In this article, we report an interesting case of
inter-arterial course of LCA originating from the
right coronary sinus. Although the multi-detector
CT provided excellent information about the
origin and inter-arterial course of coronary artery,
echocardiography is also helpful to detect such
suspicious cases.
The incidence of congenital coronary anomalies
ranges between 1 and 5% undergoing coronary
angiography and 0.3% in autopsy series.[1,2]
Echocardiographic studies in pediatric population
reported an incidence of 0.3%.[3] Potentially serious
coronary anomalies include ectopic coronary origin
from the pulmonary artery, ectopic coronary origin
from the opposite sinus, single coronary artery, and
coronary fistula.[1] Our patient had LCA originating
from right sinus. The pattern of single or common
ostium is considered to represent single coronary
artery, as in our case.
Four anatomical variants have been described
according to the course of the LMCA to the left side of
the heart in single coronary artery arising from the right
coronary sinus: (i) anterior: LMCA courses anteriorly
to the right ventricular outflow tract; (ii) inter-arterial:
LMCA passes between the great vessels; (iii) septal:
LMCA has an intramyocardial septal course; and (iv) posterior: LMCA courses posteriorly behind the
aorta in the inferoposterior direction.[4] Our patient had
an inter-arterial variant. The incidence of inter-arterial
variant ranges between 0.03 and 0.05%.[1] However,
the inter-arterial course has been known as a cause
of sudden cardiac death. Ischemia or sudden cardiac
death are thought to occur due to the vascular kinking
or compression. According to the most common
postulated hypothesis, exercise results in enlargement
of the aorta, which obstructs the acutely angulated slitlike
orifice of the LMCA.[1] Van Camp et al.[5] reported
that coronary anomalies accounted for 11.8% of deaths
in high school and college athletes. In addition, the
Sudden Death Committee of the American Heart
Association states that coronary anomalies account
for 19% of deaths in athletes.[6] In a study concerning
death in young athletes with coronary anomalies
arising wrong sinus, premonitory symptoms including
chest pain and syncope were substantially rare, and
electrocardiography and exercise tests were within
normal limits in most cases.[7]
Echocardiography is essential in the diagnosis
of coronary anomalies. However, it is imperative
to define the course of coronary arteries to predict
prognosis. Coronary angiography may cause some
misinterpretations in cases with coronary anomalies.
Therefore, imaging methods such as CT or MR
angiography have been suggested.[4] Multi-detector
CT offers an excellent delineation of the LCA origin
and provides the surgeon with a clear image of course
of anomalous coronary artery. Therefore, we did not
use conventional angiography in our case. Although
patients are commonly asymptomatic, surgical repair
is recommended, particularly after 10 years of age.[8]
In conclusion, coronary anomalies can be lethal
during or shortly after vigorous physical activity, typically
in young individuals. Diagnosis of coronary artery
anomalies requires a high index of suspicion. Although echocardiography is useful, computed tomography
angiography provides an excellent information about
the coronary anomalies, as in our case.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
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