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A rare coronary anomaly consisting of a single right coronary ostium in an adult undergoing surgical coronary revascularization: a case report and review of the literature
© The Author(s). 2016
Received: 1 March 2016
Accepted: 7 June 2016
Published: 1 July 2016
Coronary arteries originating from the right coronary ostium in the ascending aorta represent a very rare anatomic presentation. Also, the presence of a single coronary ostium is an extremely rare finding.
We present the case of a 74-year-old Albanian man from Kosovo. He had unstable angina due to critical triple vessel disease and a single coronary artery originating from a single ostium in the right sinus of Valsalva with an anomalous course of his left anterior descending artery anteriorly to the right ventricular outflow tract as a “T-vessel” from which originated the proximal and distal left anterior descending artery, the circumflex artery originating from the mid portion of the right coronary artery which had a normal course. He underwent successful coronary revascularization consisting of three vein grafts to the right coronary artery, first diagonal and obtuse marginal artery, and left internal mammary artery anastomosed to left anterior descending artery.
We describe a proposed IID1 pattern. After a careful revision of the literature, only six cases have been reported with a similar anomalous coronary origin. Only two out of six patients underwent surgical coronary revascularization. In our case the aberrant vessel arising from his right coronary artery coursed anteriorly to the right ventricle and continued as a left anterior descending artery at its mid portion which then continued distally as the distal left anterior descending artery and proximally as a proximal left anterior descending artery, having the shape of a “T vessel”. The “T-vessel” configuration has never been reported in the literature.
The reported case with its specific presentation adds further information on this rare form of anomalous origin of the coronary arteries, representing a first report of a configuration that we name the “T-vessel” of the left anterior descending artery. Diagnosis of the coronary anatomy is very important for the invasive cardiologist and cardiac surgeon in cases with a single coronary ostium, such as our case, so that they can proceed with the invasive or surgical treatment when critical coronary artery disease is present.
Coronary arteries originating from a single coronary ostium are very rare , occurring in less than 0.02 to 0.06 % of the general population . Classifications have evolved as different anatomical variations were reported either angiographically or as necropsy findings . We present a case with triple vessel disease and all three coronary arteries originating from a single ostium in the right sinus of Valsalva with an anomalous course of the left anterior descending artery anterior to the right ventricular outflow tract trunk as a “T-vessel”, and circumflex artery originating from the mid portion of the right coronary artery which had a normal course. The reported case represents the first reported configuration of the coronary arteries anatomy that we name the “T-vessel” of the left anterior descending artery. Diagnosis of the coronary anatomy is very important for the invasive cardiologist and cardiac surgeon in cases with a single coronary ostium, so that they can proceed successfully with invasive or surgical treatment.
He underwent coronary artery bypass grafting. His heart was arrested employing intermittent anterior cold blood cardioplegia. The aortic cross clamping time was 57 minutes and extracorporeal circulation was 70 minutes. Intraoperatively the aberrant vessel from which the left anterior descending artery originated was easily found (Fig. 2c). The coronary revascularization consisted in left internal mammary artery anastomosed to the left anterior descending artery, and vein graft to the first diagonal artery, obtuse marginal artery and posterior descending artery (Fig. 2d). His postoperative course was uneventful.
The coronary circulation arising from a single coronary ostium has little clinical significance, except for cases in which a coronary artery traverses between the pulmonary artery and aorta, which can cause sudden death at a young age due to extrinsic coronary arterial occlusion . The other clinical implications involve difficulty visualizing the circulation angiographically and accidental damage to an aberrant coursing artery during cardiac surgery .
Literature review (cases with single ostium from the right sinus, anterior course of the left anterior descending artery, and circumflex artery originating from the right coronary artery)
1. Neil et al. 
2. Smedema et al. 
3. Gleeson et al. 
4. Mihl et al. 
5. Ramos et al. 
6. Present case
Coronary anomalies are usually detected during coronary angiography, but exact course determination and relationships are difficult to visualize. The use of computed tomography allows visualization of the entire course of the coronary artery in a three-dimensional image. This was the diagnostic tool of choice in four patients in the reported cases, furnishing further information to the surgical team.
The reported case with its specific presentation adds further information on this rare form of anomalous origin of the coronary arteries, representing a first report of the configuration that we name the “T-vessel” of the left anterior descending artery. Diagnosis of the coronary anatomy is very important for the invasive cardiologist and cardiac surgeon in cases with a single coronary ostium, such as our case, so that they can proceed with the invasive or surgical treatment when critical coronary artery disease is present.
We would like to thank Prof. Vittorio Vanini who gave a considerable contribution in the development of our cardiac surgery service.
EP performed the surgery. KK assisted in the surgical procedure. FA and ER diagnosed the patient and treated him postoperatively. MZ performed the anesthesiology and wrote the manuscript. AD treated the patient postoperatively and wrote the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval was received by the institutional ethics committee. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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