Anomalous coronary arteries are a rare but recognized cause of myocardial ischemia and sudden death. Identification currently requires x-ray angiography, which may have difficulty defining the three-dimensional course of the anomalous vessel. Magnetic resonance coronary angiography (MRCA) has been shown to image coronary artery anatomy noninvasively

1. Abnormal Coronary
Artery
RAMACHANDRA

2. Something should go wrong
anatomically?
• Number
• Location of ostium
• Diameter
• Cross-sectional area
• Course
• Branches

3. Hemodynamically wrong
• Major
• Minor

4. Functional anomaly
• Ischemia
• Shunt
• Nothing

5. What is normal coronary?
• That is found in more than 1% of a general population
• That is found within 2 SD of the µ value for Gaussian distribution
continuous bell curve

6. Figure 3. Conceptual diagram that shows most of the possible paths (1 through 5) by which the
RCA, left anterior descending artery (LAD), and circumflex artery (Cx) can potentially connect
with the opposite coronary cusps.
Angelini P Circulation. 2007;115:1296-1305
Copyright © American Heart Association, Inc. All rights reserved.

7. Normal Coronary Anatomy

8. Normal Coronary Angiogram
• Three primary coronary arteries
• Left main trunk common stem for LAD and LCX- 90% of cases and is
not essential
• LAD & LCX are essential
• LAD &LC originate from an aortic area located above the upper or
middle third of the left coronary sinus of Valsalva (also called the left
posterior sinus)
• The RCA originates from the upper or middle third of the right sinus
of the Valsalva
• Coronary ostium is orthogonal to aortic wall.

9. Anatomical Classification
Origin
Course
Vessel wall
collateral
termination

10. Angelini P, Villason S, Chan AV, Diez JG. Normal and anomalous
coronary arteries in humans. In: Angelini P, ed. Coronary Artery
Anomalies: A Comprehensive Approach. Philadelphia: Lippincott
Williams & Wilkins; 1999: 27–150

11. Origin
• 0.6% to 1.2% of CAG in adult
• LAD & RCA from LCS but different origin[Split]
• High/ Low/ Commissural
• From neighbouring sinuses
• From neighbouring arteries like ALCAPA

12. Abnormal origin……..(TGA)

13. Abnormal origin……..(TGA)

14. Abnormal origin……..(TGA)

15. Abnormal origin……..(TGA)

16. Course
• Intramural
• Extramural

17. Intrinsic to any artery
• Stenosis
• Ectasia
• Dual RCA/LAD
• Abnormal septal arteries
• Myocardial bridge
• Subendocardial
• Crossing

18. Collaterals
• Coronary cameral fistulas

19. Relationship
• Transposition of the great arteries
• Tetralogy of Fallot: 2-9% of tetralogy of Fallot have coronary arterial
anomalies. The most common anomaly is origin of the left anterior
descending (LAD) coronary artery from the RCA in approximately 4%
• Pulmonary atresia with intact ventricular septum : absence of
effective egress of blood from the cavity of the right ventricle may
preserve primitive embryonic sinusoidal connections to coronary
vasculature, resulting in the filling of the connections from the right
heart in systole and filling from the aorta in diastole

20. Tests
• Clinical guess
• ECG
• Echo
• TMT
• CAG/CTCAG/MR Angio
• Nuclear
• PET
• IVU
• OCT

21. Alarms
•
•
•
•
•
•
•
•
•
•
•
•
Irritability
Poor Feeding
Slowed Or Poor Growth And Development
Dyspnea (Difficulty Breathing)
Wheezing
Diaphoresis (Sweating) /Syncope
Grayish Skin Color In Conjunction With Other Symptoms
Periods Of Pallor (Pale Skin)
Heart Failure
Unexpected Chest Pain
Presentation In Unusual age
SCD

22. Mortality/Morbidity
• Many coronary anomalies are clinically silent
• The incidence of incidental coronary anomalies at autopsy includes a
single coronary artery in 0.024% and coronary arterial fistulae in 0.2%
• After hypertrophic cardiomyopathy, coronary artery abnormalities are
the second most common cause of sudden death in young athletes
• Race/Sex-No racial predisposition is known.

23. Treatment Options of symptomatic
• Medical treatment/observation
• Coronary angioplasty with stent deployment
• Surgical repair

24. Thanks