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Imaging
Origin of All Three Coronary Arteries from One
Aortic Sinus with Multiple Separate Ostia Peiman Jamshidi is Director of Cardiology in
This rare anomaly is similar to a single coronary artery. There is
Kontonsspital Lucerne in Switzerland. Prior to this
role he served as a senior cardiologist in the same
absence of a coronary ostium in either the left or right aortic sinus.
institution. Dr Jamshidi graduated from medical school
The missing vessels arise in the contralateral aortic sinus, but in 1990, then continued his studies in internal
instead of arising as a single coronary artery they arise through two
medicine and cardiology at Iran University in Tehran,
and subsequently served as an Assistant Professor
or even three separate ostia.
of Cardiology in Tabriz University Hospital in Iran
until 2002.
High Anterior Origin of the Right Coronary Artery
Paul Erne is Head of the Department of Cardiology at
This anomaly is commonly encountered but of no haemodynamic
the Luzerner Kantonsspital Luzern in Switzerland, a
significance. The inability to engage the ostium of the RCA selectively position he has held since 1991. Since 1996 he has also
from conventional catheter manipulation raises the question of this
served as a Professor of Medicine at the University of
Basel. Dr Erne completed studies in chemistry and
superior origin of the RCA above the sinotubular ridge. Forceful non-
medicine at the University of Basel before specialising
selective injection of contrast medium into the right sinus of Valsalva in internal medicine and cardiology in Switzerland,
may reveal the anomalous take-off of the RCA, which can then be
England and the US between 1978 and 1988.
selectively engaged with an amplatz left catheter (see Figure 3). ■
1. Johnsrude CL, Perry JC, Cecchin F, et al., Differentiating adults, J Thorac Cardiovasc Surg, 1977;73:887–93. aortic origin of coronary arteries, Circulation, 1978;58:
anomalous left main coronary artery originating from the 7. Cheitlin MD, DeCastro CM, McAllister HA, Sudden death 606–15.
pulmonary artery in infants from myocarditis and dilated as a complication of anomalous left coronary origin from 14. Serota H, Barth CW III, Seuc CA, et al., Rapid identification
cardiomyopathy by electrocardiogram, Am J Cardiol, the anterior sinus of Valsalva, a not-so-minor congenital of the course of anomalous coronary arteries in adults:
1995;75:71–4. anomaly, Circulation, 1974;50:780–87. The “dot and eye” method, Am J Cardiol, 1990;65:891–8.
2. Levin DC, Fellows KE, Abrams HL, Hemodynamically 8. Liberthson RR, Dinsmore RE, Fallon JT, Aberrant coronary 15. Fernandes F, Alam M, Smith S, et al., The role of
significant primary anomalies of the coronary arteries: artery origin from the aorta: Report of 18 patients, review transesophageal echocardiography in identifying
Angiographic aspects, Circulation, 1978;58:25–34. of literature and delineation of natural history and anomalous coronary arteries, Circulation, 1993;88:2532–40.
3. Holley DG, Sell JE, Hougen TJ, et al., Pulsed Doppler management, Circulation, 1979;59:748–54. 16. Lipton MJ, Barry WH, Obrez I, et al., Isolated single
echocardiographic and color flow imaging detection of 9. Roberts WC, Major anomalies of coronary arterial origin coronary artery: Diagnosis, angiographic classification,
retrograde filling of anomalous left coronary artery from seen in adulthood, Am Heart J, 1986;111:941–63. and clinical significance, Radiology, 1979;130:39–47.
the pulmonary artery, J Am Soc Echocardiogr, 1992;5:85–8. 10. Roberts WC, Siegel RJ, Zipes DP, Origin of the right 17. Click RL, Holmes DR Jr, Vlietstra RE, et al., Anomalous
4. Houston AB, Pollock JC, Doig WB, et al., Anomalous origin coronary arterial from the left sinus of Valsalva and its coronary arteries: Location, degree of atherosclerosis and
of the left coronary artery from the pulmonary trunk: functional consequences: Analysis of 10 necropsy effect on survival-a report from the Coronary Artery
elucidation with colour Doppler flow mapping, Br Heart J, patients, Am J Cardiol, 1982;49:863–8. Surgery Study, J Am Coll Cardiol, 1989;12:531–7.
1990;63:50–54. 11. Kragel AH, Robers WC, Anomalous origin of either the 18. Page HL Jr, Engel HJ, Campbell WB, et al., Anomalous
5. Jureidini SB, Nouri S, Crawford CJ, et al., Reliability of right or left main coronary artery from the aorta with origin of the left circumflex coronary artery: Recognition,
echocardiography in the diagnosis of anomalous origin of subsequent coursing between aorta and pulmonary trunk: angiographic demonstration and clinical significance,
the left coronary artery from the pulmonary trunk, Am Analysis of 32 necropsy cases, Am J Cardiol, 1988;62:771–7. Circulation, 1974;50:768–73.
Heart J, 1991;122:61–8. 12. Brandt B III, Martins JB, Marcus ML, Anomalous origin of 19. Angelini P, Velasco JA, Flamm S, Coronary anomalies:
6. Wilson CL, Dlabal PW, Holeyfield RW, et al., Anomalous the right coronary artery from the left sinus of Valsalva, incidence, pathophysiology, and clinical relevance,
origin of left coronary artery from pulmonary artery: Case N Engl J Med, 1988;309:596–8. Circulation, 2002;105:2449–54.
reports and review of literature concerning teenagers and 13. Kimbiris D, Iskandrian AS, Segal BL, et al., Anomalous
Related Article
The Role of Transesophageal Echocardiography in Identifying Anomalous Coronary Arteries
Fernandes F, et al., Circulation, 1993;88:2532–40.
The study objective was to evaluate the role of transoesophageal the course of the anomalous left main coronary artery between the
echocardiography in identifying the origin of anomalous coronary aorta and pulmonary artery better than angiography. Other
arteries and confirming their course in relation to the great vessels. anomalies that were visualised included two patients with origin of
The diagnosis of coronary anomalies is made by angiography. The the right coronary arteries from the left aortic sinus, one patient
anomalous left main artery with a course between the pulmonary with origin of the left anterior descending from the right sinus, one
artery and the aorta has been associated with myocardial patient with origin of circumflex from the right sinus, and one
infarction and sudden death. The course of these anomalous patient with origin of the left main coronary artery from the
coronary arteries is difficult to demonstrate by angiography alone. pulmonary artery.
Nine patients with angiographically confirmed anomalous coronary
arteries were studied by transoesophageal echocardiography with Transoesophageal echocardiography is a useful non-invasive test
colour flow Doppler. The abnormal origin of the anomalous for diagnosing anomalous origin of the coronary arteries.
coronary arteries was confirmed by transoesophageal Furthermore, it is a valuable adjunct to angiography in
echocardiography in all nine patients. In four patients, the left main demonstrating the abnormal course of the left main coronary
coronary artery originated from the right sinus of Valsalva. In all of artery interposed between the aorta and the pulmonary artery, a
these patients, transoesophageal echocardiography demonstrated potentially life-threatening entity. ■
14 EUROPEAN CARDIOLOGY
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