andreou · A. Tryfonos · C. Christodoulou · S. Theodorou · P.C. Avraamides

Isolated single coronary artery with dual right coronary artery distribution. A rare anatomical variation

AbstractWe present the case of a 76-year-old patient in whom coronary angiography, performed due to non-ST-segment elevation myocardi-al infarction, revealed an isolated single coro-nary (SCA) artery with dual right coronary ar-tery (RCA) distribution. One RCA arose from the mid segment of the left anterior descend-ing (LAD) artery and followed a prepulmonic course to the right, while the other RCA arose as the terminal extension of the left circum-flex artery beyond the crux cordis. This is the second reported case of the combination of these two variants of SCA and the first such 

case in which the LAD-derived RCA originat-ed as a single branch. Furthermore, this is the first report presenting a sinus node artery with origin from an ectopic LAD-connected RCA. The clinical implications of this rare cor-onary artery pattern are discussed.

KeywordsCoronary artery anomaly · Coronary  angiography · Single coronary artery ·  Anomalous right coronary artery ·  Cardiovascular abnormalities

Isolierte einzelne Koronararterie mit Aufzweigung in 2 rechte Koronararterien. Eine seltene anatomische Variante

ZusammenfassungBei der Koronarangiographie eines 76 Jah-re alten Patienten, durchgeführt wegen eines Nicht-ST-Elevations-Infarkts, zeigte sich über-raschend die Koronarversorgung durch eine einzelne Koronararterie (ECA). Die dual ange-legte rechte Koronararterie (RCA) entsprang einerseits aus dem mittleren Segment des Ramus interventricularis anterior (RIVA) und zeigte einen präpulmonalen Verlauf nach rechts. Andererseits entsprang die 2. RCA als Anschlussausleger des Ramus circumfle-xus (RCX) jenseits der Crux cordis. Dies ist die 2. Fallbeschreibung, die diese Kombination von ECA-Varianten aufzeigt, und zugleich die 

1. Veröffentlichung einer einzeln angelegten Koronararterie mit einer aus dem RIVA abge-henden RCA. Außerdem wird der Abgang der den Sinusknoten versorgenden Arterie aus einer ektopen, mit dem RIVA verbundenen RCA erstmalig beschrieben. Die klinischen Auswirkungen dieser seltenen Koronarano-malie werden diskutiert.

SchlüsselwörterKoronaranomalie · Koronarangiographie · Einzelne Koronararterie · Anomale rechte  Koronararterie · Kardiovaskuläre Anomalien

434 |  Herz 4 · 2012

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Corresponding address

A.Y. AndreouDepartment of Cardiology, Limassol  General HospitalNikeas Str, Pano Polemidia, 3304 LimassolCyprusy.andreas@yahoo.com

Conflict of interest.  The corresponding author states that there are no conflicts of interest.

References

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435Herz 4 · 2012  |