Left Main Coronary Anomaly Arising From the Right Sinus of Valsalva—Interarterial, Septal, or a Continuum?

Abstract

Multidetector computed tomography angiography is increasingly used to visualize the coronary tree. It is emerging as the test of choice for the detection of anomalous coronary artery origin. It provides excellent spatial resolution and the ability to see the course of the coronary arteries and their proximity to adjacent structures. Invasive angiography has been the gold standard but does not allow the visualization of adjacent anatomic structures, which is crucial to correctly diagnosing the anomaly and determining the prognosis. We report a case of a 47-year-old woman with an anomalous left main coronary artery that arises from the right sinus of Valsalva where multidetector computed tomography angiography was key to the diagnosis and provided additional information that was not discernible from the invasive angiography.

Dual Left Main Coronary Arteries With Ischemia and Coronary Steal

“… 5 However, newer evidence has challenged this idea: a higher rate of adverse cardiac events including sudden death has been reported in these patients. 5 , 6 According to Torres et al, 7 trying to identify subtypes with conventional coronary angiography is “too simplistic and does not capture the entire anatomical spectrum detected by CT [computed tomography].” 8 Coronary CTA can detect which sinus the anomaly originates from, the exact location on the aortic wall, the take-off angle, the initial or distal vessel diameter, any fibrous hyperplasia or stenosis, plaque or outward remodeling, abnormal collateral connections, the exact course (whether in the epicardial fat or intramural in the pulmonary artery or RVOT or the aorta), and the potential for compression as it traverses in the aortopulmonary window of fat. Coronary CTA has the advantage of rapid scan time and excellent spatial resolution but exposes the patient to radiation and iodinated contrast material, a limitation that is particularly relevant in younger patients or those with renal insufficiency.…”

Discovery of a Symptomatic Left Anomalous Coronary Artery from the Opposite Sinus and Postoperative Considerations

“…Traditionally, when an LMCA originates from the RCC, it takes one of four courses: retroaortic, anterior free wall, interarterial, or septal [4]. Eighty percent of these patients with sudden cardiac death are found to have an intra-arterial pathway, while the other pathways are considered more benign [2].…”

“…Eighty percent of these patients with sudden cardiac death are found to have an intra-arterial pathway, while the other pathways are considered more benign [2]. However, case reports documenting unstable angina, ventricular tachycardia, and syncope in patients with septal courses are challenging the benign labeling of septal course LMCA [4]. …”

“…This condition does not have a high prevalence in the US, however, when present can have catastrophic results [4]. Many patients are identified on postmortem exam, indicating that a higher index of suspicion along with complete imaging is needed to identify and treat patients before complications arise [3].…”

A Rare Case of a Coronary Artery Anomaly Detected on Multidetector Computed Tomography

“…However, there have been several reports in which a septal course, diagnosed on conventional coronary angiography (CCA), with symptoms (20) and a fatal outcome (21), was subsequently characterized as a mixed course based on the use of MDCT-CA, suggesting that the traditional dichotomous classification of either interarterial or septal encompasses a heterogeneous group of patients with different prognoses, thereby introducing the concept of a continuum (22).…”