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Congenital Anomalies of Coronary Artery Origin in Adults: 64-MDCT Appearance

Jonathan D. Dodd1, Maros Ferencik1, Richard R. Liberthson2, Ricardo C. Cury1, Udo Hoffmann1, Thomas J. Brady1 and Suhny Abbara1

1 Department of Radiology and Cardiac MR-PET-CT Program, Massachusetts General Hospital and Harvard Medical School, 55 Fruit St., Boston, MA 02114.
2 Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114.


Figure 1
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  		Fig. 1A —48-year-old man with intermittent palpitations and abnormal exercise stress test result. Three-dimensional volume-rendered reformation shows normal left main coronary artery originating from left sinus of Valsalva (straight white arrow) and passing obtusely downward before dividing into left anterior descending coronary artery (black arrow) and circumflex artery (curved arrow). Left main coronary artery occasionally trifurcates with additional ramus intermedius branch (open arrow). Left anterior descending coronary artery usually extends to apex and may even supply inferior apical region. Diagonal branches (arrowhead) vary in number and supply lateral wall of left ventricle.

 

Figure 2
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  		Fig. 1B —48-year-old man with intermittent palpitations and abnormal exercise stress test result. Three-dimensional volume-rendered reformation shows right coronary artery originating from right sinus of Valsalva (straight white arrow), passing down right atrioventricular groove, and giving off acute marginal branch (curved arrow) before dividing into posterior descending artery (open arrow) and posterior lateral ventricular branch (black arrow). Posterior descending artery courses in posterior interventricular groove to supply posterior interventricular septal branches.

 

Figure 3
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  		Fig. 2A —Schematic of primary coronary anomalies shows group 1, anomalous aortic origin. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 1a-1e. Type 1a (A) is illustrated in Figure 7A, 7B, type 1c (C) in Figure 10A, 10B, and type 1e (E) in Figure 6A, 6B, 6C. RVOT = right ventricular outflow tract.

 

Figure 4
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  		Fig. 2B —Schematic of primary coronary anomalies shows group 1, anomalous aortic origin. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 1a-1e. Type 1a (A) is illustrated in Figure 7A, 7B, type 1c (C) in Figure 10A, 10B, and type 1e (E) in Figure 6A, 6B, 6C. RVOT = right ventricular outflow tract.

 

Figure 5
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  		Fig. 2C —Schematic of primary coronary anomalies shows group 1, anomalous aortic origin. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 1a-1e. Type 1a (A) is illustrated in Figure 7A, 7B, type 1c (C) in Figure 10A, 10B, and type 1e (E) in Figure 6A, 6B, 6C. RVOT = right ventricular outflow tract.

 

Figure 6
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  		Fig. 2D —Schematic of primary coronary anomalies shows group 1, anomalous aortic origin. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 1a-1e. Type 1a (A) is illustrated in Figure 7A, 7B, type 1c (C) in Figure 10A, 10B, and type 1e (E) in Figure 6A, 6B, 6C. RVOT = right ventricular outflow tract.

 

Figure 7
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  		Fig. 2E —Schematic of primary coronary anomalies shows group 1, anomalous aortic origin. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 1a-1e. Type 1a (A) is illustrated in Figure 7A, 7B, type 1c (C) in Figure 10A, 10B, and type 1e (E) in Figure 6A, 6B, 6C. RVOT = right ventricular outflow tract.

 

Figure 8
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  		Fig. 3A —Schematic of primary coronary anomalies shows group 2, anomalous aortic origin and anomalous proximal course. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 2a-2e. Type 2a (A) is illustrated in Figure 12A, 12B, type 2b (B) in Figure 13A, 13B, 13C, type 2c (C) in Figure 14A, 14B, type 2D (D) in Figure 8, and type 2e (E) in Figure 15A, 15B, 15C. RVOT = right ventricular outflow tract.

 

Figure 9
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  		Fig. 3B —Schematic of primary coronary anomalies shows group 2, anomalous aortic origin and anomalous proximal course. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 2a-2e. Type 2a (A) is illustrated in Figure 12A, 12B, type 2b (B) in Figure 13A, 13B, 13C, type 2c (C) in Figure 14A, 14B, type 2D (D) in Figure 8, and type 2e (E) in Figure 15A, 15B, 15C. RVOT = right ventricular outflow tract.

 

Figure 10
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  		Fig. 3C —Schematic of primary coronary anomalies shows group 2, anomalous aortic origin and anomalous proximal course. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 2a-2e. Type 2a (A) is illustrated in Figure 12A, 12B, type 2b (B) in Figure 13A, 13B, 13C, type 2c (C) in Figure 14A, 14B, type 2D (D) in Figure 8, and type 2e (E) in Figure 15A, 15B, 15C. RVOT = right ventricular outflow tract.

 

Figure 11
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  		Fig. 3D —Schematic of primary coronary anomalies shows group 2, anomalous aortic origin and anomalous proximal course. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 2a-2e. Type 2a (A) is illustrated in Figure 12A, 12B, type 2b (B) in Figure 13A, 13B, 13C, type 2c (C) in Figure 14A, 14B, type 2D (D) in Figure 8, and type 2e (E) in Figure 15A, 15B, 15C. RVOT = right ventricular outflow tract.

 

Figure 12
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  		Fig. 3E —Schematic of primary coronary anomalies shows group 2, anomalous aortic origin and anomalous proximal course. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 2a-2e. Type 2a (A) is illustrated in Figure 12A, 12B, type 2b (B) in Figure 13A, 13B, 13C, type 2c (C) in Figure 14A, 14B, type 2D (D) in Figure 8, and type 2e (E) in Figure 15A, 15B, 15C. RVOT = right ventricular outflow tract.

 

Figure 13
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  		Fig. 4A —Schematic of primary coronary anomalies shows group 3, anomalous origin from pulmonary artery. RVOT = right ventricular outflow tract. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 3a-3e.

 

Figure 14
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  		Fig. 4B —Schematic of primary coronary anomalies shows group 3, anomalous origin from pulmonary artery. RVOT = right ventricular outflow tract. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 3a-3e.

 

Figure 15
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  		Fig. 4C —Schematic of primary coronary anomalies shows group 3, anomalous origin from pulmonary artery. RVOT = right ventricular outflow tract. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 3a-3e.

 

Figure 16
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  		Fig. 4D —Schematic of primary coronary anomalies shows group 3, anomalous origin from pulmonary artery. RVOT = right ventricular outflow tract. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 3a-3e.

 

Figure 17
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  		Fig. 4E —Schematic of primary coronary anomalies shows group 3, anomalous origin from pulmonary artery. RVOT = right ventricular outflow tract. Solid line = left main coronary artery/left anterior descending coronary artery; dashed line = right coronary artery; dotted line = left circumflex artery. Types 3a-3e.

 

Figure 18
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  		Fig. 5A —49-year-old man with intermittent atypical chest pain and strong family history of heart disease. Five-millimeter oblique maximum intensity reconstructions show anomalous right coronary artery with high origin (straight arrow, A) above sinotubular junction (straight arrow, B) relative to origin of left main coronary artery (curved arrows).

 

Figure 19
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  		Fig. 5B —49-year-old man with intermittent atypical chest pain and strong family history of heart disease. Five-millimeter oblique maximum intensity reconstructions show anomalous right coronary artery with high origin (straight arrow, A) above sinotubular junction (straight arrow, B) relative to origin of left main coronary artery (curved arrows).

 

Figure 20
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  		Fig. 5C —49-year-old man with intermittent atypical chest pain and strong family history of heart disease. Three-dimensional volume-rendered reformation shows high origin of right coronary artery (straight solid arrow) above sinotubular junction (open arrow) and clockwise rotation of right sinus of Valsalva. Myocardial bridge (curved arrow) of left anterior descending coronary artery is evident.

 

Figure 21
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  		Fig. 6A —77-year-old woman after myocardial infarction. Five-millimeter axial maximum intensity reconstruction shows anomalous origin of left anterior descending coronary artery (arrow) originating from right coronary artery, which passes between aorta and right ventricular outflow tract to interventricular groove.

 

Figure 22
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  		Fig. 6B —77-year-old woman after myocardial infarction. Five-millimeter axial maximum intensity reconstruction shows circumflex artery originating from right coronary artery (white arrow) and passing posteriorly behind aorta to left atrioventricular groove. Stent (black arrow) is evident in proximal portion.

 

Figure 23
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  		Fig. 6C —77-year-old woman after myocardial infarction. Coronary angiogram shows anomalous origin of left anterior descending coronary artery (straight white arrow) and circumflex artery (black arrow), both originating from right coronary artery (curved arrow).

 

Figure 24
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  		Fig. 7A —65-year-old man with atypical chest pain. Eight-millimeter maximum-intensity-projection reconstruction shows anomalous circumflex artery (white arrow) originating from right sinus of Valsalva and passing posteriorly between aorta and left atrium (black arrow) to reach left atrioventricular groove (open arrow). In this case, left anterior descending coronary artery originated from left sinus of Valsalva.

 

Figure 25
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  		Fig. 7B —65-year-old man with atypical chest pain. Coronary angiogram shows anomalous circumflex artery traveling backward from right sinus of Valsalva (black arrow). Early filling of right coronary artery (white arrow) is evident.

 

Figure 26
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  		Fig. 8 —39-year-old man with hyperlipidemia after myocardial infarction. Five-millimeter maximum intensity reconstruction shows anomalous origin of circumflex artery (black arrow) from right sinus of Valsalva, which passes posterior to aorta (white arrow). Left anterior descending coronary artery (open arrow) originates from anomalous circumflex artery.

 

Figure 27
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  		Fig. 9A —82-year-old woman with shortness of breath and elevated cardiac enzyme levels. Five-millimeter axial maximum intensity reconstruction shows entire coronary system originating from right sinus of Valsalva. Left anterior descending coronary artery (white arrow) passes anterior to right ventricular outflow tract. Circumflex artery (black arrow) passes posteriorly between left atrium and aortic root to resume its normal position in left atrioventricular groove. Right coronary artery (open arrow) has normal configuration.

 

Figure 28
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  		Fig. 9B —82-year-old woman with shortness of breath and elevated cardiac enzyme levels. Angiogram from coronary catheterization shows entirely right-sided coronary arterial system with left anterior descending coronary artery (black arrow) and circumflex artery (white arrow) arising from right coronary sinus (open arrow).

 

Figure 29
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  		Fig. 10A —40-year-old man with congenital aortic stenosis and atrial fibrillation. Five-millimeter maximum intensity reconstruction shows anterior origin of right coronary artery (arrow) with no compression between aorta and right ventricular outflow tract.

 

Figure 30
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  		Fig. 10B —40-year-old man with congenital aortic stenosis and atrial fibrillation. Coronary angiogram shows bend (arrow) in proximal right coronary artery characteristic of this anomaly but no evidence of stenosis.

 

Figure 31
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  		Fig. 11A —30-year-old woman with chest pain. Five-millimeter maximum intensity reconstruction illustrates right coronary artery originating from left sinus of Valsalva. Compression (arrow) is evident where artery passes between aortic root and right ventricular outflow tract.

 

Figure 32
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  		Fig. 11B —30-year-old woman with chest pain. Coronary angiogram shows slight narrowing (arrow) of proximal portion of right coronary artery during systolic phase of coronary cycle.

 

Figure 33
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  		Fig. 12A —52-year-old man with atypical chest pain. Five-millimeter axial maximum intensity reconstruction shows right coronary artery (white arrow) originating entirely from left sinus of Valsalva. Stent (black arrow) is evident in distal left anterior descending coronary artery.

 

Figure 34
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  		Fig. 12B —52-year-old man with atypical chest pain. Three-dimensional volume-rendered reformation shows origin of right coronary artery (white arrow) from left sinus of Valsalva. Anomaly and stent position (black arrow) are more easily appreciated than in A.

 

Figure 35
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  		Fig. 13A —54-year-old man with positive stress test result. Five-millimeter axial maximum intensity reconstruction shows left main coronary artery originating entirely from right sinus of Valsalva and compression (arrow) of left main coronary artery as it passes between aorta and right ventricular outflow tract.

 

Figure 36
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  		Fig. 13B —54-year-old man with positive stress test result. Five-millimeter axial maximum intensity reconstruction shows left anterior descending coronary artery (black arrow) and circumflex artery (white arrow) originating from left main coronary artery in normal configuration.

 

Figure 37
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  		Fig. 13C —54-year-old man with positive stress test result. Coronary angiogram shows abnormal course of left main coronary artery and compression (arrow) of portion between aorta and right ventricular outflow tract.

 

Figure 38
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  		Fig. 14A —63-year-old woman with chest pain and hyperlipidemia. Five-millimeter maximum intensity reconstruction shows anomalous origin of left main coronary artery from right sinus of Valsalva and passage anterior to right ventricular outflow tract (arrow).

 

Figure 39
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  		Fig. 14B —63-year-old woman with chest pain and hyperlipidemia. Three-dimensional volume-rendered reformation shows left main coronary artery continues around right ventricular outflow tract (straight solid arrow) and branches into left anterior descending coronary artery (open arrow) and circumflex artery (curved arrow).

 

Figure 40
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  		Fig. 15A —48-year-old woman with atypical chest pain and family history of coronary artery disease. Five-millimeter axial maximum intensity reconstruction shows left anterior descending coronary artery (arrow) originating from right sinus of Valsalva and passing between aorta and right ventricular outflow tract.

 

Figure 41
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  		Fig. 15B —48-year-old woman with atypical chest pain and family history of coronary artery disease. Five-millimeter axial maximum intensity reconstruction shows anomalous left anterior descending coronary artery passes intramyocardially (arrow) before reentering epicardial fat in interventricular groove.

 

Figure 42
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  		Fig. 15C —48-year-old woman with atypical chest pain and family history of coronary artery disease. Five-millimeter axial maximum intensity reconstruction shows circumflex artery (arrow) originating from left sinus of Valsalva.

 

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