AJR ARRS Member Benefits
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Dodd, J. D.
Right arrow Articles by Abbara, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dodd, J. D.
Right arrow Articles by Abbara, S.
Social Bookmarking
Add to CiteULike   Add to Complore   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?
DOI:10.2214/AJR.05.2098
AJR 2007; 188:W138-W146
© American Roentgen Ray Society

Pictorial Essay

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.

Received December 5, 2005; accepted after revision February 14, 2006.

 
Address correspondence to J. D. Dodd (jddodd{at}partners.org).

WEB This is a Web exclusive article.


Abstract
Top
 Abstract
Introduction
 Normal Anatomic Features
 Classification of Coronary...
 Conclusion
 References
 
OBJECTIVE. The purpose of this pictorial essay is to review the 64-MDCT appearance of congenital anomalies of the origins of the coronary arteries in adults.

CONCLUSION. Increasing use of MDCT for cardiac imaging of adults requires familiarity with the cross-sectional appearance of congenital coronary artery anomalies visualized with noninvasive imaging techniques. Many of these anomalies are benign, but a small number are associated with myocardial ischemia and sudden death. Increasing use of MDCT in cardiac imaging may yield diagnostic information not obtained with coronary angiography. Axial, multiplanar, and 3D volume-rendered reconstructions should aid in detection and improve interpretation of such anomalies.

Keywords: angiography • cardiac imaging • coronary angiography/methods • CT coronary angiography • tomography • X-ray computed


Introduction
Top
 Abstract
 Introduction
Normal Anatomic Features
 Classification of Coronary...
 Conclusion
 References
 
Primary congenital anomalies of the coronary arteries have an incidence of 1-2% in the general population [1]. Noninvasive techniques such as MRI, electron-beam CT, and MDCT depict these anomalies with high accuracy [2, 3]. MDCT in particular provides high-resolution 3D data sets that allow precise definition of 3D spatial relations of the anomalies. Comprehensive reviews of 16-MDCT of primary congenital coronary anomalies have been limited [2-5]. To our knowledge, this is the first review to provide comprehensive data from 64-MDCT. Recognition of coronary anomalies, particularly those associated with a malignant course, increased morbidity, and sudden death, is important. The aim of this article is to illustrate the appearance and course of congenital coronary anomalies on 64-MDCT with coronary angiographic correlation in selected cases.


Normal Anatomic Features
Top
 Abstract
 Introduction
 Normal Anatomic Features
Classification of Coronary...
 Conclusion
 References
 
The left main coronary artery (LMCA) originates from the left sinus of Valsalva (Fig. 1A). It can bifurcate into the circumflex and left anterior descending (LAD) branches or trifurcate with an additional intermediate ramus branch. The LAD coronary artery usually descends in the anterior interventricular groove. Septal branches arise from the LAD coronary artery and course into the interventricular septum, supplying the anterior two thirds of the septum. Diagonal branches arise from the LAD coronary artery and descend toward the lateral margin of the left ventricular wall. The circumflex branch enters the left atrioventricular groove to supply obtuse marginal branches to the lateral and posterolateral walls of the left ventricle. In left coronary dominant patients (10%), the circumflex branch travels all the way around the ventricle, supplying both the posterior descending coronary artery and the posterior left ventricular branch. More commonly, however, the circumflex branch terminates as a small branch in the atrioventricular groove or continues as a small terminal posterior ventricular branch.


Figure 1
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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.

 
The right coronary artery (RCA) originates from the right coronary sinus of Valsalva at a slightly lower level than the origin of the left main coronary artery (Fig. 1B). The RCA descends in the anterior right atrioventricular groove. It usually gives off the conus branch as its first branch and then two or three large right ventricular wall branches. The acute marginal branch is the first large branch, which occasionally continues to the apex. In 70% of patients the RCA passes down the atrioventricular groove to the crux of the heart, where it gives off the posterior descending artery and posterior left ventricular branches. Approximately 20% of patients have a codominant supply, in which the posterior descending artery originates from the RCA, but branches from the circumflex artery also supply this territory.


Figure 2
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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.

 

Classification of Coronary Artery Anomalies
Top
 Abstract
 Introduction
 Normal Anatomic Features
 Classification of Coronary...
Conclusion
 References
 
Various classification systems exist for primary congenital coronary anomalies. For this review we divided coronary anomalies into the following three broad categories [6]: anomalous aortic origin (Fig. 2A, 2B, 2C, 2D, 2E), anomalous aortic origin with anomalous proximal course (Fig. 3A, 3B, 3C, 3D, 3E), and anomalous origin from the pulmonary artery (Fig. 4A, 4B, 4C, 4D, 4E). The third category in this classification (anomalous coronary origin from the pulmonary artery) is not discussed or illustrated further in this article.


Figure 3
View larger version (33K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (20K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (20K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (20K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (21K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (31K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (31K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (31K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (30K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (30K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (32K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (27K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (30K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (33K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (27K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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.

 
Anomalous Aortic Origin
The coronary artery ostia may have abnormal origins in the aorta and then course in a normal direction. The most common is a high origin of the RCA above the sinotubular junction [7] (Fig. 5A, 5B, 5C). This anomaly usually occurs a few millimeters above the sinotubular junction, but distances of 2.0 cm have been reported [8]. It is important for cardiac surgeons to be aware of this anomaly, because during cardiac bypass surgery when the aorta is cross-clamped, high cannulation is needed to avoid accidental crossclamping or transection of the RCA.


Figure 18
View larger version (113K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (138K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (116K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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.

 
The LAD coronary artery can arise from the right coronary sinus or RCA and take a course anterior to the right ventricular outflow tract (RVOT) or it may take an anomalous proximal course (see next section and Fig. 6A, 6B, 6C). The former anomaly is not associated with myocardial ischemia. Anomalous origin of the LAD coronary artery should be suspected when injection of contrast material into a coronary vessel originating in the right sinus of Valsalva reveals a long, nonbranching proximal segment that courses anteriorly in the intraventricular groove. Cardiac surgeons need knowledge of such anatomic features to avoid intraoperative complications during valve surgery.


Figure 21
View larger version (148K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (128K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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).

 
The circumflex artery can arise from the right sinus of Valsalva or the RCA. In the Coronary Artery Surgery Study [9], which included coronary angiograms of 24,959 patients, the most common anomaly (60%) involved the circumflex artery. In 69% of these cases, the circumflex artery arose from a separate ostium in the right coronary sinus of Valsalva, and in 31% of cases it originated as a branch of the RCA. The circumflex artery always takes a posterior course. It may be an isolated anomaly with the LAD coronary artery originating normally from the LMCA (Fig. 7A, 7B), or may be associated with other branch anomalies, such as origin of the LAD coronary artery from the anomalous circumflex artery (Fig. 8).


Figure 24
View larger version (118K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (61K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (143K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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.

 
In rare instances, all three coronary arteries arise from the right coronary sinus (Fig. 9A, 9B). Only a small number of case reports [10] have described this anomaly. The arteries have a normal course once they have reached their respective atrioventricular and interventricular grooves.


Figure 27
View larger version (140K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (138K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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).

 
Anomalous Aortic Origin with Anomalous Proximal Course
The RCA can originate from the left side of the aorta above the commissure between the right and left coronary sinuses, from the left sinus of Valsalva, or from the LMCA. The origin can be anterior to or immediately adjacent to the left coronary sinus and may dictate the degree of RCA opposition between the aorta and the RVOT (Figs. 10A, 10B and 11A, 11B). Less often the RCA arises entirely from a single left coronary sinus (Fig. 12A, 12B). The anomalous RCA can take a course anterior or posterior to the great vessels. This coronary anomaly is also the most common to course between the great vessels [9].


Figure 29
View larger version (141K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (129K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (158K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (80K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (158K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (115K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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.

 
The LMCA can arise from the right coronary sinus and take a course between the aorta and the RVOT (Fig. 13A, 13B, 13C); anterior to the RVOT, which can result in long (5-6 cm) arteries (Fig. 14A, 14B); to the right and posterior to the RCA and the aortic root; and in an intramyocardial direction through the crista supraventricularis (Fig. 15A, 15B, 15C). It has been suggested that the last anomaly may be more easily visualized with MDCT than with angiography [3].


Figure 35
View larger version (151K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (126K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (101K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (130K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (100K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (150K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (98K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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
View larger version (113K):
[in this window]
[in a new window]
[as a PowerPoint slide]
  		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.

 
Many congenital coronary anomalies are benign, but a small number cause symptoms ranging from chest pain and dyspnea to cardiorespiratory arrest and sudden death [1, 11]. The most common abnormalities include anomalous origin of the left coronary artery from the pulmonary artery (Bland-Garland-White syndrome), coronary artery fistulas, and coronary arteries coursing between the great vessels [12]. The presence of an anomalous course between the great vessels is more relevant than is ectopic origin of the coronary artery [13]. The LMCA can arise from the RCA or right coronary sinus of Valsalva and pass between the aorta and RVOT, where it can become compressed, a condition that results in myocardial ischemia [14]. This anomaly appears to have a closer association with sudden death than does origin of the RCA from the left sinus of Valsalva or LMCA passing between the aorta and the RVOT [15]. The LAD coronary artery can arise from the RCA or right coronary sinus of Valsalva and course between the great vessels, where it can be compressed [16].

Whether ischemia results from coronary artery anomalies coursing between the great vessels depends on several factors. These anomalies often originate at an acute angle from a slitlike hypoplastic ostium, which can become compressed between the great vessels during exercise [17]. It is hypothesized that during exercise, expansion of the aortic and pulmonary roots increases angulation of the slitlike ostium with subsequent luminal compromise of the anomalous coronary artery. In addition, whether the aberrant artery exhibits dominance strongly influences the clinical presentation.

Finally, there is a close association with strenuous exercise, sudden death classically occurring during or immediately after exercise [15, 17]. Any young patient with angina pectoris, myocardial infarction, or cardiac syncope needs noninvasive imaging to rule out such anomalies.


Conclusion
Top
 Abstract
 Introduction
 Normal Anatomic Features
 Classification of Coronary...
 Conclusion
References
 
Knowledge of the appearance of anomalies of congenital coronary origin in adults is important. Most of these anomalies are benign, but a small number, principally those with a course between the great vessels, are associated with myocardial ischemia and even sudden death. Increased use of MDCT in cardiac imaging highlights the value of recognizing such anomalies on cross-sectional, multiplanar, and volume-rendered reconstructions.


References
Top
 Abstract
 Introduction
 Normal Anatomic Features
 Classification of Coronary...
 Conclusion
 References
 

  1. Hoffman JI, Kaplan S, Liberthson RR. Prevalence of congenital heart disease. Am Heart J 2004;147 : 425-439[CrossRef][Medline]
  2. Schmitt R, Froehner S, Brunn J, et al. Congenital anomalies of the coronary arteries: imaging with contrast-enhanced, multidetector computed tomography. Eur Radiol 2005;15 : 1110-1121[CrossRef][Medline]
  3. Datta J, White CS, Gilkeson RC, et al. Anomalous coronary arteries in adults: depiction at multi-detector row CT angiography. Radiology 2005;235 : 812-818[Abstract/Free Full Text]
  4. Shi H, Aschoff AJ, Brambs HJ, Hoffmann MH. Multislice CT imaging of anomalous coronary arteries. Eur Radiol2004; 14:2172 -2181[CrossRef][Medline]
  5. van Ooijen PM, Dorgelo J, Zijlstra F, Oudkerk M. Detection, visualization and evaluation of anomalous coronary anatomy on 16-slice multidetectorrow CT. Eur Radiol 2004;14 : 2163-2171[CrossRef][Medline]
  6. Perloff JK. Clinical recognition of congenital heart disease, 5th ed. Philadelphia, PA: Saunders, 2003:580 -595
  7. Frescura C, Basso C, Thiene G, et al. Anomalous origin of coronary arteries and risk of sudden death: a study based on an autopsy population of congenital heart disease. Hum Pathol1998; 29:689 -695[CrossRef][Medline]
  8. Thakur R, Dwivedi SK, Puri VK. Unusual "high take off" of the right coronary artery from the ascending aorta. Int J Cardiol 1990; 26:369 -371[CrossRef][Medline]
  9. Click RL, Holmes DR Jr, Vlietstra RE, Kosinski AS, Kronmal RA. Anomalous coronary arteries: location, degree of atherosclerosis and effect on survival—a report from the Coronary Artery Surgery Study. J Am Coll Cardiol 1989; 13:531 -537[Abstract]
  10. Neil DA, Bonser RS, Townend JN. Coronary arteries from a single coronary ostium in the right coronary sinus: a previously unreported anatomy. Heart 2000; 83:E9[CrossRef][Medline]
  11. Liberthson RR. Congenital heart disease: diagnosis and management in children and adults. Toronto, ON: Little, Brown,1989
  12. Hauser M. Congenital anomalies of the coronary arteries. Heart 2005; 91:1240 -1245[Free Full Text]
  13. Taylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol 1992; 20:640 -647[Abstract]
  14. Barth CW 3rd, Roberts WC. Left main coronary artery originating from the right sinus of Valsalva and coursing between the aorta and pulmonary trunk. J Am Coll Cardiol 1986;7 : 366-373[Abstract]
  15. Thomas D, Salloum J, Montalescot G, Drobinski G, Artigou JY, Grosgogeat Y. Anomalous coronary arteries coursing between the aorta and pulmonary trunk: clinical indications for coronary artery bypass. Eur Heart J 1991;12 : 832-834[Medline]
  16. Topaz O, DeMarchena EJ, Perin E, Sommer LS, Mallon SM, Chahine RA. Anomalous coronary arteries: angiographic findings in 80 patients. Int J Cardiol 1992;34 : 129-138[CrossRef][Medline]
  17. Liberthson RR. Sudden death from cardiac causes in children and young adults. N Engl J Med 1996;334 : 1039-1044[Free Full Text]

Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to Technorati Technorati    What's this?



This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Dodd, J. D.
Right arrow Articles by Abbara, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dodd, J. D.
Right arrow Articles by Abbara, S.
Social Bookmarking
Add to CiteULike   Add to Complore   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Reddit   Add to Technorati  
What's this?