Anomalies

Anomalous Left Coronary Artery From the Right Coronary Cusp

Pradnya Brijmohan Bhattad,1 MD; Vinay Jain,2 MD; Mohit Bhasin,3 MD

1Resident, Department of Internal Medicine, East Tennessee State University, Tennessee; 2Attending Radiologist, Department of Radiology, James H. Quillen Veterans Affairs Medical Center, Mountain Home, Tennessee; 3Cardiologist, Innovation Health Services, Norfolk, Virginia

Pradnya Brijmohan Bhattad,1 MD; Vinay Jain,2 MD; Mohit Bhasin,3 MD

1Resident, Department of Internal Medicine, East Tennessee State University, Tennessee; 2Attending Radiologist, Department of Radiology, James H. Quillen Veterans Affairs Medical Center, Mountain Home, Tennessee; 3Cardiologist, Innovation Health Services, Norfolk, Virginia

A 57-year-old male with a history of hypertension, end-stage renal disease on hemodialysis, and diabetes mellitus type 2 was found to have an anomalous left coronary artery on coronary angiography that was initially performed for the evaluation of obstructive coronary disease.

Coronary angiography showed an anomalous left coronary artery arising from the right cusp, sharing an ostium directly adjacent to the right coronary artery. The large main coronary artery comes off the right coronary cusp, then bifurcates into large anterior descending and circumflex systems. A vestigial small left main coronary artery off the left coronary cusp that feeds no significant ventricular branches was noted on coronary angiography.

CT angiography (CTA) of the coronaries and great vessels with contrast was done to evaluate the course of the left main coronary artery as it related to the aorta and pulmonary artery. It demonstrated the following interesting findings:

  • A single coronary arising from the right coronary cusps that bifurcates into the right coronary artery and left main. The left main artery courses anterior to the pulmonary artery at the level of the pulmonic valve to the anterior interventricular groove, where it bifurcates into the left anterior descending and left circumflex vessel. This represents a benign non-arterial course.
  • Calcification of the left main is severe.
  • Foci of severe calcified plaque are noted in the mid distal left anterior descending, the proximal, mid and distal left circumflex, and obtuse marginal branches as well.
  • The right coronary artery exhibits circumferential severe calcified plaque. There is severe left main and right coronary artery calcified plaque with associated blooming artifact limiting stenosis estimation.
  • Left ventricular ejection fraction is calculated at 68%, with no evidence of regional wall motion abnormalities.
  • Total calcium score is 5222, placing the patient in 99th percentile based on age and gender, indicating extensive plaque burden, with high cardiovascular risk long term and for cardiovascular events over the next 10 years.
  • A single-vessel coronary anomaly from the right cusp giving rise to the left main, which courses anterior to the pulmonary artery to the anterior interventricular groove with a nonmalignant inter-arterial course, can be identified in the CTA images (Figures 1-6). 

Disclosures: The authors report no external funding source for this study and no conflicts of interest.

Verbal informed consent was obtained from the patient for their anonymized information to be published in this article.

The authors can be contacted via Pradnya Brijmohan Bhattad, MD, at pradnyabhattad20@gmail.com.