Congenital Absence of Left Circumflex Artery: A Case Report and Review of the Literature

The Missing Coronary: A Case Series of Inferior Wall Myocardial Infarction Due to Coronary Anomalies

Coronary artery anomalies, while often asymptomatic, can sometimes present acutely in the context of myocardial infarction (MI). This case series highlights three unique instances of inferior wall MI precipitated by rare coronary anomalies. The first case involved a 40-year-old male with a congenital absence of the left circumflex artery, presenting with a "shark fin" ECG pattern in inferior leads. Urgent coronary angiography confirmed the anomaly and primary percutaneous coronary intervention (PCI) was performed on a superdominant right coronary artery (RCA). The second case details a 52-year-old male with a split RCA, initially undiagnosed due to apparently normal angiographic findings, later revealed to have a thrombotic occlusion of the posterior division. Careful re-evaluation and imaging from alternative angles facilitated successful PCI. The third case describes a 45-year-old male with an anomalous origin of the RCA from the left sinus of Valsalva, presenting difficulties during arterial engagement in PCI. A modified Judkins left catheter technique was employed to achieve selective cannulation and stent deployment. These cases underscore the importance of early recognition, accurate diagnosis, and innovative interventional strategies in managing acute MI due to congenital coronary anomalies.

Novel Anatomical Variation of Left Coronary Artery Origin at the Sinotubular Junction Level With Coeval Hypoplastic Left Circumflex, Superdominant Right Coronary Artery, and Obstructive Coronary Artery Disease: A Case Report

The isolated origin of the left coronary artery (LCA) ostium at the level of the sinotubular junction (STJ) has been described previously. Congenital absence of the left circumflex (LCx) coronary artery has also been documented with superdominant right coronary arterial circulation, either in the presence or absence of coronary artery obstruction. Earlier literature has linked the association of an absent LCx coronary artery with a superdominant right coronary artery (SRCA) but not with a hypoplastic LCx coronary artery (HLCx). The present case report details the case of a 37-year-old thin, athletic male with the risk factors of diabetes and hypertension who was admitted to the emergency unit of our hospital for losing consciousness while bicycling in the street. The current report establishes a combined association of LCA anomaly origin at STJ level along with HLCx and SRCA condition with the burden of mild to moderate coronary artery disease involving proximal left anterior descending artery, LCx, and mid right coronary artery in the literature for the first time. Further, the case report advocated that the presented case carries the risk of malignancy. Hence, with the advancement of modern imaging technologies, computed tomography angiography should be the first choice of imaging modality rather than coronary angiography to prevent fatal outcomes. Interventional cardiologists, cardiothoracic surgeons, and radiologists should have properly defined knowledge of coronary artery anatomy and associated pathology, as it is important for coronary cannulation or any coronary interventions.

Congenital Absence of the Left Circumflex Artery Presenting With Inferoposterior Wall Myocardial Infarction Due to Stenosis of the Super Dominant Right Coronary Artery: A Rare Case

The primary coronary arteries are the right coronary artery (RCA), the left main coronary artery (LMCA), which bifurcate into the left anterior descending artery (LAD), and the left circumflex artery (LCX), arising from the right coronary sinus and left coronary sinus, respectively. The congenital agenesis of LCX is a very unusual anomaly caused by the inability of LCX to form in the atrioventricular (AV) groove. This condition is usually accompanied by the presence of a large, dominant RCA that supplies its own territory and that of LCX, i.e., the inferior, posterior, and lateral walls. This anomaly is generally detected incidentally during coronary angiography. This condition usually does not manifest as a major cardiovascular event and mildly presents as chest pain upon exertion. The chest pain is vastly attributed to ischemia in the RCA territory, as this "super dominant" vessel majorly directs its supply to the LCX territory for compensation. This is known as the steal phenomenon. In this paper, we discuss a case of a 61-year-old female who came to the ED with the chief complaint of acutely radiating chest pain for five hours and was diagnosed as a case of acute myocardial infarction of the inferior and posterior walls. Coronary angiography revealed 90% stenosis of the RCA and a congenital absence of LCX, which has a significantly low prevalence.

Crescendo Angina Secondary to Congenital Absence of the Left Circumflex Coronary Artery: A Case Report

Congenital coronary artery abnormalities (CAAs) are very rare in the general population. Among these congenital anomalies, left circumflex artery (LCx) anomaly is the most common. Although many are asymptomatic, a small percentage of patients with this anomaly present with angina-like symptoms. Usually, a majority of these cases are found incidentally during coronary angiography. We present a 71-year-old male with crescendo angina with a positive chemical stress test. Coronary angiography showed an absent LCx and a superdominant right coronary artery (RCA). Although congenital LCx absence is a benign finding, the coexistence of this abnormality with significant atherosclerotic disease in the coronary artery can lead to significant morbidity and mortality in this population. Understanding the embryological and morphological significance of these anomalies is important in adequately diagnosing and managing these patients.

Congenital absence of the left circumflex artery: Case series and review

Congenital absence of the left circumflex artery (CALCx) or an anomalous origin of the left circumflex artery from the right coronary artery is a unique anomaly in the literature that has been incidentally diagnosed with coronary angiography. CALCx is characterized by an angiographical absence of the left circumflex artery, with a super-dominant right coronary artery that provides the postero-lateral wall of the left ventricle. We present a review of the literature of a total of 52 CALCx cases reported so far including our case. In our study, the average age of patients was 52.83 years (median - 55 years; standard deviation - 13.05 years; range 12-76 years) with a male to female ratio of 1.93:1. The chronic coronary syndrome was the most common clinical presentation followed by the acute coronary syndrome. In 45.5% of cases, the associated coronary artery disease was documented. A comprehensive anatomical and functional assessment is required for the appropriate management strategy.

Independent origin of anterior interventricular and left marginal arteries from the left posterior aortic sinus

We present a unique, unreported variation of the left coronary artery. During dissection classes for first-year medical students, we observed the absence of left coronary artery in an adult male cadaver aged approximately 78 years. The left aortic sinus was dilated and it gave origin to anterior interventricular and left marginal arteries independently. Left marginal artery was large and the circumflex artery arose from it. There were two independent opening for anterior interventricular and left marginal arteries in the left posterior aortic sinus. No variations were found in the origin and branching pattern of right coronary artery and the walls and chambers of the heart.

Supreme dominance of right coronary artery in a patient with typical angina

A 50-year-old woman presented to our hospital with Canadian Cardiovascular Society grade III angina of 4 months duration. Coronary angiography of the patient showed the absence of left main coronary artery from the left coronary sinus. There was a single right coronary artery (RCA) with a super dominant course from right coronary sinus. It also showed a left main coronary and left anterior descending artery arising separately from proximal RCA, with retroaortic and prepulmonic course, respectively. There was another independently arising small septal branch from the proximal RCA that supplied the proximal interventricular septum. The patient was managed with optimal medical therapy and had symptomatic relief.

Congenital anomaly of coronary artery: absence of left circumflex artery

The prevalence of congenital coronary artery anomalies is approximately 1% in the general population. They are a common cause of sudden death in younger persons. Congenital absence of the left circumflex artery is usually a benign condition but can cause symptoms of exertional angina. We present a case of a 59-year-old female who presented with complaints of chest pain. She was evaluated by the cardiology service. An invasive angiogram identified the absence of the circumflex artery, a large right coronary artery, and large septal and diagonal branches of the left main coronary artery possibly as a compensatory mechanism to supply blood to the LCx territories. It is important to define coronary anatomy as anomalies dictate which cardiac intervention should be attempted in cases of ischemia.

A Rare Case of Multiple Anomalies of the Coronary Arteries

Coronary artery anomalies represent a rare phenomenon, which is observed in approximately 1% of the population. Although not a frequent anomaly, they may lead to complications during various procedures and can sometimes present with angina pectoris or myocardial infarction. Herein, we present a rare case of a patient with origin of the left main coronary artery from the right sinus of Valsalva combined with a superdominant right coronary artery due to a hypoplastic left circumflex artery. A 67-year-old male patient presented with symptoms of chest pain on exertion, which lasted for approximately 10 minutes and resolved after rest. Physical examination, auscultation, electrocardiogram, and transthoracic echocardiography revealed normal findings. Cardiac enzymes were within the reference ranges, while the levels of triglycerides and low density lipoprotein (LDL)-cholesterol were elevated. The patient was further evaluated through coronary angiography. It revealed the origin of the left coronary artery from the right sinus of Valsalva, with a markedly hypoplastic left circumflex artery and the presence of a 'superdominant' right coronary artery. Atherosclerotic lesions were not observed, and the symptoms were discussed to have been caused by the anomalous pattern of the coronary arteries and the hypoplastic left circumflex artery in particular. The most common symptom of a hypoplastic or absent left circumflex artery is chest pain on exertion which is explained by the 'steal' phenomenon - due to increased demand in the area normally supplied by the left circumflex artery, a transitory ischemia occurs in the basins supplied by the left anterior descending artery and the right coronary artery. These findings were similar to our case. Such variations, although mostly asymptomatic, can sometimes lead to serious cardiovascular conditions and should be considered by clinicians during the assessment of cardiac symptoms.