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SUMMARY

The anomalous origin of the left circumflex coronary artery from the right sinus of Valsalva is a relatively common anatomical variation. Its recognition and angiographic demonstration assumes high priority for an adequate management of patients conducted to percutaneous coronary intervention. We describe a patient with diagnosis of inferior myocardial infarction and anomalous origin of the left circumflex coronary artery from the right sinus of Valsalva, detected by invasive coronary angiography and further multislice computed tomography coronary angiography.

Key words:Anomalous origin. Left circumflex artery. Coronary angiography. Multislice computed tomography.

Rev Fed Arg Cardiol. 2012; 41(2): 128-129

INTRODUCTION
The identification of anomalies of the coronary arteries by invasive coronary angiography is reported in 0.6% to 1.5%, from which the origin of the left circumflex coronary artery of the right Valsalva sinus is one of the most common ones [1]. However, its identification is crucial for the management of patients with coronary artery disease [2]. Most of these coronary anomalies are clinically asymptomatic. Nevertheless, myocardial ischemia may occur due to the more aggressive development, and at earlier stages, of atherosclerosis [3].

It has been pointed out that conventional coronary angiography may cause some diagnostic problems in the three-dimensional identification of the course of the anomalous artery [4]. In this regard, multislice computerized tomography (MSCT) helps to a better visualization of the proximal portion, size, course and relationship of the anomalous vessel with the surrounding structures [5].

We present a patient with diagnosis of inferior infarction and anomalous origin of the left circumflex coronary artery of the right Valsalva sinus, detected by invasive coronary angiography and later by angiography by multislice computerized tomography.

CLINICAL CASE
Female, 49-year-old patient with history of rheumatoid arthritis that presents with symptoms of acute myocardial infarction (AMI) with ST elevation in the inferior side, with successful reperfusion by thrombolysis with recombinant streptokinase. In her evolution she presents post-AMI angina. For this reason invasive coronary angiography is carried out, where the anomalous origin ofthe left Circumflex artery (Cx) is detected, starting in the right Valsalva sinus with ostium independent from the right coronary artery (RCA), which is the culprit artery for the infarction. Percutaneous coronary intervention (PCI) is made, with placement of conventional stent in the proximal RCA with success. In her evolution she presents angina in her 9-month evolution. Coronary angiography by multislice computerized tomography (MSCT) is made, with intrastent restenosis being detected and progression of the pre-stent atherosclerotic disease (Figure 1), besides with a very closed or sharp angle being evident, after the anomalous origin of the Cx, thus confirming the findings obtained during invasive coronary angiography in her previous admittance (Figure 2).

Figure 1: A: Volumetric reconstruction, Cx and RCA (arrow) emerging from the right coronary sinus. B: Volumetric reconstruction, origin of a single vessel (upper right corner) of the left coronary sinus (arrow).

Figure 2: C:Projection of maximum intensity where pre-stent non-significant soft plaque is observed (arrow head). D:Projection of maximum intensity with stent reconstruction (arrow) that shows intra-stent restenosis. Check the marked angulation of the Cx from its anomalous origin.

DISCUSSION
Although the anomalous origin of the Cx of the right Valsalva sinus is classified as benign and asymptomatic, its culpability in the development of AMI has been described recently [6]. In our case, the patient presented an inferior AMI, with the RCA being responsible for the acute coronary symptoms, and not the anomalous origin of the Cx, being treated by implantation of the conventional stent.

The test performed subsequently by MSCT provided new data about the coronary anomaly that were not detected by invasive coronary angiography (anomalous origin of the Cx with a very closed or sharp angle). In this regard, it has been pointed out that ischemic manifestations could be due to an unusual angulation of the artery due to the retro-aortic course of the Cx, which may compress the coronary ostium and restrict blood flow this way [2]. (Figures 1A and 2C).

Recently, Mendoza-Rodríguez et al. have shown an excellent sensibility and specificity in the diagnosis of coronary stent restenosis with the use of MSCT [7]. The diagnostic approach by noninvasive coronary angiography at the time of the angor episode presented by this patient allowed a proper diagnosis of restenosis of the stent previously placed in the RCA. When ruling out the participation of the anomalous origin in the posterior angina symptoms, it was decided to just optimize the medical treatment.

REFERENCES

1. Dursunoğlu D, Özalp G, Taşköylü Ö, et al. Anomalous origin of the left circumflex coronary artery: A case report. Exp Clin Cardiol 2007; 12: 207-208.
2. Papadopoulos DP, Dalianis N, Benos I, et al. Anomalous origin of circumflex artery from right sinus of Valsalva: A rare cause of non-ST elevation syndrome. Int J Cardiol 2007; 114: 105-106.
3. Tedeschi C, De Rosa R, Ratti G, et al. Anomalous origin of the circumflex artery from the right aortic sinus: assessment with conventional coronary angiography and multislice computed tomography. G Ital Cardiol 2008; 9: 421-424.
4. Carmelo V, Toste J, Castela S, et al. Anomalous Origin of the Circumflex Coronary Artery - Two Case Reports. Rev Port Cardiol 2007; 26: 789-793.
5. Dattiloa G, Lamaria A, Messinab F, et al. The chance finding at multislice computed tomography coronary angiography of an ectopic origin of the left circumflex coronary artery from the right sinus of Valsalva. Int J Cardiol 2011; 149: 43-46.
6. Grasso AE, Pennell DJ. Myocardial infarction related to aberrant left circumflex artery, Int J Cardiol 2010; 138: 51-52.
7. Mendoza-Rodríguez V, Llerena LR, Olivares-Aquiles EW, et al. Precisión de la tomografía de 64 cortes en el diagnóstico de re-estenosis de stent coronario. Arch Cardiol Mex 2011; 81: 3-10.

Publication: June 2012