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Anomalous Origin of Left Anterior Descending and Circumflex Coronary Artery from Two Separate Ostia in the Right Sinus of Valsalva With Unusual Dominant Right Coronary Artery
Case Report. A 69-year-old female with prior history of hypertension was 
admitted to the local hospital because of atypical chest pain. Her symptoms had begun more than 2 years and which worsened half a year ago before admission. The 32-slice computed tomography angiography 
was performed revealing anomalous origin of left anterior descending (LAD) and left circumflex (LCX) coronary artery from two separate ostia in the right sinus of Valsalva (RSOF) with unusual dominant right coronary artery (Figures 1–3).
The patient was admitted to our hospital for further diagnosis and therapy. She was on a calcium channel-blocker, long acting nitrate, and angiotensin-converting enzyme inhibitor.
On admission, she was hypertensive 120/80 mmHg with a regular pulse of 53 bpm. 
Cardiac auscultation was unremarkable and the chest was clear. The echocardiogram (ECG) showed sinus rhythm at 58 bpm with no significant ST-segment changes. The results of an exercise stress test were negative. Coronary angiography was performed from the right radial approach through a catheter (5 French Judkins Right 4.0). The presence of an anomalous origin of LAD and LCX 
coronary artery from two separate ostia in the RSOV was confirmed, resulting in the patient being free from atherosclerotic disease (Figure 4). Although the operator tried efforts, it was hard to engage the ostium of ectopic LAD and gain clear visualization of it. Aortography showed the right coronary artery (RCA) had a normal independent origin, but the visualization of the left coronary arteries was indefinite (Figure 5).
Discussion. The prevalence for an anomalous origin of left main coronary artery (LMCA) in the RSOV has been reported to be 0.003–0.03% (1.2–7% of coronary anomalies) in patients undergoing cardiac catheterization in several large-scale studies.2,3 Much less common is the origin of LAD and LCX coronary artery from two separate ostia in the right sinus of Valsalva, with only isolated cases reported in the literature.4–6
Coronary angiography has its own limitations. In this case, to gain clear visualization of the ectopic LAD, perhaps more techniques and catheters would be required, and the lengthy procedure would be exhausting. Yet, it cannot provide the visualization of adjacent anatomic structures and proximal course yet, which is crucial to correctly diagnose the anomaly and determine the prognosis. However, the computed tomography angiography can solve all these problems. Therefore, other imaging modalities, such as computed tomography, are considered to have a complementary role according to a recent study.7
Myocardial ischemia and other cardiac symptoms, such as syncope or sudden cardiac death, are sometimes caused by congenital anomalies of the coronary arteries. In this case, the hazard mostly depends on the LAD course. Computed tomography angiography shows the LAD takes an anterior right ventricle free wall course, which is considered benign, with the exception of the intra-arterial.8 On the other hand, the ectopic LCX courses behind the aorta to the left part of the atrioventricular sulcus, where it resumes its usual configuration. This coronary anomaly has been considered potentially serious, because of repeated compression of the anomalous artery by a dilated aortic root or to unusual angling as a result of the retroaortic course of the LCX, which can compress the coronary ostium and restrict blood flow.9 Anyway, because of the unusual dominant right coronary artery, the possible restricted blood flow of the left coronary artery will slightly affect the blood supply of the myocardium. Finally, the results of exercise stress test were negative, which means the ectopic left coronary artery did not lead to myocardial ischemia. Also, there was not any proof that the patient’s symptoms correlated with myocardial ischemia. According to the benign anomalous origin of the LAD and LCX coronary arteries, most of the myocardial blood supply from the unusual dominant right coronary artery, absence of proof of myocardial ischemia, sinus bradycardia and advanced age of this patient, the patient only needs calcium channel blocker and angiotensin-converting enzyme inhibitor to control her blood pressure and avoids violent exercise. The patient was then discharged and now requires regular follow-up.
References
1. Dodd JD, Ferencik M, Liberthson RR, et al. Congenital anomalies of coronary artery origin in adults: 64-MDCT appearance. Am J Roentgenol 2007;188:W138–W146. 2. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,596 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28–40. 3. Tuncer C, Batyraliev T, Yilmaz R, et al. Origin and distribution anomalies of the left anterior descending artery in 70,850 adult patients: Multicenter data collection. Catheter Cardiovasc Interv 2006;68:574–585. 4. Sürücü H, Tatlý E, Deethirmenci A, et al. Anomalous origin of coronary arteries from three separate ostiums in the right sinus of Valsalva: Three case reports and review of the literature. Int J Cardiol 2006;106:264–267. 5. Patel KB, Gupta H, Nath H, et al. Origin of all three major coronary arteries from the right sinus of Valsalva: Clinical, angiographic, and magnetic resonance imaging findings and incidence in a select referral population. Catheter Cardiovasc Interv 2007;69:711–718. 6. Panduranga P, Riyami A. Separate origin of major coronary arteries from the right sinus with angioplasty and stenting of anomalous left circumflex and left anterior descending arteries. J Invasive Cardiol 2009;21:E33–E36. 7. ZemanekD,Veselka J, KautznerovaD, Tesar D. The anomalous origin of the left coronary artery from the right aortic sinus: Is the coronary angiography still a ‘gold standard’? Int J Cardiovasc Imaging 2006;22:127–133. 8. Latsios G, Tsioufis K, Tousoulis D, et al. Common origin of both right and left coronary arteries from the right sinus of Valsalva. Int J Cardiol 2008;128:E60–E61. 9. Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986;111:941–963.
