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(Circulation. 2002;105:e42.)
© 2002 American Heart Association, Inc.

Images in Cardiovascular Medicine

Anomalous Course of the Left Main or Left Anterior Descending Coronary Artery Originating From the Right Sinus of Valsalva

Identification of Four Common Variations by Electron Beam Tomography

Dieter Ropers, MD; Gisbert Gehling, MD; Karsten Pohle, MD; Ralph Maeffert, MD; Matthias Regenfus, MD; Werner Moshage, MD; Peter Schuster, MD; Werner G. Daniel, MD; Stephan Achenbach, MD

From the Department of Internal Medicine II (D.R., K.P., R.M., M.R., W.M., W.G.D., S.A.), University of Erlangen-Nuernberg, Germany; and the Department of Internal Medicine II (G.G., P.S.), St Marien Hospital Siegen, Germany.

Correspondence to Dr D. Ropers, Medizinische Klinik II mit Poliklinik, University of Erlangen-Nuernberg, Oestliche Stadtmauerstrasse 29, 91054 Erlangen, Germany. E-mail dieter.ropers{at}rzmail.uni-erlangen.de

An aberrant origin of the left main coronary artery (LM) or left anterior descending coronary artery (LAD) from the right sinus of Valsalva is a rare anomaly that has been associated with myocardial ischemia and sudden cardiac death. Depending on the anatomic relationship of the anomalous vessel to the aorta and the pulmonary trunk, the anomaly can be classified into 4 common courses: posterior, interarterial, anterior, and septal course. Contrast-enhanced electron beam tomography (EBT) has been shown to permit classification of anomalous coronary arteries. We present 4 cases that illustrate the common variations of this anomaly. In all cases, EBT was performed using a C-150 XP EBT scanner (Imatron Inc). During inspiratory breathhold, 40 to 50 axial cross-sections of the heart were acquired triggered to the ECG at 40% of the R-R interval (100 ms acquisition time, slice thickness 3 mm, table feed 2 mm, intravenous injection of 160 mL contrast agent at 4 mL/second). In addition to the original axial images, 2-dimensional multiplanar reconstructions and 3-dimensional reconstructions were rendered on an image processing workstation (NetraMD, ScImage) to display the anatomic course of the anomalous LM or LAD. In all cases, the results were confirmed by invasive coronary angiography.

Posterior or Retroaortic Course

In the nonprocessed axial image (Figure 1A) and the 3-dimensional reconstruction (Figure 1B), EBT shows the retroaortic course of the LM that originates from the right sinus of Valsalva and passes posterior and inferior to the aortic root.

View larger version (69K): [in this window] [in a new window]   Figure 1. Posterior or retroaortic course of the left main coronary artery. A, Axial cross-sectional image. The arrow points at the artery posterior and inferior to aortic root. LA indicates left atrium; RA, right atrium; LV, left ventricle; MV, mitral valve. B, 3-Dimensional reconstruction (lateral view). The arrows point at the left main coronary artery. The arrowhead indicates the right coronary artery. Ao indicates ascending aorta; PA, pulmonary artery.

Interarterial or Preaortic Course

The course of the LM between the aorta and the pulmonary trunk is clearly delineated both in the original cross-section (Figure 2A) and in the 3-dimensional reconstruction (Figure 2B).

View larger version (68K): [in this window] [in a new window]   Figure 2. Interarterial or preaortic course of the left main coronary artery. A, Original axial cross-section. Arrows indicate the left main taking a path between the ascending aorta and pulmonary trunk. The arrowhead points at the right coronary artery. Ao indicates ascending aorta; PA, pulmonary artery. B, 3-Dimensional reconstruction. The arrows point at the left main coronary artery. LA indicates left atrium; RA, right atrium.

Anterior or Prepulmonic Course

In a patient with a right-sided single coronary artery, the LAD originates from the proximal right coronary artery and takes a course anterior to the right ventricular outflow tract to the left anterior interventricular groove (Figures 3A and 3B). The left circumflex coronary artery (LCX) follows a retroaortic course (not displayed).

View larger version (88K): [in this window] [in a new window]   Figure 3. Anterior or prepulmonic course of the left anterior descending coronary artery. A, Original axial cross-section. The arrows point at the LAD. Ao indicates ascending aorta; PA, pulmonary artery; Vcs, superior vena cava. B, 3-Dimensional reconstruction (anterior view). The arrows point at the LAD, which takes a course anterior to the right ventricular outflow tract. The arrowhead points at the orthotopic right coronary artery. The left circumflex coronary artery (which follows a retroaortic course) is not displayed.

Septal or Subpulmonic Course

In this case, the LM ostium is located adjacent to the right coronary ostium. The LCX takes a prepulmonic path, whereas the LAD follows an intramyocardial course through the interventricular septum beneath the right ventricular infundibulum (Figure 4A). The artery surfaces in the midsection of the interventricular groove, which is clearly shown in the 3-dimensional reconstruction (Figure 4B).

View larger version (76K): [in this window] [in a new window]   Figure 4. Septal or subpulmonic course of the left anterior descending coronary artery. A, Curved multiplanar reconstruction. The arrows point at the LAD, which takes an intramyocardial course through the interventricular septum beneath the right ventricular infundibulum. Ao indicates ascending aorta; PA, pulmonary artery. B, 3-Dimensional reconstruction that shows the LAD surfacing in the midsection of the anterior interventricular groove (white arrow). The black arrow indicates the left circumflex coronary artery, which follows a course anterior to the pulmonary artery. Arrowhead indicate right coronary artery.

These examples illustrate the potential of contrast-enhanced EBT to visualize the exact 3-dimensional course of anomalous coronary arteries.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St.Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editoral Office, St.Luke's Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MCI-267, Houston, TX 77030.

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