Anomalous origin of left circumflex coronary artery: An easy ‘pick’ on transthoracic echocardiography

Abstract is not required for Clinical Imagesis not required for Clinical Images (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 8 No. 2, February 2017. ISSN – [0976-3198] Int J Case Rep Images 2017;8(2):155–157. www.ijcasereportsandimages.com Vora et al. 155 CASE REPORT OPEN ACCESS Anomalous origin of left circumflex coronary artery: An easy ‘pick’ on transthoracic echocardiography Keyur Vora, Alok Ranjan


DISCUSSION
Anomalous origin of LCX from right coronary sinus is the most common congenital variant with prevalence of 0.18-0.67% [1]. An aberrant but normal LCX arising from the right coronary sinus (common or separate ostium with the RCA) has no clinical significance per se, and it does not predispose the LCX to a higher incidence of obstructive disease [2]. Although the LCX anomaly In apical four-chamber view, a coronary artery is found arising from right side of aortic root, (blue arrow), (B) Anomalous coronary artery on echocardiography. In apical five-chamber view, a coronary artery is found arising from right side of aortic root, entering into left atrioventricular groove (blue arrow), (C) Course of anomalous coronary artery. The part of the anomalous course of coronary artery was also depicted on parasternal long axis (PLAX) view (red dotted lines), (D) Course of anomalous coronary artery. The part of the anomalous course of coronary artery was also depicted on apical two-chamber view (green arrow), (E) Origin of coronary arteries. Left main coronary artery (LMCA) is arising from left coronary sinus as shown on parasternal short axis view (orange arrow), RCA is arising from right coronary sinus as shown on parasternal short axis view (yellow arrow), and (F) Anomalous artery on coronary angiogram. Anomalous origin of left circumflex coronary artery is depicted on conventional coronary angiogram (white arrow). is classified as benign and asymptomatic, it can cause myocardial ischemia, and in some cases sudden death, myocardial infarction, and angina pectoris in the absence of atherosclerotic lesions. These manifestations might be due to repeated compression of the anomalous artery by a dilated aortic root or to unusual angling as a result of the retroaortic course of the LCX, which can compress the coronary ostium and restrict blood flow.
On the other hand, the presence of obstructive disease, however, especially in a vessel of large distribution, makes it mandatory that the anomaly be recognized and angiographically demonstrated, especially in acute myocardial infraction. Sometimes, in acute myocardial infraction, no evidence of an occluded coronary artery can be seen during angiography. This might lead to a large spectrum of differential diagnoses to explain the acute chest pain or the electrocardiogram modification [3]. The absence of an epicardial vessel or its branch, which is anatomically supposed to supply a myocardial ischemic area identified at the left ventriculography, suggests that an anatomical variation of the normal coronary tree (i.e. the aberrant artery) has to be actively searched.
Computed tomography angiography (CTA) is more useful than conventional angiography. Three dimensional information of the course of the coronary arteries in relationship to the great vessels and the origin are clearly detected by CTA. The transthoracic echocardiography is most limited in such cases as it can only detect part of the anomalous course of the artery. Usually, the origins of coronary arteries from its respective coronary sinuses are relatively easy to detect on transesophageal echocardiography. The subsequent course of artery is even more difficult and most of the times only a proximal part of the course is detected on TTE. The distal course and intramural course of the artery are not seen on TTE. The role of TTE is even more limited in adult as compared to children in detecting coronary abnormalities.
Transesophageal echocardiography may be more useful in detecting the origin and the proximal part of coronary arteries but the subsequent course is even more difficult to detect. Transesophageal echocardiography offers several advantages that may potentially overcome the technical problems associated with the transthoracic approach, including closer proximity of the transducer to the proximal coronary arteries and avoidance of anterior chest wall structures that cause degradation of the ultrasonic signal. This allows the routine use of higher frequency transducers and thus better spatial resolution and more detailed image quality. With these advantages, TEE is only helpful in detecting proximal coronary abnormalities [4].

CONCLUSION
In conclusion, our imaging experience highlights the significance of evaluation of coronary arteries on emergency echocardiography study and proactive preparation for uneventful interventional procedures. Careful evaluation of coronary arteries on echocardiography is inexpensive, quick and time saving modality as well as contrast and radiation exposure is saved. Such a high level of anticipation can be extremely useful information for emergency percutaneous coronary interventions (PCI). The reliable anticipation and identification is of paramount importance to the interventional cardiologists. Appropriate anatomical and technical understanding is vital for a successful interventional treatment of anomalous coronary arteries.

Edorium Journals: An introduction
Edorium Journals Team

But why should you publish with Edorium Journals?
In less than 10 words -we give you what no one does.

Vision of being the best
We have the vision of making our journals the best and the most authoritative journals in their respective specialties. We are working towards this goal every day of every week of every month of every year.

Exceptional services
We care for you, your work and your time. Our efficient, personalized and courteous services are a testimony to this.

Editorial Review
All manuscripts submitted to Edorium Journals undergo pre-processing review, first editorial review, peer review, second editorial review and finally third editorial review.

Peer Review
All manuscripts submitted to Edorium Journals undergo anonymous, double-blind, external peer review.

Early View version
Early View version of your manuscript will be published in the journal within 72 hours of final acceptance.

Manuscript status
From submission to publication of your article you will get regular updates (minimum six times) about status of your manuscripts directly in your email.

Favored Author program
One email is all it takes to become our favored author. You will not only get fee waivers but also get information and insights about scholarly publishing.

Institutional Membership program
Join our Institutional Memberships program and help scholars from your institute make their research accessible to all and save thousands of dollars in fees make their research accessible to all.

Our presence
We have some of the best designed publication formats. Our websites are very user friendly and enable you to do your work very easily with no hassle.
We request you to have a look at our website to know more about us and our services.
We welcome you to interact with us, share with us, join us and of course publish with us.

Invitation for article submission
We sincerely invite you to submit your valuable research for publication to Edorium Journals.

Six weeks
You will get first decision on your manuscript within six weeks (42 days) of submission. If we fail to honor this by even one day, we will publish your manuscript free of charge.*

Four weeks
After we receive page proofs, your manuscript will be published in the journal within four weeks (31 days).
If we fail to honor this by even one day, we will publish your manuscript free of charge and refund you the full article publication charges you paid for your manuscript.* This page is not a part of the published article. This page is an introduction to Edorium Journals and the publication services.
* Terms and condition apply. Please see Edorium Journals website for more information.