Anomalous Origin of the Right Coronary Artery from the Left Sinus Valsalva with Coronary Ectasia

doi:10.4236/ijcm.2011.23043

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International Journal of Clinical Medicine, 2011, 2, 269-271

doi:10.4236/ijcm.2011.23043 Published Online July 2011 (http://www.SciRP.org/journal/ijcm)

269

Anomalous Origin of the Right Coronary Artery

from the Left Sinus Valsalva with Coronary

Ectasia

Nihat Söylemez1, Recep Demirbağ1, Tuncay Hazırolan2, Onur Akpınar3*

1Department of Cardiology, Harran University, Şanlıurfa, Turkey; 2Department of Radiology, Hacettepe University, Ankara, Turkey;

3Department of Cardiogy, Gaziantep Medical Park Hospital, Gaziantep, Turkey.

Email: *[email protected]

Received January 26th, 2011; revised April 6th, 2011; accepted June 27th, 2011.

ABSTRACT

The abnormal origin of the right coronary artery from the left aortic sinus coursing between the aorta and the pulmo-

nary trunk is a rare congenital anomaly. It may remain asymptomatic or may result in cardiac morbidity or mortality.

In the past, an anomalous origin of the right coronary artery from the left sinus of Valsalva was considered a benign

finding; it is now evident that this anomaly can be associated with atypical chest pain, m y oca rdial ischemia, and sudden

death. We thought that; the diagnosis of left sinus Valsalva aneurysm, described by transtora sic echocardiography and

transeusophageal echocardiography, might need de m on st r at ed a dvanced scanning tech niques.

Keywords: Congenital Anomaly, Coronary Ectasia, Echocardiography, Multi Detector Computerize Tomography

1. Introduction

Coronary artery anomalies are a relatively rare condition.

The clinical presentation of coronary artery anomalous

is variable, ranging from being asymptomatic to symp-

toms of syncope, unstable angina, myocardial ischemia

and sudden death. The incidence of anomalous coronary

arteries has been reported to be approximately 1% to 2%

[1]. Variations in the origin and/or course of anomalous

coronary arteries are well documented in the literature

but in this case, “interestingly” there was an anomalous

right coronary artery arising from the left coronary sinus

with proximal ectasia.

2. Case Presentation

A 56-year-old woman with a history of typical angina on

effort and without history of smoking, hypertension and

diabetes mellitus was admitted to our hospital. The pre-

senting symptoms had begun approximately since one

year however chest pain became more intensive dated

from last one week. On admission, her heart rate were 68

beat/min, her blood pressure were 110/72 mmHg and her

respiratory rate were 22 breath/min. Physical examina-

tion was normal. Electrocardiography showed minimal

ST depression and T wave inversion in DII-DIII and

AVF leads. The results of the laboratory revealed crea-

tine phosphokinase isoenzyme of 117 ng/mlt, troponin I

of 0.02 ng/mlt, total cholesterol of 224 mg/dL, high den-

sity lipoprotein cholesterol of 53 mg/dL, low density

lipoprotein-cholesterol of 162 mg/dL, and triglycerides of

45 mg/d. Other biochemistry and blood test values were

within normal limits. Exercise treadmill testing was posi-

tive. Coronary angiography was recommended but the

patient didn’t accept it.

Normal systolic (Ejection fractions: 58% with Simp-

son’s) and diastolic (E/A > 1) function, normal wall mo-

tion and suspicious images for aneurysm of left sinus

valsalva in transtorasic echocardiography (TTE). Tran-

seusophageal echocardiography (TEE) findings were

similar to TTE for the aneurysm of left sinus valsalva

(Figure 1).

Then the right coronary artery which arise from the

left sinus valsalva and courses between the ascending

aorta and pulmonary artery with proximal ectasia dem-

onstrated by multi detector computerize tomography

(MDCT) heart angiography (Figure 2 (a) and (b)).

3. Discussion

In 0.03% - 0.17% of patients undergoing angiography,

the right coronary arises from the left sinus of valsalva

as a separate vessel or as a branch of a single coronary

Anomalous Origin of the Right Coronary Artery from the Left Sinus Valsalva with Coronary Ectasia

270

Figure 1. Transeusophageal echocardiography showed the

aneurysm of left sinus valsalva.

(a)

(b)

Figure 2(a) and (b). The right coronary artery which arises

from the left sinus valsalva and courses between the as-

cending aorta and pulmonary artery with proximal ectasia

demonstrated by multi detector computerizes tomography

(MDCT) heart angiography.

artery [2]. And anomalous origin of the right coronary

from the left aortic sinus was first described in 1948 by

White and Edwards [3].

There are three subtypes based on the anatomic course

of the artery. The aberrant vessel may cause posterior to

the aorta (retroaortic), between the ascending aorta and

pulmonary trunk (interarterial), or anterior to the pul-

monary trunk. In this case we illustrated interarterial

subtype. The interarterial subtype has been reported to

be associated with sudden death, angina pectoris or

myocardial infarction in the absence of atherosclerosis

[3]. In the previous study this anomaly named malignant

right coronary artery anomaly. The pathophysiologic

basis for this association, however, is unclear. Mechani-

cal compression of the right coronary artery by the great

vessels is the usual explanation, because the right coro-

nary artery generally courses between the aorta and the

pulmonary artery to its normal position. Others have

suggested that the proximal portion of the right coronary

artery, situated between the aorta and the pulmonary

artery, might be more prone to spasm then it would be

otherwise [4]. Taylors et al. suggested that the oblique

angle at the juncture of the anomalous right coronary

artery and the left coronary sinus produces a slit-like

orifice in the aortic wall that can collapse during exer-

cise [5]. Identification of anomalous coronary arteries is

frequently difficult with conventional coronary an-

giography because of the lack of 3-dimensional (D) in-

formation related to the course of the coronary arteries

to the great vessels [6]. Magnetic resonance imaging

(MRI) is an alternative, noninvasive imaging modality

that feasibly can be used for the detection of anomalous

coronary arteries [7], but 3-D information had not been

available until recently [8].

In addition, detection of atherosclerotic coronary ar-

tery plaques that may overlap the anomalous coronary

artery system is not possible by MRI because of its lim-

ited spatial resolution. Multislice computed tomography

(MSCT) provides excellent spatial resolution, which

allows assessment of not only the atherosclerotic coro-

nary artery disease [9], but also of congenital coronary

artery anomalies such as coronary arteriovenous fistula

[10]. TEE has been utilized to detect coronary anomalies;

the operator may miss the diagnosis.

In this case we used TTE, TEE and MDCT Heart An-

giography. TTE showed suspicious images for aneurysm

of left sinus valsalva and this suspicious finding sup-

ported by TEE. Then the right coronary artery which

arises from the left sinus valsalva and courses between

the ascending aorta and pulmonary artery with proximal

ectasia demonstrated by MDCT Heart Angiography.

Anomalous Origin of the Right Coronary Artery from the Left Sinus Valsalva with Coronary Ectasia

271

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