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Computed tomography coronary angiographic demonstration of a single coronary artery with the right coronary artery arising as a continuation from the left circumflex coronary artery

Rafic F. Berbarie, MD, Amy S. Anderson, MD, Jeffrey M. Schussler, MD

Introduction

A 31-year-old man with a past medical history significant for hypertension (on a single medication) was sent for cardiology evaluation for a complaint of chest pain. On the basis of family history and risk factors, he was thought to be an intermediate risk for coronary artery disease. A stress echocardiogram was performed, which demonstrated excellent exercise capacity (15 min on Bruce protocol), no chest discomfort or wall motion abnormalities, but 1.5 mm of flat ST depression at peak exercise.

Although the general consensus was that the EKG changes seen on stress testing were potentially a false positive stress test, the patient was concerned that he might have premature atherosclerotic coronary disease. His chest pain persisted.

Rather than performing an invasive evaluation, it was felt that a computed tomographic coronary angiogram (CTCA) would give adequate information about the burden of disease, as well as an excellent definition of the patient's coronary tree.

The CTCA demonstrated no significant coronary atherosclerosis, but did demonstrate a coronary anomaly. It was noted that there was no true right coronary artery (RCA) seen. Instead, the patient's RCA existed as a continuation of the distal left circumflex coronary artery (LCCA) (Fig. 1). The patient had a single coronary artery arising from the left coronary cusp with the posterior circulation (usually supplied by the RCA) supplied from a continuation of the LCCA.

Figure 1.
CTCA of a patient with a single coronary artery. The 3D reconstructions (panels A and B) demonstrate the single artery, with the continuation of the LCCA becoming the artery which supplies blood to the right ventricle (RCA). The artery itself is without significant plaque, which is demonstrated in the multiplanar reformatted view (panel C). This anomaly is confirmed on axial images which show that there is no separate RCA ostium (panel D white arrow), and also shows the normally arising left main from the left coronary cusp. The LCCA continues past the posterior interventricular groove as the RCA (panel E).

Single coronary arteries are rare and can have a highly variable course, such as the one described in this patient [[1]]. An anomalous RCA, when present, usually has its origin from the left coronary cusp, or even arising from the left main. In those circumstances, the course of the RCA is typically in between the proximal aorta and the main pulmonary trunk, and not as a continuation from the LCCA as in the present case.

While unusual in its course, the patient's single coronary artery did not appear to be compromised either by coronary atherosclerosis or by a malignant proximal course between the great vessels. Therefore, it was not felt that the patient's chest pain was cardiac in origin. He was reassured, and will continue to be followed by his primary care physician for his hypertension.

References

  1. Roberts WC. Major anomalies of coronary arterial origin seen in adulthood. Am Heart J 1986; 111: 941-963.

Autor: Rafic F. Berbarie, MD, Amy S. Anderson, MD, Jeffrey M. Schussler, MD

Fuente: Catheterization and Cardiovascular Interventions

Ultima actualizacion: 3 DE DICIEMBRE DE 2007

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