We describe, in a 61 year old man, with coexistent aortic stenosis, the anomalous origin of posterior descending artery (PDA) from a stenotic left anterior descending (LAD) artery, as its continuation across the left ventricular apex, in the presence of a normally arising and atretic proximal right coronary artery. The patient underwent mechanical aortic valve replacement and triple coronary artery bypass grafting and made an uneventful recovery. To the best of our knowledge, origin of PDA as a continuation of LAD across the left ventricular apex in the presence of a normally arising but atretic proximal right coronary artery has never been described in literature before. There is one previous case report of continuation of LAD as PDA across the left ventricular apex in a patient with single left coronary coronary artery with an absent right coronary ostium. As the blood supply to the entire interventricular septum is derived from this \hyperdominant\" LAD system, stenosis of LAD can be catastrophic. A review of literature of the anomalies of right coronary artery and, in particular, of its anomalous origin from LAD and its coexistence with aortic stenosis, is presented.
A 61 year old current male smoker presented with moderate exertional angina and shortness of breath. Significant comorbidities included intermittent claudication, chronic bronchitis and asbestosis related benign pleural disease. Examination revealed a harsh ejection systolic murmur across the whole precordium, radiating to carotid area. Echocardiogram confirmed moderate aortic stenosis with a peak gradient of 62 mm Hg and mean gradient of 34 mm Hg across the aortic valve, mild aortic regurgitation, left ventricular hypertrophy and preserved left ventricular function. Left heart catheterization demonstrated a gradient of 30 mm Hg across the aortic valve. Aortic root angiogram showed mild aortic regurgitation and a small and atretic normally arising proximal right coronary artery and a normally arising left coronary artery (Fig 1). The selective right coronary angiogram demonstrated the atretic right coronary artery (RCA) supplying the SA nodal, right atrial and the proximal right ventricular branches and petering out thereafter (Fig 2). The selective left coronary angiogram showed a normal left main stem (Fig 3), ostial and mid vessel stenotic disease in left anterior descending artery (LAD) and a normal circumflex artery (Fig 4).
LAD continued across the left ventricular apex as posterior descending artery (PDA), running along the posterior interventricular septum up to the atrioventricular groove, where it gave off the left ventricular branch to the inferior surface of left ventricle and thereafter continued as the distal RCA without establishing any communication with the atretic proximal RCA (Fig 5). Left ventriculogram confirmed well preserved left ventricular function. At operation, there was moderately severe left ventricular hypertrophy. The left anterior descending artery, after running its normal course in the anterior interventricular groove, ran across the left ventricular apex (Fig 6) to gain the posterior interventricular groove, where it continued as the posterior descending artery up to the crux of the heart, thereafter ascending for a brief distance as the distal right coronary artery after having given off a smaller left ventricular branch to the inferior surface of the left ventricle. There was significant palpable disease in proximal and mid LAD as well as in its large diagonal (Dx) branch. There was no continuity between the atretic proximal RCA and the anomalous distal RCA. Circumflex artery was a normal sized vessel with a normal sized obtuse marginal branch. Aortic valve was tricuspid in configuration, moderately stenotic with fused commissures and thickened and calcified leaflets.
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