Case Report and Brief Review

Anomalous Origin of Right Coronary Artery from Pulmonary Artery and Severe Mitral Regurgitation (see full title below)

Harshit Modi, MD, Aekarach Ariyachaipanich, MD, Muhyaldeen Dia, MD, FACC
Harshit Modi, MD, Aekarach Ariyachaipanich, MD, Muhyaldeen Dia, MD, FACC

Anomalous Origin of Right Coronary Artery from Pulmonary Artery and Severe Mitral Regurgitation Due to Myxomatous Mitral Valve Disease: A Case Report and Literature Review

ABSTRACT: Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is an uncommon congenital coronary artery anomaly. In contrast to anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), most of the patients with ARCAPA remain asymptomatic. However, few cases of angina, heart failure and sudden cardiac death depicting the malignant nature of the disease are described in the literature. We report an unusual case of ARCAPA with severe mitral valve regurgitation and pulmonary hypertension. Echocardiography and angiography were utilized for the diagnosis. Surgical correction was provided to our patient and should be considered for all patients with this potentially fatal disease. J INVASIVE CARDIOL 2010;22:E49–E55 Key words: anomalous coronary artery, pulmonary artery, mitral regurgitation, Transesophageal echocardiography, coronary angiography
The incidence of anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is 0.002%. The natural history of the disease and its clinical features are not well described in the literature except for few a case reports. The diagnosis of anomalous ARCAPA is usually done incidentally with other cardiac anomalies such as aortopulmonary window or tetralogy of Fallot. We report the case of a patient with severe mitral regurgitation who was incidentally found to have ARCAPA. Case 1. A 62-year-old Caucasian male with a past medical history of rheumatic fever in early childhood and dyslipidemia presented with worsening shortness of breath with minimal exertion for the past 3 months. In addition, the patient did not complain of chest pain, orthopnea or paroxysmal nocturnal dyspnea. There was no family history of coronary artery disease or cardiovascular disease. He had a 10-pack per year history of smoking which he quit 30 years ago and drank alcohol occasionally. He was taking aspirin, atorvastatin and omprazole. Upon physical examination, his vital signs were normal. A cardiac examination revealed a grade 3/6 pan-systolic murmur at the apex radiating towards the left axilla. The laboratory workup was unremarkable except for a high B-type natriuretic peptide of 489 pg/dl. Electrocardiography showed normal sinus rhythm with new antero-inferior ST-T depression. An increased cardiothoracic ratio and clear lung fields were seen on chest radiograph. With the suspicion of mitral valve regurgitation, transthoracic (TTE) and transesophageal echocardiography (TEE) were performed, showing mild left ventricular hypertrophy with no significant segmental wall motion abnormality and both left and right ventricular dilatation. Evaluation of the mitral valve revealed myxomatous changes with prolapse of the P2 segment of the mitral valve and evidence of a ruptured chordae. A severe jet of insufficiency was identified over the anterior mitral valve leaflet directed toward the anterior aspect of the enlarged left atrium. The ejection fraction was around 50%. A transesophageal long-axis view showed a probable anomalous coronary artery. To confirm the diagnosis and assess the hemodynamic significance, combined right and left cardiac catheterizations were performed. Selective coronary angiography showed a large dilated and tortuous coronary artery from the left coronary sinus with a typical course of the left anterior descending artery (LAD) and left circumflex artery (LCX) (Figure 1B). The origin of the right coronary artery (RCA) was not demonstrated on aortic root angiography (Figure 1A). The RCA was later contrasted through several large epicardial collateral vessels originating from the LAD and LCX (Figure 1B). The RCA itself was dilated and drained into the pulmonary artery (Figures 1B, 1C, 1D). Left ventriculography revealed severe mitral regurgitation with an ejection fraction of about 50%. The right-heart catheterization findings are described in Table 1. The patient was found to have elevated pulmonary artery and pulmonary capillary wedge pressures. There was no significant “oxygen step-up” between the right ventricle (69.8%) and the pulmonary artery (70.6%). A diagnosis of ARCAPA with severe mitral regurgitation and severe pulmonary hypertension was made. The patient underwent surgery for reimplantation ofthe anomalous RCA to an anterior aortic sinus and mitral valve repair by ring annuloplasty with no complications. He was discharged afterwards to cardiac rehabilitation. TTE at 3 months post surgery showed an intact mitral valve annuloplasty ring with no residual mitral regurgitation. Review of the literature. Since the first case of ARCAPA was reported in 18851, 99 cases have been described. Table 3 shows the characteristics of 93 of these patients. We conducted a literature review of ARCAPA by performing a MEDLINE database search for reported cases published between 1950 and June 2009 using the following keywords: “ARCAPA,” “anomalous origin of coronary artery from pulmonary artery” and “coronary artery anomaly.” All searches were limited to studies published in English. We extracted information from abstracts and published articles when possible. Discussion. ARCAPA is a rare yet serious congenital coronary disorder. In 1945, Soloff described four possible types of anomalies of the coronary artery originating from the pulmonary artery.2 These can be an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), ARCAPA, both coronary arteries from the pulmonary artery and an accessory coronary artery from the pulmonary artery. Among these, ALCAPA is the most common anomaly, with an incidence of 0.008% in the general population compared to a rate of 0.002% for ARCAPA.44,76 From the literature review, we found that only 25–30% cases of ARCAPA are associated with structural heart defects. To the best of our knowledge, this is the second case report where ARCAPA was diagnosed with severe mitral regurgitation and severe pulmonary hypertension. Many patients with isolated ARCAPA remain asymptomatic in early on in life and it is diagnosed incidentally with other types of cardiac anomalies. 3 Table 3 shows the characteristics of 98 reported cases including the current case. Out of 98 cases, 50 were males and 39 were females, while for 9 cases, the gender was unknown. There was a vast difference in age of the patients when the disease was identified, ranging from 1,13 Twelve cases were diagnosed in infants ≤ 1 year, 44 were diagnosed in children ≤ 18 years of age, 17 were adults > 60 years of age, and 8 subjects were of unknown age. The pathophysiology and manifestations of ARCAPA depend on the direction of blood flow in the coronary artery and the impact on myocardial oxygen delivery. Massive collateralization between the normal and anomalous vessel is needed to maintain adequate myocardial perfusion in the presence of coronary steal. Coronary steal occurs when the anomalous vessel acts as a vein, which collects blood from the normal coronary artery through collaterals and delivers it to the pulmonary artery. Long-term coronary steal phenomena and blood supply from a single coronary system causes myocardial ischemia and heart failure. An increase in myocardial oxygen demand due to physiological factors like exercise, stress or anatomical lesions such as valvular abnormalities, increases the risk of ischemia. Many patients with isolated ARCAPA remain asymptomatic in childhood, however, patients with ALCAPA show signs of mitral insufficiency or anterolateral myocardial ischemia during early childhood.20 In ARCAPA, the most common presenting symptom was angina in 18% of cases. Other common symptoms were dyspnea on exertion for 13% of patients, congestive heart failure in 11%, sudden cardiac arrest in 6%,13,15,42,53,56,59 cyanosis in 4 patients, as well as acute myocardial infarction, 6,30,77 palpitation,70,83 atrial fibrillation,24,85 bradycardia24,60 and myocarditis.23 Five patients were diagnosed at the time of autopsy.13,15,42,53,59 The most frequent presenting sign is murmur found in 41% of patients. Patients with associated cardiac anomalies are diagnosed early in life compared to patients with isolated ARCAPA. Associated cardiac defects were reported in 22 (22%) of the patients reported with ARCAPA. The most common cardiac defects found in these patients were aortopulmonary window5,10,25,27,36,41,57 and tetralogy of Fallot. 3,28,37,38,58,67,76 Other uncommon associated cardiac anomalies included atrial septal defect,16,26,34 ventricular septal defect,48 double outlet right ventricle, 29 patent ductus arteriosus, 76 coarctation of the aorta,76 pulmonary stenosis,28 aortic stenosis, 22,75 mitral stenosis,76 mitral regurgitation 21 and tricuspid regurgitation.21 The modality of diagnosis of ARCPA has changed over time. Before 1965, most of the diagnoses were made during autopsy and surgery. Since 1965, angiography was the most commonly used modality for diagnosis of ARCAPA. In 1985, the first case of ARCAPA was diagnosed with echocardiography.52 Since 1985, echocardiography has gained popularity in the diagnosis of ARCAPA. The diagnosis by echocardiography was described in 21 cases (21%) from this database. The common findings on echocardiography are an anomalous RCA, left ventricular dilatation, collaterals between the left and right coronary arteries and dilated coronary arteries.90 Angiography was used as a confirmatory method when the initial diagnosis made by echocardiography in many case reports. In two cases, diagnosis was made by multislice computed tomographic (CT) angiography. 88,89 Cardiovascular magnetic resonance (CMR) was used for the first time in 2007 in for the diagnoses of ARCAPA. 19 Surgical treatment is a definitive therapy that is recommended even for asymptomatic patients. 69,84 Standard therapy is to establish a double-ostium coronary system by translocation of the aberrant vessel to the aortic root, which decreases the risk of sudden cardiac death and also provides relief from coronary steal, which may be responsible for myocardial ischemia. 8,40,84 In addition, it can prevent further dilatation and enlargement of the coronary artery, which in turn reduces the size of the shunt. 86 Ligation of the RCA at its origin and coronary artery bypass grafting (CABG) with a saphenous vein graft is also described. In 2006, Yamamoto et al performed ligation of the RCA and CABG with the radial a artery. 19 Simple ligation of the coronary system is less traumatic and is the simplest alternative, but the risk of a single ostium coronary system still persists.46 From the literature review, 57 patients underwent surgical correction. Forty-seven (47%) of these patients with surgical correction underwent reimplantation and 10 (10%) of those with surgical correction had resorted to simple ligation of the aberrant coronary vessel. In some cases, reimplantation was tried initially but could not be performed due to the fragility of the aberrant vessel. As a result, the patients underwent ligation of the anomalous vessel.24 Only a few patients were treated medically, with no follow up available.9,52 If necessary, mitral valve repair should be provided simultaneously at the time of surgery.17,19 Follow up with ARCAPA after surgical treatment is not well described in the literature. According to the case reports, reimplantation of the anomalous vessel to aorta was the successful. However, persistent symptoms and myocardial ischemia on imaging studies were described in some patients after reimplantation.14,57,74 In 1 patient, there was a reduction in the size of the LAD after reimplantation of the anomalous RCA into the aorta.51 In another case, the patient developed a clot in the RCA 4 years after reimplantation. 76 CMR was used in 1 case for serial follow ups. 19 In our case, echocardiography performed on a regular basis showed improved cardiac function without mitral regurgitation.85 We recommend long-term follow up with the patients on a regular basis to evaluate their ventricular function and the patency of the reimplanted vessel. Conclusion. ARCAPA is a rare congenital coronary anomaly that can be diagnosed by careful echocardiographic evaluation or angiography. Myocardial ischemia, heart failure or sudden cardiac deaths have been observed. Surgical reimplantation is the treatment of choice and should be considered as soon as possible for this potentially fatal condition. Long-term follow up on a regular basis is required to assess ventricular function and patency of the reimplanted vessel.

References

1. Brooks HSJ. Two cases of an abnormal coronary artery of the heart arising from the pulmonary artery with some remarks effect of this anomaly in producing cirsoid dilatation of the vessels. J Anat Physiol 1885;20:26–29.

2. Soloff LA. Anomalous coronary arteries arising from the pulmonary artery. Am Heart J 1942;24:118–127.

3. Coye JY, Radley-Smith R, Yacoub M. Clinical and hemodynamic significance of anomalous origin of right coronary artery from pulmonary artery. Thorac Cardiovasc Surg 1982;30:84–87.

4. Eugester GS, Olivia PB. Anomalous origin of right coronary artery from pulmonary artery. Chest 1973;63:294–296.

5. Luisi SV, Asharaf MH, Gula G. Anomalous origin of right coronary artery from pulmonary artery with aorto pulmonary window: Functional and surgical considerations. Thorax 1980;35:446–448.

6. Shah RM, Nanda NC, Hsiung MC. Identification of anomalous origin of right coronary artery from pulmonary trunk by Doppler color flow mapping. Am J Cardiol 1986;57:366–367.

7. Vairo U, Marino B, De Simone G. Early congestive heart failure due to the origin of right coronary artery from pulmonary artery. Chest 1992;102:1610–1612.

8. Mintz GS, Iskandrian AS, Bermis CE. Myocardial ischemia in anomalous origin of right coronary artery from the pulmonary trunk. Proof of a coronary steal. Am J Cardiol 1983;51:610–612.

9. Mahdyoon H, Brymer JF, Alam M. Anomalous origin of right coronary artery from pulmonary artery presenting with angina and aneurysmal left ventricular dilatation. Am Heart J 1989;118:182–184.

10. Brouwer MHJ, Beaufort Krol GC, Talsma MD. Aortopulmonary window associated with an anomalous origin of right coronary artery. Int J Cardiol 1990;28:384–386.

11. Bregman D, Brennan FJ, Singer A, et al. Anomalous origin of right coronary artery from pulmonary artery. J Thorac Cardiovasc Surg 1976; 72:626–630.

12. Ladowski J, Belvedere D, Wuest L. Anomalous origin of the right coronary artery from pulmonary artery: an unusual case of angina. Cardiovasc Surg 1995;3:81–83.

13. Gerlis LM, Ho SY, Milo S. Three anomalies of coronary arteries co-existing in a case of pulmonary atresia with intact ventricular septum. Int J Cardiol 1990;29:93–95.

14. Kautzner J, Veselka J, Rohac J. Anomalous origin of right coronary artery from pulmonary trunk: Is surgical reimplantation into the aorta a method of choice? Clin Cardiol 1996;19:257–259.

15. Wald S, Stonecipher K, Baldwin BJ. Anomalous origin of right coronary artery from pulmonary artery. Am J Cardiol 1971;27:677–681.

16. Kühn A, Kasnar-Samprec J, Schreiber C. Anomalous origin of right coronary artery from pulmonary artery. Int J Cardiol 2010;39:e27–e28.

17. Wu QY, Xu ZH. Anomalous origin of right coronary artery from pulmonary artery. Chin Med J (Engl) 2008;121:721–724.

18. Cronk ES, Sinclair JG, Rigdon RH. An anomalous coronary artery arising from the pulmonary artery. Am Heart J 1951;42:906–911.

19. Su JT, Krishnamurthy R, Chung T. Anomalous right coronary artery from the pulmonary artery: Noninvasive diagnosis and serial evaluation. J Cardiovasc Magn Reson 2007;9:57–61.

20. Askarragi J, Nadas AJ. Anomalous left coronary artery originating from pulmonary artery. Report on 15 cases. Circulation 1975;5:976–987.

21. Yamamoto S, Schichijo T, Matsuo S, et al. Anomalous origin of the right coronary artery from the pulmonary artery. Jpn J Thorac Cardiovasc Surg 2006;54:260–262.

22. Marik D, Gately HL and Strauss R, et al. Anomalous origin of the right coronary artery from pulmonary artery. J Card Surg 1995;10:55–58.

23. Ross TG, Latham RD, Craig WE. Anomalous origin of the right coronary artery from the main pulmonary artery. South Med J 1987;80:783–786.

24. Nakano M, Emoto H, Koyanagi K, et al. Report of a case of the anomalous origin of the right coronary artery from the pulmonary artery with atrial fibrillation and bradycardia. J Jpn Assoc Thor Surg 1993;41:479–485.

25. Achtel RA, Zaret BL, Iben AB, et al. Surgical correction of left coronary artery–main pulmonary artery fistula in association with anomalous right coronary artery. J Thorac Cardiovasc Surg 1975;70:46–51.

26. Belloroni PM, Soubrane C, Kerneis Y, et al. Coronaire droite née de l’artere pulmonaire: Revue de la literature a propos dune nouvelle observation. Arch Mal Coeur 1988;81:103–107.

27. Blieden LC, Moller JH. Aorticopulmonary septal defect an experience with 17 patients. Br Heart J 1974;36:630–635.

28. Donaldson RM, Raphael M, Radley-Smith R, et al. Angiographic diagnosis of anomalous origin of right coronary artery from pulmonary artery. Br J Radiol 1983;56:17–19.

29. Eidem BW, Cetta R,Roughneen PT, et al. Anomalous right coronary artery from the pulmonary artery in Taussing-Bing anomaly. Ann Thorac Surg 1998;66:1797–1798.

30. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn 1990;21:28–40.

31. Mönckeberg JG. Über eine seltene anomalie des koronaraterienabgangs. Zbl Herz Krankheiten 1914;6:441–445.

32. Schley J. Abnormel ursprung der rechten kranzarterie aus der pulmonalis bei einem 61-jaerigen mann. Frankfurt Z Pathol 1925;25:673–678.

33. Jordan RA, Dry TJ, Edwards JE. Anomalous origin of the right coronary artery from the pulmonary trunk. Proc Staff Meet Mayo Clinic 1950;25:673–678.

34. Rowe GG, Young WP. Anomalous origin of the coronary arteries with the special reference to surgical treatment. J Thorac Cardiovasc Surg 1960;39:777–780.

35. Pribble RH. Anatomic variations of the coronary arteries and their clinical significance. J Indiana State Med Assoc 1961;54:329–333.

36. Burroughs JT, Schmutzer KJ, Linder F, et al. Anomalous origin of the right coronary artery from the pulmonary trunk with aorticopulmonary window and ventricular septal defect. J Cardiovasc Surg 1962;3:142–148.

37. Meng CCL, Eckner FAO, Lev M. Coronary artery distribution in tetralogy of Fallot. Arch Surg 1965;90:363–366.

38. Ranniger K, Thilenius OG, Cassels DE. Angiographic diagnosis of an anomalous right coronary artery arising from the pulmonary artery. Radiology 1967;8:29–31.

39. Rhantigan RM, A. de la Torre A. Anomalous origin of the right coronary artery. Vasc Surg 1971;5:196–203.

40. Tingelstad JB, Lower RR, Eldredge WJ. Anomalous origin of the right coronary artery from the main pulmonary artery. Am J Cardiol 1972;30:670–673.

41. Stopfkuchen H, Feichter GE, Jungst BK. Anomalous origin of the right coronary artery from the pulmonary artery combined with aortopulmonary window. Z Kardiol 1974;63:1086–1098.

42. Lerberg DB, Ogden JA, Zuberbuhler JA, et al. Anomalous origin of the right coronary artery from the pulmonary artery. Ann Thorac Surg 1979;27:87–94.

43. Bermudez GA, Abdelnur R, Midell AI, et al. Anomalous origin of the right coronary artery from the pulmonary artery with large left-to-right shunt (anomalous right coronary artery). Cathet Cardiovasc Diagn 1979;5:371–384.

44. Brotherton H., Philip RK, et al. Anomalous left coronary artery from pulmonary artery (ALCAPA) in infants: A 5-year review in a defined birth cohort. Eur J Ped 2008;167:43–46.

45. Dall’Aglio V, Bazzi A, Burelli C et al. Anomalous origin of the right coronary artery from the main pulmonary artery: Report of the case. G Ital Cardiol 1979;9:422–427.

46. Salomon J, Baltazar R, Mower MM, et al. Anomalous origin of the right coronary artery from the pulmonary artery. Am J Med Sci 1981;281:152–156.

47. Glanz S, Gordon DH, Mesko Z, et al. Anomalous origin of the right coronary artery from the pulmonary artery. Cardiovasc Intervent Radiol 1981;4:256–258.

48. Burakowskii VI. Anomalous derivation of the right coronary artery from the pulmonary artery with an interventricular septal defect. Grud Knir 1981;5–10.

49. Baggioni GF, Percoco GF,Scarfo S, et al. Origine anomala della arteria coronaria destra dal tronco comune della arteria polmonare. G Ital Cardiol 1981;11:1009–1013.

50. Chantepie A, Lavigne G, March M, et al. Coronaire droite naissant de l'artere pulmonaire: traitement chirurgical. Arch Mal Coeur 1982;75:925–932.

51. Van-Meurs-van-Woezik H, Serruys PW, Reiber JH, et al. Coronary artery changes 3 years after reimplantation of an anomalous right coronary artery. Eur Heart J 1984;5:175–178.

52. Suzuki K, Yokochi K, Yoshioka F, et al. Anomalous origin of the right coronary artery from the pulmonary artery: Report of a case. J Cardiol 1985;15:241–248.

53. Huang TY, Hsueh Y, Tsung SH. Endocardial fibroelastosis and myocardial calcification secondary to an anomalous right coronary artery arising from the pulmonary trunk. Hum Pathol 1985;16:959–960.

54. Worsham C, Sanders SP, Burger BM. Origin of the right coronary artery from the pulmonary trunk: Diagnosis by two-dimensional echocardiography. Am J Cardiol 1985; 55:232–233.

55. Ueeda M, Yamada N, Shimizu A, et al. A case of anomalous origin of the right coronary artery from the pulmonary trunk: Imaging of abnormal flow by Doppler color flow mapping. J Cardiol 1988;18:583–587.

56. Saenz CB, Taylor JL, Soto B, et al. Acute myocardial infarction in a patient with anomalous right coronary artery. Am Heart J 1986;112:1092–1094.

57. Tuma S, Hucin B, Reich O, et al. Anomalous origin of the right coronary artery from the pulmonary artery: Preoperative diagnostic finding in the aortopulmonary window. Cesk Pediatr 1990;45:543–545.

58. Tuzcu EM, Moodie DS, Chambers JL, et al. Congenital heart diseases associated with coronary artery anomalies. Cleve Clin J Med 1990;57:147–152.

59. Sreenivasan VV, Jacobstein MD. Origin of the right coronary artery from the pulmonary trunk. Am J Cardiol 1992;69:1513–1515.

60. Fernandes ED, Kadivar H, Hallman GL, et al. Congenital malformations of the coronary arteries: The Texas Heart Institute experience. Ann Thorac Surg 1992;54:732–740.

61. Sundar AS, Fox KA. Anomalous origin of the right coronary artery from the pulmonary artery in association with congenital aneurysm of the sinus of valsalva: Angiographic diagnosis of a rare association. Br Heart J 1992;68:330–332.

62. Tosovsky J, Rohac J. Anomalni odstup prave vencite tepny z plicnice. Rozhl Chir 1993;72:199–200.

63. Vogt R, Tkebuchava T, Arbenz U, et al. Anomalous origin of the right coronary artery from the pulmonary artery. Thorac Cardiovasc Surg 1994;42:125–127.

64. Dahlstrom CG, Hellekant C, Johansson BW, et al. Anomalous origin of the right coronary artery from the main pulmonary artery: A case report. Angiology 1994;45:325–328.

65. Moss RL, Backer CL, Zales VR, et al. Tetralogy of Fallot with anomalous origin of the right coronary artery. Ann Thorac Surg 1995;59:229–231.

66. Barth H, Apitz J. Abnormal origin of the right coronary artery from the pulmonary artery: A case report. Z Kardiol 1995;84:72–76.

67. D’Souza VJ, Chen MY. Anomalous origin of coronary artery in association with aorticopulmonary window. Pediatr Cardiol 1996;17:316–318.

68. Garg N, Tewari S, Kapoor A, et al. Primary congenital anomalies of the coronary arteries: a coronary arteriographic study. Int J Cardiol 2000;74:39–46.

69. Hekmat V, Rao SM, Chhabra M, et al. Anomalous origin of the right coronary artery from the main pulmonary artery: Diagnosis and management. Clin Cardiol 1998;21:773–776.

70. Di Luozzo M, Berni A, Nigri A. Origine anomala della coronaria destra dalla arteria polomonare: Descrizione di un caso clinic. G Ital Cardiol 1998;28:57–60.

71. Malec E, Zajax A, Mikuta M. Surgical repair of anomalous origin of the coronary artery from the pulmonary artery in children. Cardiovasc Surg 2001;5:292–297.

72. Werner B, Wroblewska-Kaluzewska M. Pleskot M, et al. Anomalies of the coronary arteries in children. Med Sci Monit 2001;7:1285–1291.

73. Vijitbenjaronk P, Glancy L, Ferguson TB, et al. Right coronary artery arising from the pulmonary trunk in a 63-year-old man. Catheter Cardiovasc Interv 2002;57:545–547.

74. Veselka J, Widimsky P, Kautzner J. Reimplantation of anomalous right coronary artery arising from the pulmonary trunk leading to normal coronary flow reserve late after surgery. Ann Thorac Surg 2003;76:1287–1289.

75. Bossert T, Walther T, Doll N, et al. Anomalous origin of the right coronary artery from the pulmonary artery combined with aortic valve stenosis. Ann Thorac Surg 2005;79:347­–348.

76. Williams I, Gersony W, Hellenbrand W. Anomalous right coronary artery arising from the pulmonary artery: A report of 7 cases and a review of the literature. Am Heart J 2006;152:1004.e9–e17.

77. Ogiwara M, Hojo H, Ozaki M, et al. Off-pump coronary artery bypass grafting for a patient with anomalous origin of the right coronary artery from the pulmonary artery. Ann Thorac Cardiovasc Surg 2006;12:432–434.

78. Ashkenazi J, Nadas AJ. Anomalous left coronary artery originating from the pulmonary artery. Circulation 1975;51: 976–977.

79. Hurwitz RA, Caldwell RL, Girod DA, et al. Clinical and hemodynamic course of infants and children with anomalous left coronary artery. Am Heart J 1989;118:1176–1182.

80. Schwartz ML, Jonas RA, Colan SD. Anomalous origin of the left coronary artery from pulmonary artery: Recovery of left ventricular function after dual coronary repair. J Am Coll Cardiol 1997;30:547–553.

81. Kardos A, Babai L, Rudas L, et al. Epidemiology of congenital coronary artery anomalies: a coronary arteriography study on a central European population. Cathet Cardiovasc Diagn 1997;42:270–275.

82. Pillai SB, Khan MM, Diamond A, et al. The prevalence and types of coronary artery anomalies in Northern Ireland. Ulster Med J 2000;69:19–22.

83. Bortolotti D, Casarotto D, Betti D, et al. Anomalous origin of the right coronary artery from the main pulmonary artery. Eur J Cardiol 1978;7:451–455.

84. Radke P, Messemer B, Haager P, et al. Anomalous origin of the right coronary artery: ppreoperative and postoperative hemodynamics. Ann Thorac Surg 1998;66:1444–1449.

85. Fujikawa K, Asano S, Magari S. A case of anomalous right coronary artery arising from the pulmonary artery. Kalibogaku Zasshi 1975;50:241–248.

86. Yao C, Wang J, Yeh C, et al. Isolated anomalous origin of right coronary artery from the main pulmonary artery. J Card Surg 2005;20:487–489.

87. Capuno C, Sesana M, Capuno F, et al. Right coronary artery arising from the pulmonary artery. Cardiovasc Revasc Med 2007;8:76–79.

88. Waite S, Ng T, Afari A, et al. CT diagnosis of isolated anomalous origin of the RCA arising from the main pulmonary artery. J Thorac Imag 2008;23:145–147.

89. Tedeschi C, Briguori C, De Rosa R, et al. Right coronary artery arising from pulmonary trunk: assessment with conventional coronary angiography and multislice computed tomography coronary angiography. J Cardiovasc Med 2009;10:178–182.

90. Yang YL, Nanda NC, Wang XF, et al. Echocardiographic diagnosis of anomalous origin of the left coronary artery from pulmonary artery. Echocardiography 2007;4:405–411.

________________________________________________
From the University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn, Illinois. The authors report no conflicts of interest regarding the content herein. Manuscript submitted August 14, 2009, provisional acceptance given September 25, 2009, final version accepted October 6, 2009. Address for correspondence: Harshit Modi, MD, 15613 Plumtree Drive, Orland Park, IL 60462. E-mail: modiharshit@hotmail.com