Letter to the Editor Left coronary artery receiving collateral circulation from an anomalous originating right coronary artery. Clinical and procedural implications of a rare case report George Latsios, Dimitris Tousoulis ⁎, Kyriakos Dimitriadis, Nikolaos Papageorgiou, Costas Tsioufis, Kostas Toutouzas, Christodoulos Stefanadis First Department of Cardiology, University of Athens, Hippokration Hospital, Athens, Greece article info Available online 18 February 2011 Keywords: Coronary artery disease Coronary circulation Collateral circulation Congenital anomaly Coronary artery anomalies exist in 0.3% (autopsy series) to 1.3% (angiographic series) of patients [1–4]. We describe the case of a middle-aged man, suffering from typical angina pectoris with an anomalous origin of all coronary arteries from the left sinus of Valsalva (LSOV) and proximal occlusion of left anterior descending (LAD) artery with collateral supply by the right coronary artery (RCA). A 61 year old man, hypertensive, diabetic, dyslipidemic and smoker, was referred to our hospital for coronary artery catheterization, due to recent onset crescendo angina. His symptoms had begun 4 months before admission, and worsened despite maximal anti-anginal drug therapy. Physical examination, in regards to cardiovascular as well as other systems, was unremarkable for any pathology. A resting ECG and a transthoracic ultrasound exam were also well within normal range, except of concentric left ventricular hypertrophy. During catheterization, a Judkins Left 4 catheter engaged unevent- fully the ostium of the left main coronary artery (LMCA) in its usual anatomic location in the LSOV. On subsequent injections, it was shown that LMCA had a 70% stenosis in the distal part and LAD was proximally occluded, whereas the 1st obtuse marginal had a proximal 70% stenosis. However, we were unable to engage the right coronary ostium with the usual JR 4 catheter. An injection in the aortic root in LAO projection revealed the existence of an anomalous RCA originating from the LSOV (Fig. 1), which we subsequently engaged with a Judkins Left 3.5 catheter. Multiple injections revealed that the RCA originated from a separate ostium located posteriorly to the ostium of the normal LAD and had a 70% stenosis in the middle part and 60% distally. Most importantly, injection of the RCA resulted in opacification of large conductive collateral arteries arising from the donor RCA and supplying the occluded LAD, with opacification of the coronary sinus indicating complete collateral artery filling (Fig. 2a and b). The left ventriculo- graphy revealed a normal ejection fraction, without regional wall motion abnormalities. Our patient underwent surgical revascularization for his obstructive coronary heart disease and is free from any symptoms during the follow-up period of 6 months since the procedure. Anomalous origin of the LMCA from the right sinus of Valsalva (RSOV) represents a small fraction of congenital coronary artery anomalies, with an overall prevalence of about 1–2 per 10,000 patients that undergo diagnostic cardiac catheterization [4,5]. Much less common is the origin of the right coronary artery (RCA) from the left sinus of Valsalva (LSOV) and even lesser common from the left coronary artery itself, with only a few cases reported in the literature [6–8]. As already has been discussed elsewhere [9,10] the various anatomic courses are considered benign, with the exception of the intra-arterial. Briefly, the RCA passes between the aortic root and the pulmonary International Journal of Cardiology 153 (2011) e22–e23 ⁎ Corresponding author at: Athens University Medical School, Hippokration Hospital, Vasilissis Sofias 114, 115 28 Athens, Greece. Tel.: +30 2132088000; fax: +30 2132088676. E-mail address: drtousoulis@hotmail.com (D. Tousoulis). Fig. 1. Contrast injection in the aortic root in LAO projection revealed existence of an anomalous right coronary artery (RCA) originating from the LSOV, besides the left coronary artery (LCA). The two coronary ostia are marked inside the circle. 0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.01.089 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard