Case Reports in Cardiology

Case Reports in Cardiology / 2016 / Article

Case Report | Open Access

Volume 2016 |Article ID 3589214 |

Alexander Mironov, Sean Galligan, Aleksandre Kakauridze, Jonathan D. Marmur, "An Obstructed Anomalous Left Anterior Descending Coronary Artery Arising from the Right Coronary Artery Requiring Surgical Intervention", Case Reports in Cardiology, vol. 2016, Article ID 3589214, 4 pages, 2016.

An Obstructed Anomalous Left Anterior Descending Coronary Artery Arising from the Right Coronary Artery Requiring Surgical Intervention

Academic Editor: Nurten Sayar
Received07 Jun 2016
Accepted21 Aug 2016
Published19 Sep 2016


A 47-year-old female presented to our hospital with symptoms of stable angina. Cardiac catheterization revealed a rare coronary artery anomaly of the left anterior descending (LAD) artery branching off the right coronary artery ostium. Furthermore, the anomalous LAD artery exhibited significant atherosclerotic obstruction. Our review of the literature found only nine such previously described cases. Due to the unique nature of coronary artery anomalies and their complications, we would like to contribute our case to the medical literature.

1. Introduction

Anomalies of the coronary arteries are a rare finding, with most being discovered incidentally and having no effect on quality of life. Nevertheless, a small percentage of patients who do develop symptoms are at especially great risk for cardiac complications. We would like to present a case in which a middle age female develops anginal symptoms and is found to have a rare congenital coronary artery anomaly (CCAA) of the LAD artery, requiring surgical intervention. Our subsequent discussion will highlight the epidemiology of such anomalies, their consequences, and a brief approach to management.

2. Case Presentation

A 47-year-old African American female presented with worsening angina over a one-week course. Her chest pain was centrally located and exacerbated by activity. At presentation, it had worsened to Canadian Cardiovascular Society Class IV and now radiating to both arms. She denied respiratory symptoms and palpitations. Her medical history was significant for menorrhagia related anemia (Hb 11.7) and a pulmonary embolism (PE) ten years earlier, attributed to oral contraceptive use. Family history was negative for heart disease or sudden cardiac death. She was a recreational smoker ten years previously and currently denies toxic habits.

The patient was evaluated for Acute Coronary Syndrome in the emergency department. ECG (see Figure 1) showed normal sinus rhythm, mild ST depressions in leads V3-V4, and T wave inversions in V1 and V2, suggestive of possible anteroseptal ischemia. Her troponin I peaked at 0.67 ng/mL and BNP was 175 pg/mL. Assessment was negative for hyperlipidemia and hyperglycemia. CT chest angiography showed no signs of PE. She was given aspirin 325 mg, clopidogrel 300 mg, and enoxaparin 1 mg/kg for NSTEMI treatment and admitted to the cardiac service.

The following morning, our patient underwent left heart cardiac catheterization which revealed single vessel disease with a 99% diffuse obstruction of the LAD artery. Furthermore, the LAD artery had a very rare anomalous origin from the ostium of the right coronary artery (RCA). The LAD artery then crossed the myocardium and descended towards the apex along the interventricular groove (see Figures 2 and 3). Meanwhile, the left coronary artery gave rise only to the circumflex artery (see Figure 4). The ostial RCA itself was noted to have a 30% obstruction. Additional findings included right dominant coronary circulation, a 20–30% ostial obstruction of the left main coronary artery, and mildly depressed left ventricle (LV) function with anterolateral hypokinesis and an ejection fraction (EF) of 45%. Lastly, the mitral valve (MV) was observed to have moderate to severe regurgitation and mild to moderate thickening of the anterior MV leaflet with no stenosis, as confirmed by transesophageal echocardiogram.

A decision was made to not pursue percutaneous coronary intervention due to potential for compromise of a very large RCA ostium. The patient was subsequently transferred to the cardiothoracic surgery service. She underwent successful left internal mammary artery to LAD artery graft and MV repair with annuloplasty ring. Postoperative course was uneventful with mechanical ventilation and vasopressor agents being discontinued on the first postoperative day. Repeat transthoracic echocardiogram (TTE) ten days after presentation demonstrated normalized LV EF of 55% and only mild MV regurgitation. After a twelve-day hospital course, our patient was discharged home in stable condition with scheduled follow-up. Her outpatient medication regimen included aspirin 325 mg daily, atenolol 50 mg twice daily, enalapril 5 mg twice daily, atorvastatin 20 mg daily, and furosemide 40 mg daily.

3. Discussion

Congenital coronary artery anomalies are a rare phenomenon. The incidence in the general population ranges from 0.24% to 2.33%, with the largest known study reporting 1.3% [1, 710]. A single anomalous LAD artery originating from the RCA, as found in our patient, is further scarce and we are aware of only nine such cases described in the literature (see Table 1) [16]. These cases are distinct from another anomaly which may involve an LAD artery branching off the RCA called the Type IV “Dual LAD” artery whose incidence ranges from 0.01 to 0.03% [11, 12]. In comparison, more prevalent anomalies of the LAD artery include separate origin from the circumflex artery at the left sinus of valsalva or at the right sinus of valsalva, respectively, accounting for 30.4% and 2.3% of CCAAs [7].

ReferenceAge, genderPresenting symptomTreatment modalityOther CCAAs present

Tuncer et al. [1]63, FAnginaNo interventionNo
Tuncer et al. [1]66, MAnginaBypass graftYes
Tuncer et al. [1]55, MAnginaNo interventionNo
Nascimento et al. [2]57, MAnginaNo interventionNo
Ono et al. [3]66, FAnginaBypass graftNo
Ono et al. [3]42, MAnginaBypass graftNo
Masuda et al. [4]76, MAnginaStentYes
Weiguo et al. [5]67, MAnginaStentNo
Russo et al. [6]51, FAnginaNo interventionNo

Anomalous LAD artery was not the source of angina; hence, anomalous LAD artery did not require intervention and may be considered an incidental finding.

In addition to being able to identify CCAAs, it is important to understand their consequences. The majority are discovered incidentally and up to 81% are considered benign with no clinical significance. Meanwhile, those that are malignant have the potential to cause cardiac ischemia, especially during times of exertion and increased myocardial oxygen demand. This may lead to angina, syncope, cardiac arrhythmia, heart failure, or sudden cardiac death (SCD) [7]. In fact, coronary anomalies are the second leading cause of SCD in athletes at 19%, after hypertrophic cardiomyopathy at 36% [13].

Anatomic characteristics that make a CCAA malignant include (1) single coronary artery, (2) origin from the pulmonary artery, (3) origin from the opposite aortic sinus, (4) passing between the aorta and pulmonary artery, (5) passing intramurally, (6) acute-angle takeoff resulting in a slitlike orifice, and (7) small artery due to ostial stenosis or atresia. Furthermore, myocardial squeezing, vasospasm, and the development of atherosclerosis, as in our case, of the anomalous artery all have the potential to cause clinical symptoms [1, 3, 7, 14].

Management of anomalous arteries requires careful consideration. If a patient is identified to have a symptomatic malignant CCAA, corrective surgery is warranted. The difficulty occurs when asymptomatic patients are discovered to have a malignant CCAA. Due to the overall rarity of SCD, especially over the ages of 30–35, some may recommend avoiding surgery [15]. Meanwhile, atherosclerotic lesions may be treated with percutaneous stenting if the coronary anatomy is amenable to instrumentation [4, 5]. Otherwise, as in the case above, a bypass graft may be used. Lastly, while there is no known pattern of genetic inheritance of CCAAs, some authors have suggested screening at risk family members with TTE [16, 17].

4. Conclusion

While the incidence of CCAAs is low in the general population, anomalies with malignant characteristics have the potential for deadly consequences. The risks and benefits of intervention must be weighed, requiring a multidisciplinary approach with input from cardiology and cardiothoracic surgery specialists. In the case presented, an atherosclerotic anomalous LAD artery branching off the RCA combined with significant MV regurgitation necessitated a surgical approach.

Competing Interests

The authors declare that there is no conflict of interests regarding the publication of this article.


  1. C. Tuncer, T. Batyraliev, R. Yilmaz, M. Gokce, B. Eryonucu, and S. Koroglu, “Origin and distribution anomalies of the left anterior descending artery in 70,850 adult patients: multicenter data collection,” Catheterization and Cardiovascular Interventions, vol. 68, no. 4, pp. 574–585, 2006. View at: Publisher Site | Google Scholar
  2. F. O. Nascimento, M. J. Kviatkovsky, M. Larrauri-Reyes, and N. Beohar, “Asymptomatic anomalous left anterior descending artery arising from the right coronary artery with a rare anterior course,” BMJ Case Reports, vol. 10, article 1136, 2013. View at: Publisher Site | Google Scholar
  3. M. Ono, D. A. Brown, and R. K. Wolf, “Two cases of anomalous origin of LAD from right coronary artery requiring coronary artery bypass,” Cardiovascular Surgery, vol. 11, no. 1, pp. 90–92, 2003. View at: Publisher Site | Google Scholar
  4. N. Masuda, T. Matsukage, and Y. Ikari, “Successful transradial intervention for two lesions with dual anomalous origins of coronary arteries,” The Journal of Invasive Cardiology, vol. 23, no. 5, pp. E117–E120, 2011. View at: Google Scholar
  5. X. Weiguo, H. Dongyong, L. Chupeng et al., “Coronary artery anomalies: the left main coronary artery or left anterior descending coronary artery originating from the proximal of right coronary artery,” Chinese Medical Journal, vol. 127, no. 12, 2014. View at: Google Scholar
  6. G. Russo, C. Tamburino, G. Licciardello, V. Calvi, C. Cinnirella, and G. Giuffrida, “Isolated, anomalous origin of the left anterior descending coronary artery from the right coronary artery with angina pectoris,” European Heart Journal, vol. 12, no. 4, pp. 558–560, 1991. View at: Google Scholar
  7. O. Yamanaka and R. E. Hobbs, “Coronary artery anomalies in 126,595 patients undergoing coronary arteriography,” Catheterization and Cardiovascular Diagnosis, vol. 21, no. 1, pp. 28–40, 1990. View at: Publisher Site | Google Scholar
  8. S. Fujimoto, T. Kondo, T. Orihara et al., “Prevalence of anomalous origin of coronary artery detected by multi-detector computed tomography at one center,” Journal of Cardiology, vol. 57, no. 1, pp. 69–76, 2011. View at: Publisher Site | Google Scholar
  9. S. Yuksel, M. Meric, K. Soylu et al., “The primary anomalies of coronary artery origin and course: a coronary angiographic analysis of 16,573 patients,” Experimental and Clinical Cardiology, vol. 18, no. 2, pp. 121–123, 2013. View at: Google Scholar
  10. C. Graidis, D. Dimitriadis, V. Karasavvidis et al., “Prevalence and characteristics of coronary artery anomalies in an adult population undergoing multidetector-row computed tomography for the evaluation of coronary artery disease,” BMC Cardiovascular Disorders, vol. 15, article 112, 2015. View at: Publisher Site | Google Scholar
  11. H. Spindola-Franco, R. Grose, and N. Solomon, “Dual left anterior descending coronary artery: angiographic description of important variants and surgical implications,” American Heart Journal, vol. 105, no. 3, pp. 445–455, 1983. View at: Publisher Site | Google Scholar
  12. G. Oncel and D. Oncel, “A rare coronary artery anomaly: double left anterior descending artery,” Journal of Clinical Imaging Science, vol. 2, article 83, 2012. View at: Google Scholar
  13. B. J. Maron, P. D. Thompson, J. C. Puffer et al., “Cardiovascular preparticipation screening of competitive athletes,” Circulation, vol. 94, no. 4, pp. 850–856, 1996. View at: Publisher Site | Google Scholar
  14. S. F. Hill and M. N. Sheppard, “A silent cause of sudden cardiac death especially in sport: congenital coronary artery anomalies,” British Journal of Sports Medicine, vol. 48, no. 15, pp. 1151–1156, 2014. View at: Publisher Site | Google Scholar
  15. M. D. Cheitlin and J. MacGregor, “Congenital anomalies of coronary arteries: role in the pathogenesis of sudden cardiac death,” Herz Cardiovascular Diseases, vol. 34, no. 4, pp. 268–279, 2009. View at: Google Scholar
  16. J. A. Brothers, P. Stephens, J. W. Gaynor, R. Lorber, L. A. Vricella, and S. M. Paridon, “Anomalous aortic origin of a coronary artery with an interarterial course: should family screening be routine?” Journal of the American College of Cardiology, vol. 51, no. 21, pp. 2062–2064, 2008. View at: Publisher Site | Google Scholar
  17. J. M. Laureti, K. Singh, and J. Blankenship, “Anomalous coronary arteries: a familial clustering,” Clinical Cardiology, vol. 28, no. 10, pp. 488–490, 2005. View at: Publisher Site | Google Scholar

Copyright © 2016 Alexander Mironov et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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