Ectopic Common Origin of Right Coronary and Left Circumflex Arteries from Ascending Aorta in Acute Coronary Syndrome

Coronary artery anomalies are found in 0.6% to 1.55% of patients [1]. Most cases remain asymptomatic, are detected during elective coronary angiography, and are hemodynamically insignificant [2]. Anomalies can be classified based on the coronary arteries' origin, course, or termination [2,3]. Recognition of these anomalies is crucial for treatment, especially in patients with Acute Coronary Syndrome (ACS).

A 68-year-old female patient with a history of nicotinism for 20 years, previously untreated for cardiac reasons, was referred to our department as an emergency patient due to ACS without ST-segment elevation. On admission, the patient reported typical exercise-induced angina over the past five days, with resting discomfort on the day of presentation. Resting electrocardiogram showed normal sinus rhythm at a rate of 86 bpm, with a 1-mm horizontal ST-segment depression in the inferior leads (II, III, aVF) (Supplementary Figure S1). In laboratory studies, attention was drawn to slightly elevated high-sensitive cardiac troponin T concentrations: 26 ng/L (normal ectopic origin of the right coronary artery (RCA) and the left circumflex artery (LCx) directly from the aorta above the right coronary sinus, with critical stenosis in the first segment of the RCA (Figure 1A-C). An independent origin of the left anterior descending artery was visualized in the left coronary sinus, demonstrating non-significant atherosclerotic lesions (Figure 1D). Following initial RCA pre-dilation with semi-compliant and non-compliant balloons, the drug-eluting stent was implanted, resulting in successful dilatation of the lesion and Thrombolysis in Myocardial Infraction (TIMI) grade 3 flow (Figure 1E-F). Throughout the hospitalization, the patient did not experience any recurrence of angina. 

Figure 1: Invasive coronary angiography and percutaneous coronary intervention. A. Non-selective contrast injection into the right coronary sinus, the ostium of the right coronary artery was not visualized. B. Overlay of the two angiography images: nonselective contrast injection and one focused on the ostium (indicated by the arrow). C. The common origin of the right coronary artery and the left circumflex artery is directly from the aorta above the right coronary sinus; long, critical stenosis is present in the first segment of the right coronary artery. D. Independent origin of the left anterior descending coronary artery from the left coronary sinus; artery without significant atherosclerotic changes. E. Implantation of the drug-eluting stent. F. Coronary angiogram after angioplasty- complete dilatation of the lesion and TIMI grade 3 flow. Abbreviations: RCA, right coronary artery; LAD, left anterior descending artery; LCx, left circumflex artery; RCS, right coronary sinus; LCS, left coronary sinus; NCS, non-coronary sinus (Supplementary Figure 1).

Anomalies of the origin of coronary arteries are classified as benign and malignant [2-4]. Benign anomalies are generally asymptomatic, while malignant ones may potentially lead to myocardial ischemia, supraventricular and ventricular arrhythmias, myocardial infarction, or sudden death [2-4]. The ectopic origin of the RCA directly from the ascending aorta is an extremely rare anomaly, affecting just 0,006% of patients [5]. A common origin of RCA and LCx directly from the ascending aorta is a casuistic case, and to the authors' knowledge, has not been previously reported in patients with ACS without ST-segment elevation. If visualizing the coronary artery origins is difficult in patients with chronic coronary syndrome undergoing elective coronary angiography, invasive diagnostics may be postponed in favor of cardiac computed tomography angiography. However, this is not possible in patients with ACS, as in the described case, in whom a simultaneous, urgent percutaneous coronary angioplasty procedure is necessary. Such a procedure is challenging for the invasive cardiologist; it requires multiple diagnostic catheters, and the percutaneous coronary intervention is fraught with more significant technical difficulties.

Proper recognition of an anomaly such as the ectopic origin of RCA and LCx directly from the ascending aorta is of greatest importance, especially in acute clinical settings when other imaging modalities are inaccessible.

The authors declare that there is no conflict of interest regarding the publication of this paper 

Supplementary Figure 1: 12-lead resting electrocardiogram, normal sinus rhythm at a rate of 86 bpm, with a 1-mm horizontal ST-segment depression in the inferior leads (II, III, aVF).

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