Clinical vignette
Spontaneous recanalization of an anomalous left anterior descending coronary artery after acute myocardial infarction demonstrated by computed tomography
Luigi Vignali1, Fabrizio Ugo1, and Filippo Cademartiri1,2*
1Department of Radiology and Cardiology, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43100 Parma, Italy and 2Department of Radiology and Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
*Corresponding author. E-mail address: filippocademartiri@hotmail.com
We describe the case of an 80-year-old woman who came to our attention with a diagnosis of sub-acute antero-lateral myocardial infarction. She underwent coronary angiography, which revealed the presence of a rare anomaly of the left coronary artery (type R-III C according to Yamanaka's classification) in which the left anterior descending (LAD) and left circumflex artery (CX) arise separately from the proximal part of a normal right coronary artery (RCA) and run in a ‘combined’ manner (Panels A and B). In our patient, the proximal segment of the LAD showed an acute thrombotic occlusion, and percutaneous revascularization could not be completed because of the anomalous anatomy. From the coronary angiogram it was not possible to determine the LAD course. When discharged, the patient was receiving aspirin, clopidogrel, ramipril, simvastatin, and metoprolol.
Fifteen days after the acute coronary syndrome, a computed tomography (CT) (Sensation 64 Cardiac, Siemens, Germany) scan showed (Panels C–F) the course of the patent LAD anterior to the left ventricle outflow tract (Panels C,E, and F), as well as the course of the large RCA (Panels C and D). The spider (Panel E) and posterior views (Panel F) show the trifurcation of the proximal RCA with the CX running posterior to the aortic root, and the LAD running anteriorly to the right ventricle outflow tract. The CT images show coronary walls irregularities with calcific and non-calcific components at the level of the proximal segments of the three main vessels (i.e. RCA, LAD, CX). These features, with the exception of the acute thrombosis of the LAD, are less evident on conventional coronary angiography.
The use of CT, in our case, was a means of following-up a recanalized thrombosis after an acute coronary syndrome, and assessing the anomalous course of the left coronary artery.
Supplementary movies are available at European Heart Journal online.
Panel A and B Coronary angiogram. Coronary angiogram showing the common origin of the RCA, LAD, and CX. The LAD is occluded immediately after its origin and reperfused by the collateral circulation.
Panel C–F Four-dimensional computed tomography. Volume rendered multiphase reconstruction of the CT dataset showing all of the anatomical features of the coronary artery anomaly.
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