Hyperdominant left anterior descending artery continuing across left ventricular apex as posterior descending artery coexistent

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Abstract

Abstract
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.

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Case presentation
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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References
  1. Yamanaka O, Hobbs RE: Coronary artery anomalies in 126,565 patients undergoing coronary arteriography. Cathet Cardiovasc Diag 1990, 21:28-40.
  2. Click RL, Holmes DR Jr, Vlietstra RE, Kosinski AS, Kronmal RA: Anomalous coronary arteries: location, degree of atherosclerosis and effect on survival ├óÔé¼ÔÇ£ a report from the Coronary Artery Surgery Study. J Am Coll Cardiol 1989, 13:531-7.
  3. Ayalp R, Mavi A, Sercelik A, Batyraliev T, Gumusburun E: Frequency in the anomalous origin of the right coronary artery with angiography in a Turkish population. Int J Cardiol 2002, 82:253-7.
  4. Garg N, Tewari S, Kapoor A, Gupta DK, Sinha N: Primary congenital anomalies of the coronary arteries; a coronary arteriographic study. Int J Cardiol 2000, 74:39-46.
  5. Topaz O, DeMarchena EJ, Perin E, Sommer LS, Mallon SM, Chahine RA: Anomalous coronary arteries: angiographic findings in 80 patients. Int J Cardiol 1992, 34:129-38.
  6. Zhang F, Ge JB, Qian JY, Fan B, Wang QB, Chen HZ: [Frequency of the anomalous coronary origin in the Chinese population with coronary artery stenosis]. Zhonghua Nei Ke Za Zhi 2005, 44(5):347-349.
  7. Dirken MS, Bax JJ, Blom NA, Schalij MJ, Jukema WJ, Vliegen HW, van der Wall EE, deRoos A, Lamb HJ: Detection of malignant right coronary artery anomaly by multi-slice CT coronary angiography. Eur Radiol 2002, 12:S177-80.
  8. Lee J, Choe YH, Kim HJ, Park JE: Magnetic resonance imaging demonstration of anomalous origin of the right coronary artery from the left coronary sinus associated with acute myocardial infarction. J Comput Assist Tomogr 2003, 27:289-91.
  9. Benge W, Martins JB, Funk DC: Morbidity associated with anomalous origin of the right coronary artery from the left sinus of Valsalva. Am Heart J 1980, 99:96-100.
  10. Isner JM, Shen EM, Martin ET, Fortin RV: Sudden unexpected death as a result of anomalous origin of the right coronary artery from the left sinus of Valsalva. Am J Med 1984, 76:155-158.
  11. Brandt B 3rd, Martins JB, Marcus ML: Anomalous origin of the right coronary artery from the left sinus of Valsalva. N Engl J Med 1983, 309(10):596-598.
  12. Kragel AH, Roberts WC: Anomalous origin of either the right or left main coronary artery from the aorta with subsequent coursing between aorta and pulmonary trunk: analysis of 32 necropsy cases. Am J Cardiol 1988, 62:771-777
  13. Roberts WC: Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986, 111:941-963.
  14. Ilia R, Abu FA, Gueron M: Anomolous origin of right coronary artery from the ascending aorta above the noncoronary sinus of Valsalva. Cathet Cardiovasc Diagn 1994, 32:257-8.
  15. Ayogi S, Tayama KI, Fukunaga S, Takagi K, Shojima T, Akaiwa KI: Anomalous origin of the right coronary artery report of a case. Kurume Med J 2004, 51:283-6.
  16. Pijoan RP, Anguera FN, Batalla SN, Mane HS, Pujadas CR: The right coronary artery with an anomalous origin and pathway and myocardial ischaemia. Rev Esp Cardiol 1999, 52:1154-6.
  17. Charney R, Spindola FH, Grose R: Coronary angioplasty of anomalous right coronary arteries. Cathet Cardiovasc Diag 1993, 29:223-5.
  18. Lauer B, Thiele H, Schuler G: A new coronary anomaly: origin of the right coronary artery below the aortic valve. Heart 2001, 85:486.
  19. Essente P, Gensini GG, Biambarolmei A, Bernstein D: Bidirectional blood flow in angiographic normal coronary arteries. Am J Cardiol 1983, 51:1237-1238.
  20. Timurkaynak T, Ciftci H, Cengel A: Double right coronary artery with atherosclerosis: a rare coronary artery anomaly. J Invasive Cardiol 2002, 14:337-9.
  21. Altunkeser BB, Ozdemir K, Murat SN: A unique double right coronary artery abnormality. Acta Cardiol 2001, 56:259-60.
  22. Cheatham JP, Ruyle NA, McManus BM, Gammel GE: Origin of the right coronary artery from the descending thoracic aorta: angiographic diagnosis and unique coronary artery anatomy at autopsy. Cathet Cardiovasc Diagn 1987, 13:321-4.
  23. Radke PW, Messmer BJ, Haager PK, Klues HG: Anomalous origin of right coronary artery: preoperative and postoperative hemodynamics. Ann Thorac Surg 1998, 66:1444-9.
  24. Yao CT, Wang JN, Yeh CN, Huang SC, Yang YR, Wu JM: Isolated anomalous origin of right coronary artery from the main pulmonary artery. J Card Surg 2005, 20:487-9.
  25. Lessick J, Kumar G, Beyar R, Lorber A, Engel A: Anomalous origin of a posterior descending artery from the right pulmonary artery: report of a rare case diagnosed by multidetector computed tomography angiography. J Comput Assist Tomogr 2004, 28:857-9.
  26. Lipton MJ, Barry WH, Obrez I, Silverman JF, Waller L: Isolated single coronary artery: diagnosis, angiographic classification and clinical significance. Radiology 1979, 130:39-47.
  27. Arteaga RB, Tronolone J, Mandawat M: Single coronary ostium ├óÔé¼ÔÇ£ a right coronary artery arising from the left main coronary artery. J Invasive Cardiol 2006, 18:E241-3.
  28. Lopushinsky SR, Mullen JC, Bentley MJ: Anomalous right coronary artery originating from the left main coronary artery. Ann Thorac Surg 2001, 71:357-8.
  29. Chatterjee T, Erne P: Anomalous right coronary artery originating from the mid left main coronary artery. Heart 2003, 89:132.
  30. Iyisoy A, Kursaklioglu H, Barcin C, Barindk N, Kose S, Demirtas E: Single coronary artery with anomalous origin of the right coronary artery as a branch from the left anterior descending artery: a very rare coronary anomaly. Heart vessels 2002, 16:161-3.
  31. Moretti C, De-Felice F, Mazza A, Borelio G: Anomalous origin of the right coronary artery from the left anterior descending coronary artery: a case report. G Ital Cardiol 1999, 29:915-7.
  32. Rath S, Battler A: Anomalous origin of the right coronary artery from the left anterior descending coronary artery. Cathet Cardiovasc Diagn 1998, 44:328-9.
  33. Biffani G, Lioy E, Loschiavo P, Parma A: Single coronary artery, anomalous of the right coronary artery from the left anterior descending artery. Eur Heart J 1991, 12:1326-9.
  34. Amasyali B, Kursaklioglu H, Kose S, Iyisoy A, Killic A, Isik E: Single coronary artery with anomalous origin of the right coronary artery from the left anterior descending artery with a unique proximal course. Jpn Heart J 2004, 45:521-5.
  35. Hamodraka ES, Paravolidakis K, Apostolou T: Posterior descending artery as a continuity from the left anterior descending artery. J Invasive Cardiol 2005, 17:343.
  36. Kaul P, Javangula K: Single left coronary artery with separate origins of proximal and distal right coronary arteries from left anterior descending and circumflex arteries ├óÔé¼ÔÇ£ a previously undescribed coronary circulation. Journal of Cardiothoracic Surgery 2007, 2:20.
  37. Kamran M, Bogal M: Anomalous right coronary artery originating from the left anterior descending artery. J Invasive Cardiol 2006, 18(8):E221-E222.
  38. John LC: Anomalous origin of the posterior descending artery from the left anterior descending artery: cardiac surgeons beware. Heart 2002, 87:161.
  39. Hobbes RE, Millit HD, Raghavan PV, Moodie DS, Sheldon WC: Congenital coronary anomalies: clinical and therapeutic implications. In Cardiovascular Therapy". Edited by: Vidt D. Philadelphia: FA Davis; 1982:43-58.
  40. Misawa Y, Saito T, Oki SI, Fuse K: Management of anomalous right coronary arteries encountered during aortic valve surgery. Eur J Cardiothorac Surg 2002, 21:102-4.
  41. Ichikawa Y, Kajiwara H, Hamada T, Okamoto M, Hashiyama N, Satoh S: A case of bicuspid aortic valve stenosis with single coronary artery. Nippon Kyobu Geka Gakkai Zasshi 1997, 45:796-9.
  42. Kaul P: Repeated successful surgical rescues of early and delayed multiple ruptures of ventricular septum, right ventricle and aneurysmal left ventricle following massive biventricular infarction. Journal of Cardiothoracic Surgery 2006, 1:30.

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