One Ostium to Rule Them All: Rare Case of a Single Coronary Artery

J INVASIVE CARDIOL 2021;33(11):E917.

Key words: anomalous coronary artery, cardiac imaging, coronary computed tomography angiography

A single coronary artery (SCA) is a rare congenital anomaly, estimated to occur in 0.024% of the population, where all 3 coronary vessels arise from a single ostium. These patients can have a wide range of symptoms, from asymptomatic to angina and sudden cardiac arrest.

A 50-year-old man with hypertension and hyperlipidemia presented to the cardiology office for chest pain. He underwent an exercise stress test that was equivocal (negative electrocardiogram, but experienced reproduction of symptoms).

The decision was made to proceed with coronary angiography, which demonstrated anomalous coronary circulation with 1 ostium for all arteries at the site of the right coronary cusp. Vessels were normal caliber and without evidence of disease. The left anterior descending/left circumflex coronary course was not clearly identified and coronary computed tomography angiography (CCTA) was recommended.

CCTA confirmed anomalous common origin anterior to the sinus of Valsalva and the course was prepulmonic (Figure 1). Given the benign prognosis associated with prepulmonic course, the patient was managed conservatively.

Ischemic work-up is important in this group of patients, with coronary angiography being the gold standard. As demonstrated here, CCTA is an essential tool to define artery course and provide further risk stratification. SCAs were originally classified by Lipton et al based on the site of origin and subtypes of anatomical distribution. Some subtypes are higher risk for SCA, especially during exercise due to the artery coursing between the aorta and pulmonary artery. Prepulmonic course is generally associated with a benign course.