Anomalous Origins of the Left Main Coronary Artery From the Noncoronary Sinus and of the Right Coronary Artery From the Left Sinus of Valsalva
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 V1 through V5. 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.
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⇓).
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.
Selected Abbreviations and Acronyms
|LAD||=||left anterior descending coronary artery|
|LMCA||=||left main coronary artery|
|RAO||=||right anterior oblique|
|RCA||=||right coronary artery|
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.
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