Correspondence Address:
Pankaj Jariwala
Department of Cardiology, Yashoda Hospitals, Somajiguda, Raj Bhavan Road, Hyderabad - 500 082, Telangana
India

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A 48-year-old male, hypertensive following positive treadmill test, underwent transradial coronary angiography. It revealed a very interesting finding where the left anterior descending artery (LAD) extended beyond the cardiac apex. The continuation of the vessel along the posterior interventricular sulcus that crossed the cardiac crux to supply the posterior-lateral territory is described as hyperdominant LAD. The left circumflex artery (LCX) was nondominant with large obtuse marginal branch and diagonal branches which also supplied the posterolateral territory. The right coronary artery (RCA) was also nondominant. It also gave origin to a septal perforator [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f.{Figure 1}

Apart from the hyperdominant LAD, the unusual findings of our case were, nondominant LCX and RCA, and anomalous origin of septal perforator from the RCA. The LAD is classified into three types depending upon the pattern of its termination. Should this anomaly have classified as type IV LAD or anomalous origin of the posterior descending artery (PDA)?

About 85% of people have right-dominant coronary arteries, meaning that the PDA originates from the RCA. In 10%-15% of peaple, PDA originates from the LCX, and even less often (7%) comes from both the RCA and the LCX.[1] In very rare cases, the LAD artery may be identified as the source of PDA. When the LAD and PDA share the same epicardial channel, a condition is known as hyperdominant LAD. The clinical presentation may modify if the RCA or LCX territories are completely ceded to the LAD.

Tatari et al. described a case of hyperdominant LAD with rudimentary LCX and an absent RCA.[2] Zhou et al. described an exceptionally extended LAD course that curved around at the apex of the heart, continued as a PDA up to the crux of the heart, formed into a sac after feeding the diaphragmatic surface of the left ventricle, and eventually ended in the posterior atrioventricular groove.[3]

Our review in 2018 focused on the anomalous origin of the branches of the RCA, most notably the PDA, from the LAD artery or its branches, a rare coronary abnormality with only 19 cases recorded so far in 17 case reports in the literature.[4] Although it is found by chance during a coronary angiogram, its involvement in acute coronary syndrome has serious clinical implications, including the ischemia or infarction of more than half of the left ventricular myocardium in the anterior and inferior regions.[5] With a high index of clinical suspicion, early diagnosis and treatment are crucial.

The coronary artery architecture and what is considered normal might be difficult to define. The term “normal anatomical variations” refers to unique and relatively rare morphological features, and so fall within the umbrella of the “normal variant” category. The coronary artery abnormality (CAA) is a pattern of coronary artery disease that occurs very seldom. This most likely reflects referral bias and the varying definitions of “anomalous” and “normal variation.” According to the research, around 1% of standard autopsies have CAAs, and 0.3% - 5.6% of patients having coronary angiography had CAAs. Since the prevalence of coronary abnormalities in necropsy patients may be skewed by the cause of death, and angiography is often conducted on the suspicion of ischemia, it is possible that neither of these numbers is genuinely representative.[1]

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Conflicts of interest

There are no conflicts of interest.

Authors' contributions

PJ is a sole author of the article who is responsible for the collection of data, writing manuscript, checking, publishing and proof reading.

References