Transthoracic Echocardiographic Image of a Left Circumflex Coronary Artery with Anomalous Origin from the Right Coronary Sinus

A 62-year-old male patient was admitted for coronary angiography. He had exertional angina and a positive treadmill exercise test. The transthoracic echocardiography (TTE) showed concentric left ventricular hypertrophy, no regional wall motion abnormality, and Grade 1 diastolic dysfunction. The TTE apical four-chamber view showed an unusual finding. Just above the level of atrioventricular (AV) valves, there was a tubular structure that appears to cross the lower part of the interatrial septum [Figure 1a]. With a slight anterior tilt in a partial apical five-chamber view, this structure was seen running in the left AV groove from the region of the right coronary sinus (RCS) and overlapping the aortic root [Figure 1b]. Branching was noticed in the AV groove. This finding is suggestive of a left circumflex coronary artery (LCx) originating from the RCS and running in a retroaortic course. A coronary angiogram confirmed the findings. Both the right coronary artery (RCA) and the LCx arose from the RCS with separate ostia, suggestive of a type I anomalous origin of LCx [Figure 1c and d and Video 1]. Initial RCA injections did not show LCx. A guide catheter was then used, and the RCA was wired with a coronary guide wire. The guide catheter was then pulled out of the RCA, and an injection was made in the RCS, which revealed the ostium of the anomalous LCx inferior and posterior to the RCA ostium. There was minor stenosis of the proximal LCx, which appeared insignificant. There was 70% stenosis of the mid RCA and tight stenosis of the left anterior descending (LAD) artery. Angioplasty with stenting of LAD and RCA was done, and the patient was symptom-free on follow-up.Figure 1: (a) Transthoracic echocardiography (TTE) apical four-chamber view showing a tubular structure that appears to cross the lower part of the interatrial septum, (b) TTE apical five- chamber view showing a tubular structure in the left atrioventricular groove overlapping the aortic root. (c and d) Coronary angiogram showing right coronary artery (down arrow) and anomalous LCx (up arrow) from right coronary sinus with separate ostia and LCx with a retroaortic course {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"Coronary angiogram showing anomalous origin of LCx in left anterior oblique (LAO), right anterior oblique caudal, and LAO caudal views.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_j4bq9nqi"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Anomalous origin of LCx from RCS is a congenital coronary anomaly with an estimated prevalence of about 0.39%.[1] There are three types: Type I: Separate ostia for RCA and LCx, Type II: Common ostia in the right sinus, and Type III: LCx arising as a branch of the proximal RCA.[2] The anomalous LCx course is almost always posterior to the aorta (retroaortic) and is considered a benign coronary anomaly, although rarely, symptoms can occur due to kinking or compression. In TTE, retroaortic anomalous LCx appears as a binary structure that seems to cross the aorta perpendicularly to its long axis in a five-chamber apical view described as “retroaortic anomalous coronary” sign.[3] In coronary angiography, an unusually long left main, which is actually the LAD without LCx, should raise the suspicion of anomalous LCx from the RCS. Right coronary injection may miss the anomalous LCx if the catheter is inside the RCA. Authors’ contributions This manuscript has only one author who is responsible for the entire work. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/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.