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New congenital coronary artery anomaly – double supply of single left anterior descending coronary artery from the left and right coronary sinuses: a case report
© Daralammouri et al. 2016
Received: 27 June 2015
Accepted: 7 July 2016
Published: 2 August 2016
A normal anatomy of coronary arteries is important to have adequate cardiac muscle blood supply especially during extraneous physical activities. This case report describes a rare coronary anomaly in which the accessory coronary artery arose from the right coronary artery, reentered the left anterior descending coronary artery, and then ran as a single vessel.
We present a case of a coronary anomaly in a 47-year-old white man who presented with atypical angina. Computed tomographic angiography and coronary angiography showed a variant of dual left anterior descending coronary artery not previously described. Our patient’s accessory coronary artery arose from his right coronary artery. It took an intramuscular course beneath the right ventricular outflow tract in the interventricular septal area to the anterior interventricular sulcus, giving off septal perforators that reentered his medial left anterior descending coronary artery. Both vessels ran after the anastomosis in the anterior interventricular sulcus as a single vessel.
We propose that this anomaly represents a new variant of coronary artery anomaly. This coronary artery anomaly does not cause ischemia. Recognition of this coronary anomaly is important in patients undergoing percutaneous coronary intervention or coronary artery bypass graft operations.
A normal anatomy of coronary arteries is important to have adequate cardiac muscle blood supply especially during extraneous physical activities. Congenital coronary anomalies (CAA) are rare and reportedly occur in 0.64 to 1.3 % of patients undergoing coronary angiography. Approximately 80 % of these coronary anomalies are benign; only 20 % cause symptoms . Dual left anterior descending coronary artery (LAD) has been reported to occur with an incidence of 1 % [2, 3], and most of the patients were asymptomatic .
This case report describes a rare variation, which has not been reported in the literature, in which the accessory coronary artery arose from the right coronary artery (RCA), reentered the LAD, and then ran as a single vessel.
Dual LAD can be associated with congenital heart disease such as tetralogy of Fallot and complete transposition of the great arteries, where it has surgical importance at the time of corrective surgery . Spindola-Franco et al. classified dual LAD into four angiographic subtypes based on the origin and course of both LADs as follows . Type I: Running in the AIVS, the short LAD is generally the source of all major proximal septal perforators. The long LAD also runs in the AIVS, descending on the left ventricular side of the AIVS, and then reentering the distal AIVS. It is the source of the major diagonal vessels. Type II: The short LAD is the same as in Type I. The long LAD differs only in that it descends on the right ventricular side, rather than the left, before reentering the AIVS. Type III: The long LAD travels intramyocardially in the ventricular septum. The short LAD is the same as in Types I and II. Type IV: The long LAD originates from the RCA and enters the anterior interventricular groove. Type IV dual LAD is a rare congenital anomaly of the coronary arteries and may be mistreated. The exact description of coronary artery anatomy is important in patients undergoing coronary artery bypass graft operations or percutaneous coronary intervention . In our case, the accessory coronary artery arose from the RCA and took a course between the right ventricular outflow and aorta, then took an intramuscular course beneath the right ventricular outflow tract in the interventricular septal area to the AIVS. It gave off septal perforators, then reentered the medial LAD, and both vessels ran after the anastomosis in the AIVS as a single vessel. This course can be associated with limiting coronary blood flow, when dilation of the aorta occurs during exercise or due to the stretch of the intramural segment. The FFR measurements during the infusion of increasing doses of dobutamine showed that this coronary anomaly does not lead to ischemia. We propose that this anomaly represents a new type of dual LAD.
Our case, in which the accessory coronary artery arose from the RCA, reentered the LAD, and then ran as a single vessel, is the first such report in the literature. This coronary artery anomaly does not cause ischemia. Recognition of this coronary anomaly is important in patients undergoing percutaneous coronary intervention or coronary artery bypass graft operations.
AIVS, anterior interventricular sulcus; CAA, congenital coronary anomalies; FFR, fractional flow reserve; LAD, left anterior descending coronary artery; RCA, right coronary artery
The authors thank Al Bishawi, Ahmad from An Najah National University, Palestine for his editorial contribution.
There were no external funding sources for this study.
YD analyzed the CT scan data, interpreted the collected data, and he had a major role in writing the manuscript. BL performed the coronary angiography procedures and FFR studies. MG helped in data collection and editing. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Ethics approval and consent to participate
Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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