Coronary

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ERIC

Artery

Anomaly

J. UDOFF,1

in Double-Outlet

JEAN-MICHEL

ROLAND,2

surgical

correction.

On

the

our review of the literature, coronary artery visualization such patients.

of

this

report

girl,

and

revealed

product of a normal At age 1 month, cyanosis

a ventricular

septal

defect

to-right shunt. Digoxin was continued. pulmonary artery was banded because heart

failure,

and

catheterization

digoxin

was

fullwas

with

a 2.3:1

At age 8 months, the of persistent congestive

stopped.

A second

at age 3’/2 years revealed

cardiac

a double-outlet

right

component.

Electrocardiography

rhythm

diography

suggested

by the aorta. outlet

right

same

level

with

in both

bilateral

conus

systole.

The

was

main

demonstrated

right ventricular overriding of the

Angiocardiography ventricle

with

14

frontal

and

widely

patent

pulmonary

Echocamseptum

a classic

and pulmonary

lateral

was

double-

valves

projections

in diastole,

artery

nor-

hypertrophy. interventricular

demonstrated

the aortic

at the

(fig.

but

1). A

narrower

in

from

the

narrowed

previous banding. Aortography demonstrated the circumflex coronary artery to arise from the left coronary cusp, while the left anterior descending coronary artery originated from the right coronary artery and crossed over the outflow tract leading to the pulmonary artery (fig. 2).

branching

of

coronary

been

seen

in many

have

artery types

origin

in

2%-5%

Received I 2

Am

Division Division

of

patients

heart

December

lesions

J Ro.ntg$nol

131

tetralogy

associated

6, 1977; accepted

of Cardiovascular of Cardiovascular

© 1978 American

with

:710-712,

Roentgen

Radiology, Pediatrics, Octob$r

Ray Society

One

898,

of congenital

after Johns Johns 1978

patient

two

anterior

descending

Total

correction

coronary

artery.

for tetralogy of Surgery 74:894-

1973

2. Edwards reference

JE:

Anomalous

coronary

to arteriovenous-li

Fallot.

Other

artery

4. Fellows

Hopkins Hopkins

DC:

anomalous

coronary

revision

had

McGoon

with

tion 17:1001-1006, 3. Elliott LP, Amplatz terns in transposition 1966

of

with

BE,

Fallot

and

heart disease [1-9]. In tetmalogy of Fallot, one autopsy study [8] demonstrated a 9% incidence of anomalous coronary arteries. Angiographic and surgical series [4J have revealed incidences of coronary artery anomalies congenital

cases.

1 . Berry

patterns

transposition

REFERENCES

Discussion

Anomalous

corrected

coronary branches, one each from the left and right coronary cusps. In another patient, the right coronary artery arose as a branch of the left coronary artery, and an accessory anterior descending artery came from the right coronary cusp. The incidence of anomalous coronary arteries is well established in tetralogy of Fallot, but the incidence in patients with double-outlet right ventricle has not been described prospectively. If the origin and course of the coronary arteries are not identified at preoperative yentniculography, then aortography is recommended. Aomtography with filming in the anteropostenior and lateral projection adds little time to the study; these are the most useful projections for identification of the coronary arteries.

thrill. A 4/6 harsh systolic ejection murmur was heard all over the chest, maximally at the left sternal border. There was no mal sinus

and

single ventricle with transposition double-outlet right ventricle [3].

,

left-

ventricle with the pulmonary and aortic valves at the same level and no aortomitral continuity. The child was readmitted for evaluation for surgical repair. Physical examination revealed an active precordium without a

diastolic

complete

,

the

term delivery (3.2 kg at birth). seen with crying. By 2 months, the child experienced congestive heart failure and was begun on digoxin. Cardiac catheterization at 3 months

include

JR.1

In our patient, the anterior descending coronary artery branch arose from the right coronary artery, crossed over the right ventricular pulmonary outflow tract, and descended normally in the anterior interventricular groove. In its position on the right ventricular outflow tract, it could be damaged during total surgical repair [7]. High surgical morbidity and mortality have been experienced when an anomalous coronary artery has been injured during cardiac surgery in patients with tetralogy of Fallot and anomalous coronary arteries [1 4 5, 7]. Our patient also seems at risk since the size of the right ventniculotomy would be limited in order to avoid the left anterior descending coronary artery. In this instance a Rastelli-type right ventricle-to-pulmonary artery conduit bypassing the right ventricular outflow tract may be preferable to infundibular resection. In a postmortem study of double-outlet right ventricle, Elliott et al. [3] found two coronary artery anomalies in

Report was

Ventricle

I. WHITE,

of the great arteries, of great arteries, and

we suggest that preoperative be obtained routinely in all

Case P. A., a 9’/s-year-old

basis

ROBERT

anomalies

An anomalous coronary artery distribution exists in 2%9% of patients with tetralogy of Fallot [1-9] and less commonly with other types of congenital heart disease [3]. This report describes an anomalous origin of the anterior descending coronary artery from the right coronary artery in a child with a double-outlet right ventricle. Prior knowledge of this anomaly may alter the technique of

AND

Right

arteries

ke communications.

with

special Circula-

1958

K, Edwards complexes.

KE, Freed

MD,

Keane

JE: Coronary

arterial

Am J Cardiol

17 : 362-378,

JF, Van

Praagh

pat-

R, Bernhard

May 3, 1978. Medical Medical

Institutions, Institutions,

Baltimore, Baltimore,

710

Maryland Maryland

21205. 21205.

Address

reprint

0361 -803X/78/

requests

1 000

to E. J. Udoff.

-

071 0 $00.00

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CASE

Fig.

1.-Biplane

great arteries

right

from right

Fig. 2. - Biplane aortogram. artery (white arrow). Separate base of pulmonary valve.

ventriculogram. ventricle.

Anteroposterior

Pulmonary

Anteroposterior circumflex

artery

REPORTS

(A) and band

lateral

(white arrow)

(A) and lateral (B) radiographs

coronary

artery

arises

from

(B) radiographs and infundibular

71 1

demonstrate

narrowing

reveal origin of anterior left coronary cusp (black arrow).

typical

double-outlet origin are present.

of both

(black arrow)

descending Anterior

coronary descending

artery coronary

from

right

artery

coronary crosses

at

712

CASE

WF, Castaneda nary angiography

AC: Results in tetralogy

of routing preoperative coroof Fallot. Circulation 51 :561-

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566, 1975 5. Gadboys HL, Slomin R, Litwak RS: Trecherous coronary artery. Am J Cardiol 8 : 854-858, 1961

anomalous

6. Koops B, Kerber RE, Wexier L, Green RA: Congenital coronary artery anomalies. JAMA 226 : 1425-1429, 1973 7. Longnecker LG, Reemtsma K, Creech D Jr: Anomalous

REPORTS

coronary artery distribution associated with tetralogy of Fallot: hazard in open cardiac repair. J Thorac Cardiovasc Surg 42:258-262, 1961 8. Meng CCL, Eckner FAD, in tetralogy of Fallot.Arch

Lev M: Coronary artery distribution Surg 90:363-366, 1965

9. White RI Jr, Frech RS, Castaneda A, Amplatz K: The nature and significance of anomalous coronary arteries in tetralogy of Fallot. Am J Roentgenol 1 14 :350-354, 1972