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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 3  |  Page : 192-194

The armchair obtuse marginals: Anomalous origin of obtuse marginals from right coronary sinus - A case report


Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission07-Sep-2021
Date of Acceptance26-Oct-2021
Date of Web Publication30-Sep-2022

Correspondence Address:
Dr. Debasish Das
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_58_21

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  Abstract 

We report a rare case of anomalous origin of obtuse marginals (OMs) from a common trunk arising from the right coronary sinus in an interesting armchair shape in a 52-year-old female presenting with acute inferior wall myocardial infarction. During routine coronary angiography, the origin of the left anterior descending coronary artery was visualized and the origin of the left circumflex (LCX) coronary artery was not visualized with the sign of nonperfused myocardium in the LCX artery territory. Our case is a rare illustration of armchair OMs with nonperfused proximal and middle LCX coronary artery territory.

Keywords: Anomalous, obtuse marginals, right coronary sinus


How to cite this article:
Das D, Das T, Pramanik S. The armchair obtuse marginals: Anomalous origin of obtuse marginals from right coronary sinus - A case report. Heart Mind 2022;6:192-4

How to cite this URL:
Das D, Das T, Pramanik S. The armchair obtuse marginals: Anomalous origin of obtuse marginals from right coronary sinus - A case report. Heart Mind [serial online] 2022 [cited 2023 Mar 29];6:192-4. Available from: http://www.heartmindjournal.org/text.asp?2022/6/3/192/357553


  Introduction Top


Coronary artery anomalies have been identified in 0.6%–1.5% of coronary angiograms. An anomalous origin of the left circumflex (LCX) coronary artery (LCX) from the proximal right coronary artery (RCA) or right sinus of Valsalva is a relatively common anatomical variation but here we describe an anomalous origin of obtuse marginal branches (OMs) from the right coronary sinus in an interesting armchair shape with nonperfused proximal and mid-LCX artery territory. Recognition and adequate visualization of an anomalous coronary artery are essential for proper patient management, especially in patients undergoing percutaneous coronary intervention (PCI), coronary artery bypass surgery, or prosthetic valve replacement.


  Case Report Top


We present a case of a 52-year-old nondiabetic, nonhypertensive, normolipidemic female without any family history of coronary artery disease presenting with retrosternal chest discomfort with diaphoresis and shortness of breath for the last 8 h. Age and postmenopausal status were only two contributing factors behind the development of coronary artery disease. EKG revealed acute inferior wall ST-elevation myocardial infarction (STEMI) with regional wall motion abnormality in LCX territory with mild left ventricular systolic dysfunction (ejection fraction-42%). She was coronavirus disease-2019-negative. Serum chemistries were within the normal limit. We subjected the patient to right transradial coronary angiogram for primary PCI. Left coronary injection revealed the only origin of the left anterior descending (LAD) coronary artery from the left main coronary artery and the origin of the LCX coronary artery was not visible with the sign of nonperfused myocardium in LCX territory [Figure 1]. Right coronary injection revealed the presence of small nondominant RCA [Figure 1]. Slight anticlockwise rotation of the tiger catheter engaged the anomalous origin of a common trunk in an interesting armchair shape [Figure 2] giving rise to OMs [Figure 2] with nonperfused proximal and mid-LCX coronary artery territory and it was originating from a separate anterior ostium in the right coronary sinus. The third OM was major and harboring 70% lesion distally which we revascularized with drug-eluting stent and the patient was discharged with stable hemodynamics the next day. Most of the LCX coronary anomalies originating from the right coronary sinus originate from the anterior part of the coronary sinus and anticlockwise rotation of the catheter scanning from the left sinus toward the right picks up most of them obviating the need for computed tomography coronary angiogram.
Figure 1: Sign of nonperfused myocardium, the only origin of left anterior descending from left main coronary artery, armchair obtuse marginals with major having a distal lesion

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Figure 2: Small nondominant separate origin of right coronary artery

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  Discussion Top


Origin of the LCX coronary artery from the right sinus of Valsalva is well described but the exclusive origin of OMs from the opposite coronary sinus in a peculiar armchair shape with nonperfused proximal and mid-LCX artery territory has not been described in the literature so far. Anomalous origin of LCX from the right coronary sinus has been reported in approximately 0.67% of cases of patients undergoing invasive coronary angiography. Antopol and Kugel first described the anomalous origin of the LCX coronary artery from the proximal RCA or right sinus of Valsalva in 1933. In those cases, the anomalous artery may arise with the RCA from a common ostium, a separate ostium, or proximal part of the RCA. Then the artery passes behind the aortic root and enters the left atrioventricular groove to distribute like a proximal branch of the left coronary artery. The anomalous LCX coronary artery may be small if the RCA supplies most of the inferior ventricular myocardium or the diagonal arteries from the proximal LAD artery are very large. The presence of this anomalous coronary artery does not predispose to the increased incidence of obstructive coronary artery disease but paradoxically in our case, it was associated with coronary artery disease mandating intervention. Two characteristic angiographic signs help in reorganizing this anomaly known as the “aortic root sign” and the sign of nonperfused myocardium.

Aortic root sign

In the right anterior oblique projection, the anomalous circumflex artery courses posteriorly behind the right sinus of Valsalva except in cases of complete occlusion at the origin with the distal distribution recognized by retrograde opacification [Figure 3].
Figure 3: Aortic root sign and sign of nonperfused myocardium

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Sign of nonperfused myocardium

During the left coronary injection, an avascular area in the posterolateral left ventricular myocardium suggests an anomalous origin of the LCX artery. The size of the avascular area is directly proportional to the quantitative distribution of the anomalous artery. Left cusp injection most often delineates separate origin of LAD and LCX coronary artery [Figure 3].

In our patient, coronary angiography revealed the area of the myocardium usually supplied by proximal and mid-LCX was nonperfused (the sign of nonperfused myocardium for which we suspected, we may be dealing with some variant of LCX coronary anomaly). Bonapace et al. described the echocardiographic appearance of origin of the LCX coronary artery from the right coronary sinus emphasizing the fact that even high-resolution echocardiography can pick this anomaly.[1] Anomalous origin of LCX from the opposite sinus may be a cause of STEMI,[2],[3],[4] NonSTEMI,[5] and sudden cardiac death.[6] We describe a rare case of inferior wall STEMI in a patient with armchair OMs which was successfully revascularized. Acute proximal angulation of the LCX coronary artery close to the coronary sinus can be a cause of ischemia in those patients. Angiogram clearly delineated there was no interarterial course of the common trunk between the aorta and the pulmonary artery which may serve as a risk factor for sudden cardiac death. Torto et al.[7] reported a retroaortic course of LCX coronary artery originating from the right coronary sinus and they described abrupt acute angle downward and underneath the aorta as the cause of coronary ischemia in a 46-year-old male with suspected myocarditis. Oliveira et al. described an unheard association of the absence of LCX with super dominant RCA and anomalous origin of LAD from the right coronary sinus.[8] Ganju et al. described a case of anomalous LCX from the right coronary sinus associated with the origin of a left atrial branch from a super dominant RCA[9].


  Conclusion Top


We describe a rare case of origin of OMs from the opposite coronary sinus in an interesting armchair shape with proximal and mid-LCX coronary artery territory left nonperfused (the sign of nonperfused myocardium). Anomalous coronary artery assuming a peculiar armchair shape with an arborizing pattern of OMs is unique to our description of this rare anomaly.

Declaration of ethical approval

Institutional Ethical Committee approval has been obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bonapace S, Adamo E, Cicciò C, Chiampan A, Canali G, Valbusa F. Unusual echocardiographic image of a left circumflex coronary artery with anomalous origin from the right coronary sinus. Eur Heart J 2016;37:792.  Back to cited text no. 1
    
2.
Çitaku H, Kamberi L, Gorani D, Koçinaj D, Krasniqi X. Anomalous origin of left circumflex artery. Med Arch 2015;69:423-4.  Back to cited text no. 2
    
3.
Yamamoto M, Tsujita K, Yamanaga K, Komura N, Sakamoto K, Kojima S, et al. ST-segment elevation myocardial infarction in a patient with anomalous origin of left circumflex coronary artery. J Cardiol Cases 2015;11:120-3.  Back to cited text no. 3
    
4.
Channabasappa YM, Setty NS, Shankar S, Shankrappa RK, Kharge J, Ramegowda RT, et al. Percutaneous coronary intervention in an octagenerian with anomalous origin of LCX arising from right sinus: A rare case report. J Med Cases 2020;11:41-3.  Back to cited text no. 4
    
5.
Naseer A. Anomalous left coronary artery arising from the right coronary sinus presenting with acute coronary syndrome. Am J Phytomed Clin Ther 2021;9:26.  Back to cited text no. 5
    
6.
Anantha Narayanan M, DeZorzi C, Akinapelli A, Mahfood Haddad T, Smer A, Baskaran J, et al. Malignant course of anomalous left coronary artery causing sudden cardiac arrest: A case report and review of the literature. Case Rep Cardiol 2015;2015:806291.  Back to cited text no. 6
    
7.
Del Torto A, Baggiano A, Guglielmo M, Muscogiuri G, Pontone G. Anomalous origin of the left circumflex artery from the right coronary sinus with retro-aortic course: A potential malign variant. J Cardiovasc Comput Tomogr 2020;14:e54-5.  Back to cited text no. 7
    
8.
Oliveira MD, de Fazzio FR, Mariani Junior J, Campos CM, Kajita LJ, Ribeiro EE, et al. Superdominant right coronary artery with absence of left circumflex and anomalous origin of the left anterior descending coronary from the right sinus: An unheard coronary anomaly circulation. Case Rep Cardiol 2015;2015:721536.  Back to cited text no. 8
    
9.
Ganju N, Kandoria A, Bhardwaj R, Mahajan K, Sharma R. Anomalous origin of left circumflex artery and left atrial circumflex artery from super-dominant right coronary artery. Atheroscler Open Access 2017;2:111.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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