Anomalous origin of left circumflex artery from aorta and left anterior descending coronary artery myocardial bridge: An unusual association between two coronary artery anomalies.

To the Editor,

Coronary artery anomalies are generally reported to be about 1% based on adult angiographic series. 1, 2 The origin and course anomalies may be discovered as incidental findings during diagnostic process for other disease or on the basis of signs of myocardial ischemia. Some non-invasive technique would be helpful in rule out the diagnosis. Echocardiography provides information on the origin and proximal course of main vessels, but it is affected by the quality of the acoustic window. Computed tomography coronary angiography (CCTA) is a non-invasive tool that permits direct visualization of coronary epicardial arteries. Despite being mostly asymptomatic, clinical presentation in adults may results from myocardial ischemia, angina, syncope, arrhythmias and even sudden death. A 39-year-old male patient with no risk factors was referred to our center with history of palpitations due to paroxysmal atrial fibrillation. The patients clinical examination was normal. Also the resting electrocardiogram was normal. A transthoracic echocardiogram revealed an anomalous proximal course of left circumflex artery. An enhanced coronary computer tomography angiography (CTA) with prospective ECG-gating was performed to evaluate the coronary arteries. It showed absence of the common left trunk and separate origin of left circumflex artery directly from aorta. Also a myocardial bridge was localized in the middle segment of the left anterior descending coronary artery. (Fig. 1) The exercise ECG revealed no chest pain and no significant ST-segment depression. We decided to start a conservative treatment with propafenone (325 mg bid). The patient remained asymptomatic after one year of follow-up.

Fig. 1

Coronary CTA: a. Multiplanar reconstruction image in a para-axial plane showed origin of LCA directly from aorta. b,c. Thee-dimensional volume rendering images better depicted absence of common left trunk (arrow), independent origin of LCA (b), and myocardial bridging (arrow) in the middle segment of LAD (c).