Four Coronary Arteries Originating From the Right Coronary Sinus of Valsalva

*Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia; †Department of Radiology, Atlanta Veterans Affairs Medical Center, Decatur, Georgia; ‡Division of Cardiology, Atlanta Veterans Affairs Medical Center, Decatur, Georgia.

The authors report no conflicts of interest regarding the content herein. No grant, contract, or other sources of financial support was used for the creation of this article.

This article received a double-blind peer review from members of the Cath Lab Digest Editorial Board.

The authors can be contacted via Dr. Andro Kacharava at akachar@emory.edu.

A 61-year-old man with multiple risk factors underwent cardiac catheterization for evaluation of chest pain and a small reversible anterior/anterolateral wall defect on an exercise myocardial perfusion imaging. A selective coronary angiography revealed anomalous origins of a left anterior descending (LAD) artery (Figure 1, panel A, online videos 1 and 2), and a separate first septal branch (SB) artery (Figure 1, panel B, online video 3), from the ostium of a dominant right coronary artery (RCA) in the right coronary sinus of Valsalva. A circumflex (Cx) artery originated from a separate ostium also in the right coronary sinus of Valsalva (Figure 1, panel C, online video 4). The obtuse marginal branches of the Cx artery were small (<1.5mm in diameter) and had what appeared to be angiographically significant stenoses in the proximal segments. This could potentially explain the chest pain on exertion experienced by the patient. Prospective ECG-gated multidetector computed tomography (CT), performed to rule out “malignant” course of the LAD artery confirmed the coronary angiography findings, and showed a normal coursed RCA, a prepulmonic (“benign”) coursed LAD artery, and a preaortic coursed first SB artery, all originating from a common ostium located in the anterior/superior aspect of the right coronary sinus of Valsalva. The separate ostium of the retroaortic coursed Cx artery was located at the inferior/posterior aspect of the right coronary sinus of Valsalva (Figure 1, panels D-E). Due to the size and location of the lesions in the obtuse marginal branches, the decision was made to optimize medical therapy and to follow the patient in clinic. On 3- and 6-month follow-ups, no recurrent symptoms have been observed, and the patient is doing well. To our knowledge, there is only one published case describing similar coronary anatomy.¹ 

References

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