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CASE REPORT
Year : 2022 | Volume
: 8
| Issue : 3 | Page : 178-181
Left main coronary artery arising from the right coronary sinus presenting as acute coronary syndrome: A rare anomaly managed conservatively
Saket Toshniwal1, Twinkle Pawar1, Ruchita Kabra1, Tarun Rao2, Sunil Kumar1, Sourya Acharya1
1 Department of Medicine, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Cardiology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
Correspondence Address:
Saket Toshniwal
Department of Medicine, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpcs.jpcs_51_22
Coronary artery anomalies are extremely rare with a prevalence of 2.33% and they are extremely difficult to diagnose with the help of conventional tests. Once diagnosed, the associated life-threatening risks and complications that arise during surgical management are the dangers related to such anomalies. We present a case of a 45–year-old female, with chief complaints of chest pain radiating to back and left shoulder associated with palpitations for 7 days, a known case of systemic hypertension and diabetes mellitus type 2 for 7 years on regular medications. A series of investigations were conducted that included an electrocardiogram showing ischemic changes, a two-dimensional echocardiography that revealed globally dysfunctional left ventricle and an ejection fraction of 45%, and finally, a diagnostic coronary angiography leading to the diagnosis of the an abnormal origin of the left main coronary artery through the right coronary sinus associated with 80% stenotic lesion in the “left anterior descending artery” and 90% stenotic lesion in the “left circumflex artery”. The report concludes that anomalies arising from coronary arteries are extremely infrequent and difficult to diagnose. In addition, they can present with life-threatening complications during surgical management.
Keywords: Angiography, anomalous coronary artery, right coronary sinus
Below 1% incidence of congenital coronary artery anomalies have been accounted for which indicates that coronary artery anatomical anomalies are relatively rare. These are characterized by abnormal locations in the coronary artery orifice, including abnormalities in the origin of the aortic root of coronaries like in this case.[1],[2]
Abnormalities of the coronary arteries have sometimes led to life-threatening cardiac infarction and arrhythmias and even sudden death.[1]
In the course of a survey of 6.3 million military recruits between the ages of 18 and 35 years, the rate of sudden nontraumatic mortality was 13.0/100,000 recruit's year. One-third of 126 autopsied deaths experienced an aberrant coronary artery, representing more than half of deaths with a documented cardiac defect. Moreover, one-third of fatalities were unaccounted for.[3]
Thus, an early diagnosis and awareness of these rare coronary artery anomalies and its studies are important for greater advances in the treatment modalities.
This case study describes a 45-year-old female with double-vessel disease and abnormally arising left main coronary artery (LMCA) from the right coronary sinus diagnosed on coronary angiography (CAG).
Case ReportA 45-year-old female who was a known case of systemic hypertension for 7 years on regular medications with no other comorbidities presented to the hospital with chief complaints of pain in the chest (anginal) on rest and on exertion radiating to back and left shoulder associated with palpitations. She reported progressive worsening of her chest pain since 1 month following which she presented to the hospital for further evaluation.
On general examination, the patient's pulse was 102 beats/min, which was in rhythm, blood pressure was 140/80 mmHg in supine position measured in the right arm, respiration rate seen 18 cycles/min with normal jugular vein pressure and the absence of bipedal pitting edema and other general examination findings are not notable.
On systemic examination, both the heart sounds were heard with systolic murmur heard diffusely with apex beat felt at 4th inter-costal space just lateral to mid-clavicular line, on respiratory examination, bilateral air entry was heard with no other adventitious sounds, on per abdomen examination, abdominal wall was soft and nontender with no visible veins or scars, and the patient was conscious and well oriented to time, place and person with intact cranial nerves on central nervous system examination.
An electrocardiograph (ECG) was performed which revealed QS complexes in lead V1 to V6 with normal sinus rhythm as shown in [Figure 1].
Figure 1: Electrocardiograph of the patient showing QS complexes in V1 to V6 within normal sinus rhythm.A two-dimensional (2D) electrocardiography was done which was suggestive of globally dysfunctional left ventricle with 25% ejection fraction with severe regurgitation of mitral valve and dilated left atrium and left ventricle. Blood investigations were carried out for complete blood count, kidney function test, and cardiac markers and were found to be within normal limits and negative for cardiac markers creatine kinase-MB (15) and Trop I (34.5).
CAG was planned in view of electrocardiographic changes and 2D echocardiography findings. The patient was kept nil by mouth for the procedure and the dual antiplatelet loading dose and statins were given and CAG was performed through the right radial artery using 5F TIG catheter and nonionic omnipaque contrast.
CAG in this patient depicted abnormally originating LMCA from right coronary sinus, 80% stenosed “left anterior descending artery,” 90% stenosed “left circumflex artery” and was diagnosed with coronary artery disease (double-vessel disease) with an abnormally arising LMCA through right coronary sinus, as shown in [Figure 2],[Figure 3],[Figure 4]. The abnormal LMCA in this case arises from the right coronary sinus and traverses through the epicardium and further divides into the left anterior division and left circumflex artery. The artery also traverses the space between the aorta and the pulmonary trunk and is thus subjected to compression between these two vessels; this course of the artery is a potential danger in the present case.
Figure 2: Black arrow: LMCA originating abnormally from right coronary sinus. White arrow: RCA from right coronary sinus. RCA: Right coronary artery. LMCA: Left main coronary artery.
Figure 3: Black arrow showing long LMCA. LMCA: Left main coronary artery.
Figure 4: The long LMCA (black arrow) is further divided into left anterior descending artery and the left circumflex arteries with stenotic lesions (white arrow). LMCA: Left main coronary artery.The patient was advised for a coronary artery bypass grafting for her disease and was thoroughly explained about her condition and the need for the surgical intervention, but opted out willing due to financial constraints and hence the patient had not undergone any intervention like angioplasty or bypass surgery and was managed conservatively with anti-ischemic drugs. Tablet Ecosprin 75 mg once a day, tablet Clopidogrel 75 mg twice a day and tablet Atorvastatin 40 mg once at night along with tablet Metoprolol 25 mg once a day. The patient was doing well at routine follow-up till 2 months.
DiscussionThe aortic valve, which has an anterior and two posterior cusps, is situated near the start of the ascending aorta. There are three equivalent aortic sinuses located directly above the cusps. The right coronary artery (RCA) originates from the anterior aortic sinus, while the left coronary artery (LCA) originates from the left posterior aortic sinus.[4] The prevalence of coronary artery anomalies in a retrospective study by Kilic et al.[5] was found to be 2.33% of which the LMCA anomalies contribute 0.62% and Graidis et al. found the incidence of LCA anomalies to be 0.12% by Graidis et al.[6]
Anomalous origin of coronary arteries were classified by Lipton et al. which was furthermore altered by Yamanaka and Hobbs and was found that the abnormally origined LMCA arise through right coronary sinus in an extremely infrequent presentation which reported to about 0.04%–0.004% with the danger of unexpected demise.[7],[8],[9]
Incidences of unexpected demise of youthful individuals with coronary artery anomalies[3] and specifically in association with LMCA abnormally originating through right coronary sinus has been observed by Cheitlin et al.[10] and Taylor et al.,[11] who studied the relationship between unexpected cardiac death and congenital anomaly of coronary artery; it was discovered that a single coronary artery anomaly was related with the danger of sudden death that occurred in 14% of his subjects. Due to their uncommon and relatively rare character of presentation and the occurrences of sudden death in young individuals, as demonstrated by many studies described above, it is crucial to examine coronary artery abnormalities like the one presented in the report.
Better methods of abnormal origin are necessary and in the results of a study by Farooqui et al.[12] showed 100% accuracy on cardiac computed tomography (CT) models and 92.31% accuracy on 3D models compared to 80.77% accuracy on 2D echo. The study was concluded by establishing the superiority of cardiac CT and 3D models over other investigations in diagnosing abnormal origin of coronaries and was found to be preferred by cardiac imagers and congenital cardio-thoracic surgeons. In addition to these advanced technological diagnostic methods, early recognition of ECG changes can help diagnose stenotic lesions in the LMCA and also in all other coronaries. An early diagnosis is important for a better prognosis of the patient, as LMCA occlusions have been proven to be deadly.[13]
The patient in the present case study underwent a series of investigations and was therefore promptly diagnosed with atherosclerotic stenotic lesions in the left anterior descending and left circumflex. She was then advised a cardiovascular thoracic surgical consultation for further management. Revascularization procedures in these cases present greater challenges and a surgical opinion must be considered.
ConclusionAnomalies arising from coronary arteries are extremely infrequent and difficult to diagnose. In spite of all the advancement in cardiac disease diagnostic techniques, coronary artery anomalies are usually diagnosed later by when the related disease has already reached its severe stages. Thus, such anomalies generally present with life-threatening risks when undiagnosed as well as severe complications in its management by the time it is diagnosed. Therefore, it is important to shed light on such rare anomalies to help determine the best diagnostic tool for early diagnosis as well as the best treatment approach with minimal risks and complications. It is, therefore, recommended to use the latest available diagnostic tools for prompt diagnosis of the rare anomalies; along with this, further research and advancement in the early diagnosis and safer treatment methods for such rare anomalies must also be done. Furthermore, it is recommended for the surgeon to be up to date with the knowledge about such an anomaly and the associated risks to avoid mishaps during any coronary surgery. The recommendations of this report are clinically valuable because the mere presence of such an anomaly is principally determined either in symptomatic cases, high-risk cases, or at the time of a cardiac surgery.[5]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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