International Journal of Clinical Medicine, 2011, 2, 269-271
doi:10.4236/ijcm.2011.23043 Published Online July 2011 (http://www.SciRP.org/journal/ijcm)
269
Anomalous Origin of the Right Coronary Artery
from the Left Sinus Valsalva with Coronary
Ectasia
Nihat Söylemez1, Recep Demirbağ1, Tuncay Hazırolan2, Onur Akpınar3*
1Department of Cardiology, Harran University, Şanlıurfa, Turkey; 2Department of Radiology, Hacettepe University, Ankara, Turkey;
3Department of Cardiogy, Gaziantep Medical Park Hospital, Gaziantep, Turkey.
Received January 26th, 2011; revised April 6th, 2011; accepted June 27th, 2011.
ABSTRACT
The abnormal origin of the right coronary artery from the left aortic sinus coursing between the aorta and the pulmo-
nary trunk is a rare congenital anomaly. It may remain asymptomatic or may result in cardiac morbidity or mortality.
In the past, an anomalous origin of the right coronary artery from the left sinus of Valsalva was considered a benign
finding; it is now evident that this anomaly can be associated with atypical chest pain, m y oca rdial ischemia, and sudden
death. We thought that; the diagnosis of left sinus Valsalva aneurysm, described by transtora sic echocardiography and
transeusophageal echocardiography, might need de m on st r at ed a dvanced scanning tech niques.
Keywords: Congenital Anomaly, Coronary Ectasia, Echocardiography, Multi Detector Computerize Tomography
1. Introduction
Coronary artery anomalies are a relatively rare condition.
The clinical presentation of coronary artery anomalous
is variable, ranging from being asymptomatic to symp-
toms of syncope, unstable angina, myocardial ischemia
and sudden death. The incidence of anomalous coronary
arteries has been reported to be approximately 1% to 2%
[1]. Variations in the origin and/or course of anomalous
coronary arteries are well documented in the literature
but in this case, “interestingly” there was an anomalous
right coronary artery arising from the left coronary sinus
with proximal ectasia.
2. Case Presentation
A 56-year-old woman with a history of typical angina on
effort and without history of smoking, hypertension and
diabetes mellitus was admitted to our hospital. The pre-
senting symptoms had begun approximately since one
year however chest pain became more intensive dated
from last one week. On admission, her heart rate were 68
beat/min, her blood pressure were 110/72 mmHg and her
respiratory rate were 22 breath/min. Physical examina-
tion was normal. Electrocardiography showed minimal
ST depression and T wave inversion in DII-DIII and
AVF leads. The results of the laboratory revealed crea-
tine phosphokinase isoenzyme of 117 ng/mlt, troponin I
of 0.02 ng/mlt, total cholesterol of 224 mg/dL, high den-
sity lipoprotein cholesterol of 53 mg/dL, low density
lipoprotein-cholesterol of 162 mg/dL, and triglycerides of
45 mg/d. Other biochemistry and blood test values were
within normal limits. Exercise treadmill testing was posi-
tive. Coronary angiography was recommended but the
patient didn’t accept it.
Normal systolic (Ejection fractions: 58% with Simp-
son’s) and diastolic (E/A > 1) function, normal wall mo-
tion and suspicious images for aneurysm of left sinus
valsalva in transtorasic echocardiography (TTE). Tran-
seusophageal echocardiography (TEE) findings were
similar to TTE for the aneurysm of left sinus valsalva
(Figure 1).
Then the right coronary artery which arise from the
left sinus valsalva and courses between the ascending
aorta and pulmonary artery with proximal ectasia dem-
onstrated by multi detector computerize tomography
(MDCT) heart angiography (Figure 2 (a) and (b)).
3. Discussion
In 0.03% - 0.17% of patients undergoing angiography,
the right coronary arises from the left sinus of valsalva
as a separate vessel or as a branch of a single coronary

Anomalous Origin of the Right Coronary Artery from the Left Sinus Valsalva with Coronary Ectasia
270
Figure 1. Transeusophageal echocardiography showed the
aneurysm of left sinus valsalva.
(a)
(b)
Figure 2(a) and (b). The right coronary artery which arises
from the left sinus valsalva and courses between the as-
cending aorta and pulmonary artery with proximal ectasia
demonstrated by multi detector computerizes tomography
(MDCT) heart angiography.
artery [2]. And anomalous origin of the right coronary
from the left aortic sinus was first described in 1948 by
White and Edwards [3].
There are three subtypes based on the anatomic course
of the artery. The aberrant vessel may cause posterior to
the aorta (retroaortic), between the ascending aorta and
pulmonary trunk (interarterial), or anterior to the pul-
monary trunk. In this case we illustrated interarterial
subtype. The interarterial subtype has been reported to
be associated with sudden death, angina pectoris or
myocardial infarction in the absence of atherosclerosis
[3]. In the previous study this anomaly named malignant
right coronary artery anomaly. The pathophysiologic
basis for this association, however, is unclear. Mechani-
cal compression of the right coronary artery by the great
vessels is the usual explanation, because the right coro-
nary artery generally courses between the aorta and the
pulmonary artery to its normal position. Others have
suggested that the proximal portion of the right coronary
artery, situated between the aorta and the pulmonary
artery, might be more prone to spasm then it would be
otherwise [4]. Taylors et al. suggested that the oblique
angle at the juncture of the anomalous right coronary
artery and the left coronary sinus produces a slit-like
orifice in the aortic wall that can collapse during exer-
cise [5]. Identification of anomalous coronary arteries is
frequently difficult with conventional coronary an-
giography because of the lack of 3-dimensional (D) in-
formation related to the course of the coronary arteries
to the great vessels [6]. Magnetic resonance imaging
(MRI) is an alternative, noninvasive imaging modality
that feasibly can be used for the detection of anomalous
coronary arteries [7], but 3-D information had not been
available until recently [8].
In addition, detection of atherosclerotic coronary ar-
tery plaques that may overlap the anomalous coronary
artery system is not possible by MRI because of its lim-
ited spatial resolution. Multislice computed tomography
(MSCT) provides excellent spatial resolution, which
allows assessment of not only the atherosclerotic coro-
nary artery disease [9], but also of congenital coronary
artery anomalies such as coronary arteriovenous fistula
[10]. TEE has been utilized to detect coronary anomalies;
the operator may miss the diagnosis.
In this case we used TTE, TEE and MDCT Heart An-
giography. TTE showed suspicious images for aneurysm
of left sinus valsalva and this suspicious finding sup-
ported by TEE. Then the right coronary artery which
arises from the left sinus valsalva and courses between
the ascending aorta and pulmonary artery with proximal
ectasia demonstrated by MDCT Heart Angiography.

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271
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