ACAOS (Anomalous Coronary Artery From the Opposite Sinus) as Part of a Chaos: 75 Years of Harmonious Occult Coexistence

Keywords: anomalous coronary artery, ACAOS, coronary artery atresia

A 75-year-old woman was referred to our center for coronary angiography (CA) due to atypical chest discomfort unrelated to exertion and accompanying coronary artery disease risk factors (hypertension, type 2 diabetes, former smoker). CA was unremarkable for significant stenosis, but revealed complex anatomic anomalies. Left coronary artery system cannulation (Figure 1A and Video 1) illustrated a 75-year proved-to-be nonfatal, left main coronary artery atresia (LMCAA) and bifurcation to the left circumflex (LCX) and a hypoplastic proximal left anterior descending artery (hpLAD). An ectopic branch (EB) originated from the left coronary sinus and retrogradely supplied the LCX through the first obtuse marginal (OM1) by a coronary bridge (CB). The right coronary artery (RCA) catheterization (Figure 1B and Video 2) depicted a dominant RCA and, unexpectedly, an ectopic LAD (eLAD) originating from the proximal RCA; in other words, an anomalous coronary artery from the opposite sinus (ACAOS). The eLAD coursed obliquely to the left, exhibiting an intraseptal route (resembling the anomalous septal course of the LMCA originating from the right coronary sinus) and continued as mid-distal LAD, heading down to the anterior interventricular sulcus (note the septal branches throughout the vessel course). Coronary computed tomography angiography (CCTA) deciphered the 3-dimensional path of her coronary tree (Figures 1C, 1D).

It is uncommon for the LAD to arise from the contralateral Valsalva sinus, and more of a rarity to see coexistent LMCAA. Our patient reported normal daily physical activity and denied further evaluation (stress test, scintigraphy) or cardiothoracic consultation. She continues to be symptom free at 1-month follow-up.

Affiliations and Disclosures

From the Cardiology Department, Trikala Hospital, Trikala, Thessaly, Greece.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted January 15, 2022.

Address for correspondence: Dimitrios Karelas, MD, R. Feraiou 13, 43100, Karditsa, Greece. Email: dim.f.karelas@gmail.com