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| CASE REPORT |
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| Year : 2023 | Volume
: 24
| Issue : 1 | Page : 59-62 |
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Origin of all three coronaries from single ostium: A rare case report
Surender Deora, Jai Bharat Sharma, Atul Kaushik, Rahul Choudhary
Department of Cardiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| Date of Submission | 03-Sep-2022 |
| Date of Acceptance | 22-Jan-2023 |
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Dr. Surender Deora
Department of Cardiology, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/heartviews.heartviews_81_22
 Abstract | | |
Origin of coronary arteries from the opposite sinus of Valsalva is rare and origin from a single ostium is extremely rare. Patients with these anomalies may have myocardial ischemia because of altered ostial configuration, exit angulation from the aorta, the course between great arteries, and atherosclerosis. Usually, these anomalies are diagnosed during coronary angiography either by computed tomography or catheter-based. Management depends upon the coronary anomaly and associated clinical condition.
Keywords: Common origin, coronary anomaly, right sinus of Valsalva
How to cite this article:
Deora S, Sharma JB, Kaushik A, Choudhary R. Origin of all three coronaries from single ostium: A rare case report. Heart Views 2023;24:59-62 |
| Introduction | |  |
The anomalous origin of the coronary artery has an incidence ranging from 0.03% to 5.64%.[1] Although uncommon, congenital anomalies of the coronary arteries may cause serious myocardial damage, ischemic cardiomyopathy, and sudden cardiac death. These anomalies vary in number, location, and origin with the orientation of the Ostia and course of the coronary arteries. Solitary coronary ostium in the aorta, in the absence of other major congenital cardiovascular anomalies, is extremely rare.
Here, we report an interesting case of single ostial origin of all three coronaries from the right coronary sinus presenting with non-ST-segment elevation myocardial infarction (NSTEMI), which was managed successfully by coronary artery bypass grafting (CABG).
| Case Presentation | | |
A 63-year-old male with dyslipidemia, nonsmoker, nondiabetic, and normotensive presented with a complaint of angina on exertion for 2 months and resting chest pain intermittently for 2 days lasting for 1 h.
A 12-lead electrocardiogram revealed ST segment depressions in lead V2-5 [Figure 1] and had raised troponin I level. | Figure 1: 12-lead electrocardiogram revealing ST segment depression in anterior precordial leads V2-V5
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Echocardiography revealed no regional wall motion abnormality and normal left ventricular ejection fraction. The patient was diagnosed as a case of acute coronary syndrome– NSTEMI. He was managed with guideline-directed medical therapy and subjected to coronary angiography (CAG).
Selective coronary artery cannulation was attempted with a 5F TIG diagnostic catheter through the right radial artery. No coronary artery was seen arising from the left coronary cusp. Right coronary artery (RCA) cannulation revealed all three coronaries arising from a single ostium from the right coronary cusp [[Figure 2] and S Video 1]. The RCA revealed a significant 90% stenotic lesion in the ostium, 80% in the proximal segment, and 99% in the posterior left ventricular branch. The left anterior descending artery (LAD) also revealed 70%–80% ostial lesion, followed by 80% lesion in mid-segment. Left circumflex artery (LCx) showed 80%–90% ostioproximal lesion. To further identify the proximal course of these anomalous coronary arteries, coronary computed tomography angiography (CCTA) was performed [Figure 3]. This confirmed that the RCA, LAD, and LCX, all arose independently from single Ostia in the right coronary cusp. None of the anomalous coronary arteries (ACAs) demonstrated an interarterial course between the aorta and the pulmonary trunk. The LAD was found to take a course anterior to the pulmonary artery, and the LCX was coursing posterior to the aortic root. The RCA was a dominant vessel. It further delineated the atherosclerotic lesions as in CAG. The patient was advised early CABG because of the significant ostial lesion in all three coronaries. The patient underwent CABG successfully and was asymptomatic at 1-month follow-up. | Figure 2: Coronary angiogram in different views (Panel a, b, c, d) revealing common origin of all three coronaries from the right sinus of Valsalva with significant disease in the proximal segment
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 | Figure 3: Reconstructed computed tomography coronary angiography showing the separate origin of all three coronaries from the right coronary sinus. LAD: Left Anterior Descending, LCx: Left Circumflex, RCA: Right Coronary Artery
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[Additional file 1]
| Discussion | | |
Single ostium of coronary artery (SOCA) was first time reported by Hyrtl in 1840 but the first angiographic case report was by Halperin et al. in 1967.[2],[3]
Several classification systems for SOCA have been proposed earlier in the last few decades. As per the modified Lipton classification, the case presented here belongs to the combined type R III group in which the LAD passes anterior to the pulmonary artery, without an inter-arterial course; while the septal branch and the LCX are posterior to the aorta. This type of anomaly is very rare but potentially life-threatening. Yamanaka and Hobbs have reported that it only occurs in 0.004% cases of patients who underwent invasive CAG in a case study involving 126,595 patients.[4]
In a case report by Deora et al., the patient had the origin of all coronary arteries separately from the right coronary cusp with an atherosclerotic lesion in RCA and anomalous course of LAD (type B), but in this case, there is a single ostial origin and all three arteries are diseased.[5]
Another case by Asciutto et al. has shown the separate origin of all three coronaries from the right sinus of Valsalva with a moderate disease in RCA and significant disease in the LAD which was successfully treated with percutaneous coronary intervention with a drug-eluting stent.[6]
Recently, a similar case was reported by Nesheiwat et al. with a common origin of all three coronaries from the right coronary cusp with a nonmalignant course of LAD as in our case. However, the patient had a recent myocardial infarction with severe left ventricular systolic dysfunction and the disease was not involving the osteoproximal segment as in our case and was managed medically.[7]
SOCA is rarely encountered in CAG and prognosis depends on the angle of the origin, course of the coronaries, and any associated atherosclerosis. CCTA played a pivotal role to delineate the complex coronary anatomy of this case. Delineation of the proximal course is very important and requires the utilization of CCTA as a part of the full evaluation of SOCA.
The stenosis in anomalous coronaries is usually due to atherosclerosis but may also be due to altered ostial configuration, acute takeoff angle, and hypoplastic or stretched coronary segment. An analysis from the CASS study showed that the risk of stenosis is increased in anomalous circumflex coronary arteries as compared to nonanomalous arteries in age- and gender-matched control patients.[8] The degree of atherosclerosis may also be high in anomalous coronaries because of increased stress on the coronary arterial wall.[9],[10]
| Conclusion | | |
SOCA is very rarely seen in routine clinical practice. The atypical origin and unusual passage of the coronary arteries can be asymptomatic for many years. With time, the addition of atherosclerotic complications exacerbates the symptoms and complicates the clinical picture. The new imaging modalities that have emerged, enable the accurate visualization of anatomical configurations and the detection of structural malformations. The choice of the revascularization method is difficult and the associated technical difficulties increase the procedural risk of surgical and percutaneous coronary revascularization.
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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| 2. | Shirani J, Roberts WC. Solitary coronary ostium in the aorta in the absence of other major congenital cardiovascular anomalies. J Am Coll Cardiol 1993;21:137-43. |
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| 4. | Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28-40. |
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| 8. | 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;13:531-7. |
| 9. | Hutchins GM, Miner MM, Boitnott JK. Vessel caliber and branch-angle of human coronary artery branch-points. Circ Res 1976;38:572-6. |
| 10. | Wilkins CE, Betancourt B, Mathur VS, Massumi A, De Castro CM, Garcia E, et al. Coronary artery anomalies: A review of more than 10,000 patients from the Clayton Cardiovascular Laboratories. Tex Heart Inst J 1988;15:166-73. |
[Figure 1], [Figure 2], [Figure 3]
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