Images in CAD 281
Images in CAD Coronary Artery Disease 2015, 26:281–282
Type I dual left anterior descending coronary artery anomaly presenting with non-ST-segment elevation myocardial infarction, initially mimicking normal coronary angiogram Ji Bak Kim, Jae Joong Lee and Eung Ju Kim, Department of Cardiology, Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea Correspondence to Eung Ju Kim, MD, PhD, Department of Cardiology, Cardiovascular Center, Korea University Guro Hospital, 80, Guro-dong, Guro-gu, Seoul 152-703, Korea Tel: + 82 2 2626 3020; fax: + 82 2 864 3062; e-mail: [email protected]
A 50-year-old woman presented to our hospital with chest pain. ECG showed right bundle branch block without ST-segment elevation, and cardiac enzymes were elevated (CK-MB/troponin-T 87.2/0.06 ng/ml). Transthoracic echocardiography (see Video, Supplemental digital content 1, http://links.lww.com/MCA/ A25) showed isolated mid anteroseptal wall akinesia, whereas other myocardial segments were normal (Fig. 1a–c). The patient was diagnosed with non-STsegment elevation myocardial infarction and admitted to the coronary care unit.
Received 29 November 2014 Accepted 3 December 2014
Fig. 1
(a)
(c)
(b) V
V
V 5
5 5 10
10 10 15
(d)
(e)
(f)
Transthoracic echocardiography shows reduced motion of the mid anteroseptal wall on the parasternal short axis (a), apical four-chamber (b), and apical three-chamber view (c). White lines indicate the isolated segment of reduced wall motion. Initial coronary angiography in the right anterior oblique views with cranial (d) and caudal (e) angulation resembles normal coronary arteries. However, the angiography of the right coronary artery shows extensive collateral supply to the short left anterior descending coronary artery (arrows) (f).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.coronary-artery.com). 0954-6928 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/MCA.0000000000000211
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
282 Coronary Artery Disease 2015, Vol 26 No 3
Fig. 2
Baseline (a) and postintervention (b) coronary angiography in the anteroposterior–cranial view. After stent implantation, the coronary blood flow to the short left anterior descending artery that provides the septal branches was restored.
A severe lesion in the left anterior descending artery (LAD) was expected, however, on the initial coronary angiography (see Video, Supplemental digital content 2, http://links.lww.com/MCA/A26) the LAD appeared to be free of any lesions (Fig. 1d and e). However, on the right coronary angiography, mild opacification of distal LAD was noted through collateral flow originating from the posterior left ventricular branch of the right coronary artery (Fig. 1f, arrow). Thus, under suspicion of obstruction of a big septal branch, a percutaneous coronary intervention was performed. An Orsiro stent (hybrid sirolimus-eluting stent; Biotronik, Bülach, Switzerland) was implanted at the proximal segment of the branch. In the follow-up angiogram after stent implantation, many septal branches originated from the recannalized branch; thus, the branch turned out to be a major epicardial vessel, one of the dual LADs (Fig. 2). The short LAD was relatively small, and ended before reaching the apex, whereas the other long LAD passed by the short LAD, supplying the apex. These findings indicated a type I dual LAD system. The patient had an uneventful recovery without any other complication and was discharged 3 days after the procedure. The dual LAD is a congenital anomaly of the coronary artery, defined as the existence of two LADs that supply different parts of the anterior interventricular sulcus, and are reported from 1 to about 4% [1,2]. Traditionally, it has been classified into four subtypes [1]; recently, more subtypes have been reported [2]. Among these, type I dual LAD is the most common type, which occupies about 86% of the total dual LAD cases [2]. In type I dual LAD, the short LAD runs along the anterior interventricular sulcus but does not reach the apex and the
long LAD enters to the distal sulcus, and supplies the apex. In a case of dual LAD, both arteries have distinct areas to supply and are related to left ventricular function. Therefore, it is important to know the existence of dual LAD for successful revascularization. In the present case, total occlusion of the short LAD in type I dual LAD was identified. As the long LAD was intact, this case could be misinterpreted as normal. Actually, cases of initially unrecognized dual LAD have been reported that turned out to be abnormal during follow-up angiography or surgery [1,3]. However, isolated mid anteroseptal wall akinesia and collateral circulation originating from the right coronary artery provided crucial information, making successful revascularization of the short LAD possible. Therefore, in conclusion, if isolated wall motion abnormality in the left ventricular septal wall is present, total occlusion of the short LAD in dual LAD should be considered even though the initial coronary angiogram appears normal.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2
3
Spindola-Franco H, Grose R, Solomon N. Dual left anterior descending coronary artery: angiographic description of important variants and surgical implications. Am Heart J 1983; 105:445–455. Bozlar U, Uğurel MS, Sarı S, Akgün V, Örs F, Taşar M. Prevalence of dual left anterior descending artery variations in CT angiography. Diagn Interv Radiol 2014. [Epub ahead of print]. Andreou AY, Andreou AY, Andreou AY, Ioannides MA, Georgiou GM, Avraamides PC. Angiographically ‘missing’ coronary artery: occluded or aberrant? J Card Surg 2013; 28:278–279.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
Images in CAD Coronary Artery Disease 2015, 26:281–282
Type I dual left anterior descending coronary artery anomaly presenting with non-ST-segment elevation myocardial infarction, initially mimicking normal coronary angiogram Ji Bak Kim, Jae Joong Lee and Eung Ju Kim, Department of Cardiology, Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea Correspondence to Eung Ju Kim, MD, PhD, Department of Cardiology, Cardiovascular Center, Korea University Guro Hospital, 80, Guro-dong, Guro-gu, Seoul 152-703, Korea Tel: + 82 2 2626 3020; fax: + 82 2 864 3062; e-mail: [email protected]
A 50-year-old woman presented to our hospital with chest pain. ECG showed right bundle branch block without ST-segment elevation, and cardiac enzymes were elevated (CK-MB/troponin-T 87.2/0.06 ng/ml). Transthoracic echocardiography (see Video, Supplemental digital content 1, http://links.lww.com/MCA/ A25) showed isolated mid anteroseptal wall akinesia, whereas other myocardial segments were normal (Fig. 1a–c). The patient was diagnosed with non-STsegment elevation myocardial infarction and admitted to the coronary care unit.
Received 29 November 2014 Accepted 3 December 2014
Fig. 1
(a)
(c)
(b) V
V
V 5
5 5 10
10 10 15
(d)
(e)
(f)
Transthoracic echocardiography shows reduced motion of the mid anteroseptal wall on the parasternal short axis (a), apical four-chamber (b), and apical three-chamber view (c). White lines indicate the isolated segment of reduced wall motion. Initial coronary angiography in the right anterior oblique views with cranial (d) and caudal (e) angulation resembles normal coronary arteries. However, the angiography of the right coronary artery shows extensive collateral supply to the short left anterior descending coronary artery (arrows) (f).
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.coronary-artery.com). 0954-6928 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/MCA.0000000000000211
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
282 Coronary Artery Disease 2015, Vol 26 No 3
Fig. 2
Baseline (a) and postintervention (b) coronary angiography in the anteroposterior–cranial view. After stent implantation, the coronary blood flow to the short left anterior descending artery that provides the septal branches was restored.
A severe lesion in the left anterior descending artery (LAD) was expected, however, on the initial coronary angiography (see Video, Supplemental digital content 2, http://links.lww.com/MCA/A26) the LAD appeared to be free of any lesions (Fig. 1d and e). However, on the right coronary angiography, mild opacification of distal LAD was noted through collateral flow originating from the posterior left ventricular branch of the right coronary artery (Fig. 1f, arrow). Thus, under suspicion of obstruction of a big septal branch, a percutaneous coronary intervention was performed. An Orsiro stent (hybrid sirolimus-eluting stent; Biotronik, Bülach, Switzerland) was implanted at the proximal segment of the branch. In the follow-up angiogram after stent implantation, many septal branches originated from the recannalized branch; thus, the branch turned out to be a major epicardial vessel, one of the dual LADs (Fig. 2). The short LAD was relatively small, and ended before reaching the apex, whereas the other long LAD passed by the short LAD, supplying the apex. These findings indicated a type I dual LAD system. The patient had an uneventful recovery without any other complication and was discharged 3 days after the procedure. The dual LAD is a congenital anomaly of the coronary artery, defined as the existence of two LADs that supply different parts of the anterior interventricular sulcus, and are reported from 1 to about 4% [1,2]. Traditionally, it has been classified into four subtypes [1]; recently, more subtypes have been reported [2]. Among these, type I dual LAD is the most common type, which occupies about 86% of the total dual LAD cases [2]. In type I dual LAD, the short LAD runs along the anterior interventricular sulcus but does not reach the apex and the
long LAD enters to the distal sulcus, and supplies the apex. In a case of dual LAD, both arteries have distinct areas to supply and are related to left ventricular function. Therefore, it is important to know the existence of dual LAD for successful revascularization. In the present case, total occlusion of the short LAD in type I dual LAD was identified. As the long LAD was intact, this case could be misinterpreted as normal. Actually, cases of initially unrecognized dual LAD have been reported that turned out to be abnormal during follow-up angiography or surgery [1,3]. However, isolated mid anteroseptal wall akinesia and collateral circulation originating from the right coronary artery provided crucial information, making successful revascularization of the short LAD possible. Therefore, in conclusion, if isolated wall motion abnormality in the left ventricular septal wall is present, total occlusion of the short LAD in dual LAD should be considered even though the initial coronary angiogram appears normal.
Acknowledgements Conflicts of interest
There are no conflicts of interest.
References 1
2
3
Spindola-Franco H, Grose R, Solomon N. Dual left anterior descending coronary artery: angiographic description of important variants and surgical implications. Am Heart J 1983; 105:445–455. Bozlar U, Uğurel MS, Sarı S, Akgün V, Örs F, Taşar M. Prevalence of dual left anterior descending artery variations in CT angiography. Diagn Interv Radiol 2014. [Epub ahead of print]. Andreou AY, Andreou AY, Andreou AY, Ioannides MA, Georgiou GM, Avraamides PC. Angiographically ‘missing’ coronary artery: occluded or aberrant? J Card Surg 2013; 28:278–279.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
