Case Report. A 65-year-old male with no known history of coronary disease presented with dyspnea on exertion and electrocardiographic (ECG) changes suggesting an old inferior infarct. Stress testing suggested ischemia based on ECG criteria. The patient’s ejection fraction by echocardiography was ~40% without focal hypokinesis. In order to define his anatomy, invasive coronary angiography was performed. Angiography revealed an anomalous left circumflex artery which collateralized an occluded right coronary artery (Figure 1).

Discussion. In 1927, Kugel described atrial anastomotic branches that connected the anterior coronary circulation located around the aortic root (left main, proximal left circumflex artery, proximal right coronary artery) to the posterior arterial circulation (usually the distal right coronary artery). Kugel’s original article describes this “arteria anastomotica auricularis magna”, which means large atrial anastomotic branch.¹ This artery can serve as an important collateral in patients with severe atherosclerotic coronary disease.²
Work on necropsy hearts by Nerantzis et al demonstrated that all hearts have an anastomotic network that courses through the atrial septum and connects the proximal anterior coronary arteries with the distal posterior coronary arteries. However, they found a single identifiable “Kugel’s artery” in only 6% of the cases.³ This variation of the traditional description of the Kugel’s artery has not, to our knowledge, been previously described.