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.