Circulation. 1997;96:2731-2732
(Circulation. 1997;96:2731-2732.)
© 1997 American Heart Association, Inc.
Anomalous Origins of the Left Main Coronary Artery From the Noncoronary Sinus and of the Right Coronary Artery From the Left Sinus of Valsalva
Bernd Nowak, MD;
Iri Kupferwasser, MD;
Eckhard Mayer, MD;
Hans-Jürgen Rupprecht, MD;
Thomas Voigtländer, MD;
Christoph Bickel, MD;
;
Jürgen Meyer, MD
From the II. Medical Clinic and Clinic for Cardiothoracic and Vascular
Surgery (E.M.), Johannes Gutenberg University, Mainz, Germany.
Correspondence to Bernd Nowak, MD, II. Medical Clinic, Johannes Gutenberg University, Langenbeckstr 1, D-55131 Mainz, Germany.
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Introduction
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 Top
 Introduction
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A
70-year-old man was referred for recent-onset angina. The
ECG showed a
right-axis deviation and signs of an old anterior
infarction with loss
of R waves in leads V
1 through V
5. Chest
radiograph
demonstrated a markedly enlarged heart, which was shifted to
the
left side with discrete signs of pulmonary congestion.
Transthoracic
echocardiography, which
was limited by poor imaging quality,
revealed a normal left
ventricular cavity with reduced ejection
fraction (40%)
due to hypokinesia of the anterior wall.
Coronary angiography showed the dominant RCA to originate
from the left sinus of Valsalva. It coursed between the aorta and the
pulmonary artery to the right (Figs 1
and 2).
The midportion of the vessel showed two high-degree stenoses.
The LMCA originated from the noncoronary sinus of Valsalva (Fig 3). The LAD was shown to have proximal
high-degree stenosis. Course and origin of the anomalous
vessels were determined in the 30° RAO projection.
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Figure 1. Coronary angiogram, 30° RAO view.
Anomalous origin of RCA from left sinus of Valsalva. Angiogram was
obtained with a left Judkins catheter. Stenoses of vessel are
not visualized in this projection.
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Figure 2. Ventriculogram, 30° RAO view. Anomalous RCA
appears as radiopaque "dot" (arrow) anterior to aorta as it
courses to right between aorta and pulmonary artery.
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Figure 3. Coronary angiogram, 30° RAO view. LMCA
originates from noncoronary sinus of Valsalva. A high-degree
stenosis is visible in LAD (arrow).
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Origin and proximal course of the anomalous coronary
arteries were confirmed by multiplane transesophageal
echocardiography. The origin of the RCA from the
left sinus of Valsalva and its proximal course with a sharp turn to the
right were clearly demonstrated (Fig 4),
as was the origin of the LMCA from the noncoronary sinus of
Valsalva (Fig 5).
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Figure 4. Multiplane transesophageal
echocardiogram of aortic root demonstrating origin of RCA from left
sinus of Valsalva. Sharp angle of vessel turning to right shortly after
its origin is demonstrated. AO indicates aorta; R, L, and N, right,
left, and noncoronary sinus of Valsalva; LA, left atrium; and
RA, right atrium.
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Figure 5. Multiplane transesophageal
echocardiogram of aortic root showing origin of LMCA from
noncoronary sinus of Valsalva and origin of RCA from left sinus
of Valsalva. Abbreviations as in Fig 4 .
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Because of the coronary artery disease, the patient underwent
coronary artery bypass graft surgery. During surgery, a
congenital absence of the pericardium was found. Only a small part of
the right atrium was covered with pericardium. In this
area, the pericardium was adhesive to the underlying atrial wall.
To the best of our knowledge, the combination of such coronary
anomalies as ectopic origin of the RCA from the left sinus of Valsalva
and ectopic origin of the LMCA from the noncoronary sinus of
Valsalva has not been reported before. These anomalies were associated
with congenital absence of the pericardium.
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Selected Abbreviations and Acronyms
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| LAD |
= |
left anterior descending coronary artery |
| LMCA |
= |
left main coronary artery |
| RAO |
= |
right anterior oblique |
| RCA |
= |
right coronary artery |
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Footnotes
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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 Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner, MC 4-265, Houston, TX 77030.
