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(Circulation. 2002;106:1881.)
© 2002 American Heart Association, Inc.

Images in Cardiovascular Medicine

Malignant Right Coronary Artery Anomaly Detected by Magnetic Resonance Coronary Angiography

Martijn S. Dirksen, MD; Susan E. Langerak, MSc; Albert de Roos, MD; Hubert W. Vliegen, MD; J. Wouter Jukema, MD; Jeroen J. Bax, MD; Piotr A. Wielopolski, PhD; Ernst E. van der Wall, MD; Hildo J. Lamb, PhD

From the Departments of Radiology (M.S.D., S.E.L., A.d.R., H.J.L.) and Cardiology (S.E.L., H.W.V., J.W.J., J.J.B., E.E.v.d.W.) of the Leiden University Medical Center, Leiden, and Department of Radiology (P.A.W.), Daniel den Hoed Clinic, University Hospital Rotterdam, Rotterdam, the Netherlands.

Correspondence to Martijn S. Dirksen, MD, Department of Radiology, C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands (e-mail M.S.Dirksen{at}lumc.nl); and reprint requests to Albert de Roos, MD, Department of Radiology C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands (e-mail A.de_Roos@lumc.nl).

A 66-year-old man presented with typical angina pectoris. The angina was exercise related and had developed in the past few weeks. Treadmill exercise testing induced the angina but did not reveal signs of ischemia on the ECG. Technetium myocardial perfusion scintigraphy showed a minor perfusion defect in the inferoposterior wall (Figure 1). Coronary catheterization showed the left main, left anterior descending, and left circumflex arteries without clinically significant stenoses. The origin of the right coronary artery (RCA), however, could not be engaged, preventing selective visualization. Distally, the RCA showed retrograde filling. A second catheterization effort failed for the same reason.

View larger version (67K): [in this window] [in a new window]   Figure 1. Myocardial perfusion scintigraphy revealing a reversible perfusion defect inferoposterior (arrow).

The patient was diagnosed with a total occlusion of the RCA and/or possible right coronary anomaly. He was referred to our university hospital, in which, according to protocol, suspected coronary anomalies are evaluated using magnetic resonance (MR) coronary angiography before an eventual cardiac catheterization. A state-of-the-art MR technique without exogenous contrast was used.

The MR acquisition revealed an anomalous RCA originating from the left coronary sinus and coursing between the aortic root and main pulmonary artery, providing a rare example of a classic malignant RCA anomaly. Additionally, the suspicion of a stenotic lesion in the proximal RCA was raised (Figure 2). A 3-dimensional reconstruction was made to illustrate the anatomic perspective (Figure 3).

View larger version (61K): [in this window] [in a new window]   Figure 2. Anomalous RCA with interarterial course visualized with MR coronary angiography. A transverse slice at the level of the ascending aorta shows that the RCA originates from the left coronary sinus. The RCA follows an interarterial course between the aortic root and pulmonary trunk, which is known to be associated with myocardial ischemia and sudden death. *Possible stenotic lesion. Ao indicates aortic root; PT, pulmonary trunk; LAD, left anterior descending artery; and LCx, left circumflex artery.

View larger version (144K): [in this window] [in a new window]   Figure 3. Three-dimensional reconstruction of the anomalous coronary artery. *Stenosis in proximal RCA. Abbreviations as in Figure 2. Orientation: view from above; dorsal is the left of the image, ventral the right.

On the basis of the MR findings and symptoms, the patient was scheduled for coronary artery bypass graft surgery. The MR findings prevented the need for a third catheterization procedure because the diagnosis and preferred treatment were now clear. During surgery, the anomalous origin of the RCA and the stenotic lesion as seen on the MR acquisitions were confirmed. The patient received a bypass graft to the right descending posterior artery and recovered uneventfully.

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 Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dirksen, M. S. Articles by Lamb, H. J. Search for Related Content PubMed PubMed Citation Articles by Dirksen, M. S. Articles by Lamb, H. J. Related Collections Coronary imaging: angiography/ultrasound/Doppler/CC CT and MRI