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The article highlights peculiarities of localization of myocardial bridges. It is believed that the coronary arteries and their branches are located in the subepicardial tissue. However, some researchers describe cases of intramural localization of their sections. Myocardial bridges – a set of fibers of the ventricular myocardium located over a certain area of the subepicardial branch of the coronary artery - represent variants of such localization.The aim of the study was to establish the patterns of macroscopic anatomy and topography of myocardial bridges investigating anatomical sections of the human heart in the adult and elderly people. Material and methods. The study involved 65 formalin-fixed sample preparations of the human heart of the adult and elderly people who died of conditions that were not associated with heart diseases. The authors measured transverse and longitudinal dimensions of the ventricular complex of the heart, and calculated the transverse-longitudinal index. Subepicardial vessels were prepared without prior injection. The number of myocardial bridges over the main branches of the coronary arteries was counted and their length was measured. The type of blood supply to the heart was determined according to a three-member classification, depending on the source of discharge of the posterior interventricular branch. Results. Myocardial bridges were observed on 44 (67.6%) sample preparations. As a rule, they were located over the branches of the left coronary artery (91.5%). They were typically located in the proximal half of the anterior interventricular sulcus. The length of the bridges ranged from 2.5 to 64 mm (Me = 13 mm). A direct positive correlation was found between the length of the ventricular complex of the heart and the length of the bridges. The relationship between the type of blood supply to the heart and the presence of bridges was not revealed. In 26 preparations, a cone artery departed from the right coronary sinus of the aorta, in addition to the right coronary artery, and bridges were observed in 17 sample preparations. Conclusion. Myocardial bridges are more typical for the branches of the left coronary artery compared to the right. They are typically localized in the proximal third of the anterior interventricular sulcus. There is a dependence between the length of the bridges and the length of the ventricular complex of the heart. The distribution and number of myocardial bridges does not depend on the type of blood supply to the heart, but is associated with the independent discharge of the cone artery from the aorta.

The coronary artery, which divides into the left coronary artery and the right coronary artery, is the first branch of the ascending aorta. The left coronary artery is a short trunk that originates from the left aortic sinus. It passes through the beginning of the pulmonary artery and the left atrial appendage and travels 3–5 mm along the coronary sulcus to the front of the left side of the heart. It is immediately divided into the anterior descending branch and the circumflex branch. The anterior descending branch descends along the anterior interventricular sulcus, bypassing the apical notch to the diaphragm of the heart, and anastomoses with the posterior interventricular branch of the right coronary artery. The right coronary artery originates from the right aortic sinus, travels along the right coronary sulcus between the root of the pulmonary artery and the right auricle, bypasses the right edge of the heart, continues along the coronary sulcus of the diaphragm, and projects into the posterior descending branch near the atrioventricular junction, that is, the posterior interventricular branch.

OBJECTIVES Detailed anatomical information is essential for planning of surgical therapy in patients with congenital heart disease. We wanted to determine whether cinematic rendering, the novel 3-dimensional visualization technique, could help paediatric cardiac surgeons achieve better preoperative visualization of the extracardiac anatomy in patients with complex congenital heart defects. Therefore, cinematic rendering was compared to the traditional volume rendering technique by means of a questionnaire with predefined criteria. METHODS Picture sets from 20 infant patients (mean age = 17 days) were generated from computed tomography data with both the cinematic rendering and the volume rendering techniques. These were presented side by side in a digital high-resolution portfolio without labelling them. Three experienced paediatric cardiac surgeons were provided with these portfolios and a questionnaire. They were asked to evaluate the images individually in predefined categories on a 4-point Likert scale from 1 = 'fully acceptable' to 4 = 'unacceptable'. RESULTS Cinematic rendering scored significantly better values on the Likert scale in 7 of 9 categories, namely 'spatial impression in general', 'depth perception', 'delineation of the atrial appendages/pulmonary veins/peripheral pulmonary arteries', 'assessability of the anterior interventricular sulcus' and 'assessability of the aortic arch branches'. CONCLUSIONS Cinematic rendering is a valuable software tool, and our data suggest that it provides significantly better visualization than volume rendering. The surgeons appraised improved depth perception and delineation of structures adjacent to the heart as the most significant advantages.

Outflow Tract VT With Pattern Break in Lead V2Introduction In outflow tract ventricular arrhythmias (OT-VAs), an abrupt loss of the R wave in lead V2 compared to V1 and V3 (pattern break in V2–PBV2) suggests an origin close to the anterior interventricular sulcus (anatomically opposite to lead V2) and adjacent to proximal coronaries. We studied the outcome of catheter ablation of OT-VAs with a PBV2. Methods and Results Of 130 consecutive patients with idiopathic left bundle block morphology OT-VAs and transition ≤V4, 12 (9%) had PBV2. Outcomes in this group were compared to the remaining 118 patients. Patients with PBV2 were more likely to be younger (41 ± 18 vs. 50 ± 14 years, P = 0.0384) and women (11 [92%] vs. 70 [59%], P = 0.0302). The earliest activation was at the RVOT in seven, left coronary cusp (LCC) in one, anterior interventricular vein (AIV) in two and the epicardium in two. In five (42%) cases (earliest activation in the AIV in two, epicardium in two, and RVOT below the valve level in one), ablation was aborted due to proximity to the left anterior descending (LAD) coronary artery. After 36 ± 17 months and 1.3 ± 0.5 procedures, VAs elimination was achieved in 58% of patients with PBV2 compared to 89% of the reference population (P = 0.0125) with effective site in five of seven at the most anterior and leftward RVOT adjacent to the pulmonic valve (PV). Conclusions OT-VAs with PBV2 demonstrate a unique ECG pattern and challenging catheter ablation. Proximity to LAD precludes ablation in about half. Long-term VA suppression could be achieved in only 58% of cases most commonly when the earliest site is at the anterior and leftward RVOT just under the PV.

The Left anterior descending artery (LAD) is a branch of the left main coronary artery which runs obliquely towards the apex of the heart in the anterior interventricular sulcus. Among all of the coronary arteries, the LAD artery has the most constant course. Amongst the anomalies of coronaries, the duplication or bifurcation of the LAD artery is infrequent. The classification of the bifurcation of the LAD has been extensively described in various reports with the widespread use of CT Angiography. We describe herein, an anomalous LAD detected on autopsy. This unusual case highlights the gross autopsy finding of Type-I anomalous dual LAD coronary artery in a young adult who died of Myocardial Infarction.

We describe the heart from a 79-year-old woman with no medical history of cardiac complaints. Her heart shows a regular right coronary artery (RCA) and a variant left coronary artery (LCA) arising from the right sinus of Valsalva. The common stem of the RCA and the LCA is extremely short. The LCA depicts a preinfundibular course with a cranial-anterior loop and reaches the intersection of the anterior interventricular sulcus and the left coronary sulcus, where it divides into the regular branches, the anterior interventricular branch (left anterior descending, LAD) and the circumflex branch (left circumflex, LCx). All further branching resembles a normal distribution with the posterior interventricular branch coming for the RCA. Such a variant LCA is extremely rare with a reported incidence of 0.17 %. However, recognition and angiographic demonstration of such a variation assume the highest priority in a patient undergoing, for instance, direct coronary artery surgery or prosthetic valve replacement.

Objective: A routine dissection of the cadaver of a 67-year-old man revealed a very rare morphological variant of the great cardiac vein (GCV). Presentation: The vein originated in the upper third of the anterior interventricular sulcus, crossed the anterior interventricular artery superficially, ran beneath the circumflex artery, crossed the transverse pericardial sinus, and drained directly into the superior vena cava. Conclusion: This variant of the GCV is interesting due to its rarity. It is important to know about it for procedures that require venous access such as coronary surgery requiring retrograde cardioplegia, surgical ablation of aberrant conducting pathways, pacemaker insertion, and valve surgery.

Coronary artery anomalies are rare and generally benign clinical situations seen in 1.3% of the total population (1). Dual left anterior descending artery (LAD) has a variant course and is formed from two branches of LAD defined as short and long LAD. Several types of LAD have been described in the literature (2-4). Type IV dual LAD is a very rare form. The short LAD originates from left main coronary artery (LMCA) and terminates proximally in anterior interventricular sulcus (AIVS) giving off diagonal and septal branches. The long LAD originates from right sinus Valsalva passing through the anterior of infundibulum of the right ventricle and terminates in distal AIVS. In this case report, we present a patient with type IV dual LAD misdiagnosed as chronic total occlusion of LAD.

CT angiography in a 45-year-old woman with atypical chest pain revealed two left anterior descending (LAD) arteries in the anterior interventricular sulcus (AIS). The longer LAD (white arrowhead in [figure 1A–D][1]) was arising from the left main coronary artery (LMCA) and was coursing up to the

Congenital coronary anomalies are rare and reported to occur in 0.64-1.3% of patients undergoing coronary angiography. The dual left anterior descending coronary artery (LAD) is a rare coronary anomaly defined as the presence of two LADs in the anterior interventricular sulcus (AIVS). It consists of a short LAD that ends high in the AIVS and a longer LAD that enters the distal AIVS and feeds apex. Percutaneous interventions are even more uncommon in dual LAD especially Type V LAD. Thus we describe an interesting case of percutaneous transluminal coronary angioplasty (PTCA) with stenting to Type V dual LAD in a patient with chronic stable angina who was refractory to maximal anti-anginal medications. Our case was unique for these aspects - 1)Type V dual LAD is rare.2)Ramus artery is present in fewer cases of dual LAD.3)Long LAD had a myocardial bridge.4)Few cases have been reported of PTCA with stenting to short LAD. .

We studied an extremely rare great cardiac vein anomaly in a 65-year-old woman during dissection practice at the Akita University School of Medicine (2013). The great cardiac vein has two main roots, one accompanied by a left marginal vein that pours into the coronary sinus, and the other ascending along the anterior interventricular sulcus from the apex, and running over the circumflex branch of the left coronary artery. It then runs along the atrial side of the transverse sinus of the pericardium, and drains directly into the superior vena cava. No anastomosis between these veins was evident. The great cardiac vein might originate from two venous systems, one in the posterior wall of the left ventricle, and the other running along the anterior interventricular sulcus. These venous systems flow in the venous network of the left edge of the coronary sulcus. The former venous system always selected the course, which went to the coronary sinus in the venous network. The latter system may drain into one of the following four courses: the first one contacts the former course; the second passes to the transverse sinus of the pericardium and flows to the (right) superior vena cava; the third passes between a pulmonary trunk and ascending aorta from the dorsum of the pulmonary trunk, turns around in a ventral aspect, and then flows into the left superior vena cava; and the fourth flows to the anterior cardiac vein. The first of these belongs to the normal great cardiac vein, but the others are anomalous.

Coronary vessel development has been investigated in avian and mouse embryonic hearts. Quail embryos are a useful tool to examine vascular development, particularly because the QH1 antibody and transgenic quail line, Tg (tie1:H2B-eYFP), are useful to trace endothelial cells. However, there are only a few descriptions of the quail coronary vessels. Using ink injection coronary angiography, we examined the course of coronary vessels in the fetal quail heart. The major coronary arteries were the right and left septal arteries, which, respectively, branched off from the right and left coronary stems. The right septal artery ran posteriorly (dorsally) and penetrated the ventricular free wall to distribute to the posterior surface of the ventricles. The left septal artery ran anteriorly (ventrally) and penetrated the ventricular free wall to distribute to the anterior surface of the ventricles. The right and left circumflex arteries were directed posteriorly along the atrioventricular sulci. The cardiac veins consisted of three major tributaries: the middle, great, and anterior cardiac veins. The middle cardiac vein ascended along the posterior interventricular sulcus and emptied into the right atrium. The great cardiac vein ran along the anterior interventricular sulcus, entered the space between the left atrium and conus arteriosus and emptied into the right atrium behind the aortic bulb. The anterior cardiac vein drained the anterior surface of the right ventricle and connected to the anterior base of the right atrium. The course of coronary vessels in the quail heart was basically the same as that observed in chick but was different from those of mouse and human.

1900 years ago Galen stated that blood seeps through the perforations in the interventricular septum. However, William Harvey, working 400 years ago, failed to find any. In this study an aqueous solution of a black dye was gently pumped by hand into the right ventricle of 20 porcine hearts. The area in the middle ofthe left muscular part of the interventricular septum in 13 of the hearts was bloodstained under the endocardium at the time the heart stopped beating. The same area of all 20 hearts eventually became stained black. A small amount of black dye seeped through the endocardium of 18 hearts in the middle of the left muscular part of the interventricular septum. In another 20 porcine hearts theinterventricular septa were dissected after boiling. The deep pit under the anterior interventricular sulcus communicated with the right ventricle and with the middle of the left muscular part of the interventricular septum between the fibres of the muscle. The communication closed tight at the very early systole. The communication resembled that reported by Galen 1900 years ago. The communication may be the real foetal route for diastolic circulation through the muscular part of the interventricular septum from right to left. The results suggested that the anatomy, function and embryology of the African monkey, human and porcine heart are not yet fully understood.

To the Editor, Anomalies of and variations in the coronary arteries are important in pathophysiology and the treatment of cardiovascular diseases. The left anterior descending (LAD) coronary artery has the most constant origin, course, and distribution in the human heart; anomalies are rare. Dual LAD was first reported and classified into four types by Spindola-Franco et al. [1] Among these four types, a type 4 anomaly comprises two LADs: a short LAD that originates from the left coronary arteries, terminates in the middle of the anterior interventricular sulcus (AIVS), and does not reach the apex, and a long LAD that originates from the right coronary artery (RCA) transverse to the right ventricular infundibulum, enters the AIVS, and courses to the apex. Type 4 dual LAD is one of the rarest of coronary anomalies. Here, we report a rare case of dual LAD arising from the left and right coronary arteries with superimposed atherosclerotic coronary artery disease (CAD). A 69-year-old man presented to our cardiology department with chest pain, which was aggravated by fast walking and relieved by rest. His medical history included surgery for spinal stenosis, prolonged steroid use, and iatrogenic Cushing syndrome. He had a 60-pack-year history of smoking, but had quit 3 years earlier. No specific findings were obtained from a physical examination and laboratory testing other than serum hepatitis B virus surface antigen positivity. A normal chest X-ray was obtained. An electrocardiogram showed a normal sinus rhythm without any remarkable abnormalities. Transthoracic echocardiography revealed suspicious hypokinesia at the posterolateral wall with aortic valve sclerosis and an ejection fraction of 57%. The patient also underwent cardiac single-photon emission computed tomography (SPECT), which showed an irreversible photon deficiency in the septum and reversible photon deficiency in the anterior wall and apex. To evaluate the patient’s chest pain and rule out CAD, we performed coronary angiography using the standard right femoral Judkin technique. A left coronary angiogram revealed a short LAD and left circumflex artery (LCX). The LAD was not visualized near the apicoseptal region of the left ventricle. The mid and distal portions of the LAD were avascular and free of collateral circulation. The LAD traveled normally and terminated after the small second septal and diagonal branches (Fig. 1A). A selective right coronary angiogram revealed an anomalous branch that originated from the proximal RCA and coursed very closely with the short LAD, which originated from the left main artery in the AIVS and terminated at the apex (Fig. 1B). We interpreted this angiographic finding as the LAD, supplied by both the left main coronary artery and RCA. Significant atherosclerotic stenosis was detected in the proximal and middle portions of the LCX (Fig. 2A). On-site percutaneous coronary intervention (PCI) was performed for the LCX with a 3.5 × 24.0-mm Pico stent for the proximal lesion and a 3.0 × 30.0-mm Pico stent for the middle lesion (Fig. 2B). The patient was discharged 1 day after PCI without complications. Figure 1. A coronary angiogram showing the left anterior descending (LAD). (A) A short LAD (arrow) was found to terminate in the middle of the anterior interventricular sulcus after small second septal and diagonal branches. (B) An anomalous branch from the proximal ... Figure 2. A coronary angiogram showing the left circumflex artery (LCX). (A) Critical stenosis was seen in the proximal and middle LCX (arrows). (B) Successful coronary intervention for the LCX was performed using two Pico stents and balloon angioplasty. The broad application of coronary angiography has revealed many anomalies of the coronary arteries that vary in number, origin, course, distribution, and termination point. In 1983, Spindola-Franco et al. [1] reported 23 cases of dual LAD and classified the anomaly into four subtypes according to the origin and course of the long LAD, as follows. Type 1: the short LAD runs in the AIVS and is generally the source of all major proximal septal perforators. The long LAD also runs in the AIVS, descending on the left ventricular side of the AIVS and reentering the distal AIVS to reach the apex. Type 2: the short LAD is the same as in type 1, but the long LAD descends over the right ventricular side before reentering the AIVS. Type 3: the short LAD is consistent with that in types 1 and 2. The long LAD travels intramyocardially in the ventricular septum. Type 4: high in the AIVS, a very short vessel is formed by the LAD proper and the short LAD. The major septal perforators and diagonal branches originate from this vessel. The long LAD is from the RCA. Type 1 to 3 anomalies arise separately from the proximal part of the LAD and are divided into two left coronary arteries. In a type 4 LAD, the LAD is supplied by the LAD proper and the RCA. It is extremely rare among the four types; only a few cases have been reported worldwide to date [1-5]. Kunimoto et al. [2] reported a case of type 4 dual LAD confirmed by both multidetector-row computed tomography and coronary angiography, while Kosar [4] reported a type 4 dual LAD found incidentally in a patient with LCX stenosis. In our patient, the long LAD originated from the RCA and coursed very closely with a short LAD originating from the left main artery in the AIVS that terminated at the apex. Therefore, this anomaly was classified as a type IV dual LAD. Dual LAD is benign in nature and usually asymptomatic. However, when atherosclerotic CAD is present, it is difficult to differentiate major stenosis or occlusion of the mid or distal portion of the LAD from this anomaly. Whether or not this anomaly can precipitate CAD has not been established. The angiographic evaluation of coronary artery anomalies is crucial for both coronary artery intervention and surgery involving the coronary arteries [1-5]. In patients with suspected acute coronary syndrome superimposed by coronary artery anomalies, a mismatch may occur between the results of noninvasive studies of the involved vessel (e.g., echocardiography or cardiac SPECT) and those of coronary angiography. Knowledge of these anomalies would help clinicians locate the correct culprit lesion and prevent erroneous decisions. Spindola-Franco et al. [1] described a patient with type 4 dual LAD and an acute ventricular septal defect in the apical portion of the interventricular septum. Occlusion of the RCA and severe disease of the long LAD explained the apical septal rupture in the presence of a patent LAD proper and a normal, short LAD [1]. In conclusion, we treated a patient with type 4 dual LAD and an atherosclerotic lesion in the LCX. Being alert to this coronary artery anomaly will help clinicians to diagnose and manage patients properly. To our knowledge, this is the first such case in Korea.

Background and aims: Coronary arteries are known for their wide variations which are not readily covered in the standard Anatomy textbooks. Unpreparedness about these variations can lead to diagnostic misinterpretations and therapeutic catastrophes. Therefore a thorough knowledge of the coronary anatomy with demographic variations is highly essential. The Anterior interventricular artery or Left Anterior Descending artery is one of the most common site of coronary infarction and has been named as 'the artery of coronary occlusion' and 'the artery of sudden death'. Therefore, this study is focused on the variations of this artery with special reference to its origin, course and termination. Materials and methods: One hundred hearts were studied, using standard methods of dissection. The anterior interventricular artery was dissected out and its origin, course and termination were noted. Results: The anterior interventricular artery originated as a terminal branch from the left coronary artery, descended along the anterior interventricular sulcus and terminated near the apex or up the posterior interventricular sulcus. It terminated anterior to the apex in 12%, 2-5 cm up the posterior interventricular sulcus in 57% and >5cm up the sulcus in 31 % cases. Conclusion: The present study contributes to the increasing database of coronary artery variations and would help clinicians in better understanding of coronary anatomy and in better patient management.

Background A normal anatomy of coronary arteries is important to have adequate cardiac muscle blood supply especially during extraneous physical activities. This case report describes a rare coronary anomaly in which the accessory coronary artery arose from the right coronary artery, reentered the left anterior descending coronary artery, and then ran as a single vessel. Case presentation We present a case of a coronary anomaly in a 47-year-old white man who presented with atypical angina. Computed tomographic angiography and coronary angiography showed a variant of dual left anterior descending coronary artery not previously described. Our patient’s accessory coronary artery arose from his right coronary artery. It took an intramuscular course beneath the right ventricular outflow tract in the interventricular septal area to the anterior interventricular sulcus, giving off septal perforators that reentered his medial left anterior descending coronary artery. Both vessels ran after the anastomosis in the anterior interventricular sulcus as a single vessel. Conclusions We propose that this anomaly represents a new variant of coronary artery anomaly. This coronary artery anomaly does not cause ischemia. Recognition of this coronary anomaly is important in patients undergoing percutaneous coronary intervention or coronary artery bypass graft operations.

Coronary artery anomalies are usually asymptomatic and associated with other cardiac malformations. Dual left anterior descending coronary artery (LAD) is an uncommon congenital anomaly with four subtypes. This anomaly has been described in the angiographic literature and dual LAD types depending on the origin of major septal and diagonal branches and course within the anterior interventricular sulcus. Type IV expresses the anomaly of a rudimentary LAD artery ending in the mid-portion of the anterior interventricular sulcus, and the presence of other LAD originating from the right coronary artery and continuing to the anterior interventricular sulcus. We report the rare case of a patient with the type IV dual left anterior descending coronary artery.

Coronary CT angiography (CCTA) has the advantage over invasive coronary angiography in that its non-invasive nature and minimal risk on patients. CCTA enables accurate assessment of the entire heart, coronary artery system and thorax, displaying three-dimensional information about the spatial relations of the anomalous vessels and surrounding intraluminal and extraluminal anatomy, and thereby contributing clinically important prognostic information. Dual left anterior descending (LAD) coronary artery consists of of two LAD arteries within the anterior interventricular sulcus (AIVS). Type 4 is infrequently reported subtype and differs from the others, with a long LAD originating from the right coronary artery (Mercado, A., Johnson Jr, G., Calver, D., & Sokol, R. J. (1989). Cocaine, pregnancy, and postpartum intracerebral hemorrhage. Obstetrics & Gynecology, 73(3, Part 2), 467-468. and the short LAD originating from the left main coronary artery. However, the radiological features between the short LAD and septal coronary arteries remain a controversy, with the latter being determined by CCTA. We present a case report based on short LAD terminating proximally in the AIVS and the long LAD originating from the RCA and terminating into the distal AIVS with the later having a long septal travelling parallel to the long LAD.

An asymptomatic obese 60-year-old man with an increased cardiovascular risk profile (arterial hypertension and hypercholesterolemia) was checked prior to hip surgery. Resting ECG was normal. Exercise test was not possible. A dipyridamole myocardial perfusion scintigraphy showed inferolateral ischemia and a preserved left ventricular (LV) function. Coronary angiography demonstrated moderate atherosclerosis in the proximal segment of the right coronary artery (RCA) and a moderate stenosis in the distal segment of the posterolateral branch (Fig. A). The left anterior descending artery (LAD) and diagonal branches were visualized simultaneously. No additional coronary ostium could be found. The contrast enhanced cardiac CT was performed and it confirmed the absence of a left coronary ostium and a single RCA with two large right ventricular (RV) branches continuing to the left coronary artery (LCA). The first RV branch continued to the diagonal branch. The second RV branch continued to the LAD. Interestingly, in the anterior interventricular sulcus, the LAD had a bidirectional course proximally and distally, with proximally the emergence of an hypoplastic left circumflex artery (LCX) (Fig. B, C). None of the branches were running between the pulmonary artery and the ascending aorta, corresponding with a R-II A classification according to Lipton/ Yamanaka.

Summary Using the thiocholine method and histological techniques, the topography and morphology of cardiac ganglia in midday gerbil, Egyptian spiny mouse, chinchilla laniger and pigeon were studied. The results demonstrated that cardiac ganglia in all investigated species are embedded in epicardial fat. They formed plexo-ganglionic structures. Each of them composed of many ganglia (from seven up to 36) different in size and shape, and interconnected by fascicles of nerve fibres. Comparative analysis showed that the density of neural network and cell aggregations was different in individual species. The richest plexo-ganglionic structure was in pigeon. It was organized in three plexo-ganglia with an average of 30 ganglia. The largest one was located along the anterior interventricular sulcus. The cardiac ganglia of investigated mammals were localized mainly on the epicardium of atria; in Egyptian spiny mouse and chinchilla laniger on the ventral surface of right atrium, but in midday gerbil on the dorsal surface of left atrium. Moreover, in midday gerbil and Egyptian spiny mouse the little plexo-ganglionic structure on the ventricle were noticed. Additionally, in midday gerbil the single nerve cells might be observed between cardiac muscle of atria. It can be said that, the strongly developed cardiac plexus in pigeon is probably connected with his behaviour and functional properties of the heart. The arrangement of neurones in cardiac ganglia of all examined mammals was uniform over the whole surface of the sections, while in the pigeon, neurones were located mainly in the peripheral part of the ganglion.

A left single coronary artery of heart was observed during anatomy practice at Kumamoto University School of Medicine in a 73-year-old female cadaver who died from a thalamic hemorrhage. The left single coronary artery, having a single orifice in the left aortic sinus, bifurcated into the anterior interventricular (IVa) and circumflex (CIR) arteries. No orifice of the right coronary artery was found on the aortic wall. Giving off a branch which traversed the upper part of the infundibulum to supply the anterior upper region of the right ventricle, the IVa descended in the anterior interventricular sulcus to supply the apex of the heart. The CIR curved leftwards in the atrioventricular sulcus to reach the posterior surface, after which it continued to emerge again into the anterior surface. The atrial arteries showed no anomalous distribution pattern and histological observation revealed no pathological abnormality other than a slightly thickened tunica intima. Furthermore, we observed the distribution patterns of bilateral coronary arteries in 377 hearts dissected during anatomical practice over 13 years at Kanazawa University (1980-1986) and Kumamoto University (1993-1998). Although the reason why only the right coronary artery was absent is left unexplained, it was concluded that the left single coronary artery in this study, having the developed left conal and circumflex branches, was an extreme case of the left dominant series of coronary arteries. The formation of single coronary arteries can be explained embryologically by the change of flow in the capillary plexus established on the ventricle wall.

We thank Dr Kaleda for his commentary [1] on our recent publication [2]. We appreciate his valid observation that mixed two different classifications: one related to single coronary artery [3] and the other related to dual left anterior descending coronary [4]. Angelini et al. [5] suggested a new classification that instead of alphabetical–numerical listings (as R-IIIC type, Type IV dual LAD), preferred to be more descriptive, using clear terminology that identifies each anomaly. Moreover, Angelini preferred to combine the traditional headings ‘anomalies of origin’ and ‘anomalies of course’ in one classification group, because the proximal course of a coronary artery can only be abnormal if the origin of the artery is abnormal (except in the case of intramural or subendocardial coronary arteries) [4]. Recently, Sithamparanathan et al. [6] suggested that previous classifications [3, 4] are limited to invasive angiography and not transferable for use with other imaging modalities. Additionally, they are not applicable to patients with congenital heart disease. For all these reasons, Sithamparanathan et al. have proposed a new descriptive and alphanumeric classification for the complete delineation of coronary anatomy and great vessels. However this new classification needs to be clinically validated in the near future [6]. In our recent publication [2], the coronary anomaly was correlated with a single coronary ostium and the left circumflex artery presented a retroaortic path and partly supplied the proximal portion of the anterior interventricular sulcus. This anatomical pattern did not contraindicate a conventional surgical approach to the aortic valve. It is important to recognize preoperatively coronary anomalies in order to understand the pathophysiological mechanisms that could be potentially lethal during cardiac surgery. For this reason, we consider that any classification should be clinically oriented [5].

Background: It is necessary knowing the large variability of right coronary (RCA) artery specialty for its implications in surgical procedures and clinic events. This variability is usually related to the length, branches quantity, origin and irrigated territories. Objective: To evaluate by dir ect examination the morphologic expression of RCA in Colombian people. Methods: RCA were measured in 221 fresh hearts by RCA ostium canalization with polyester synthetic resin that was injected in their branches. Results: The caliber of the RCA proximal segment and at the level of the acute angle of the heart was 3.42 ± 0.66 mm and 2.9 ± 0.50 mm, respectively. It ended between crux cordis and the left margin in 75.6% of specimens. Posterior interventricular artery (PIA) reached the inferior third, or the apex, or the anterior interventricular sulcus in 149 (67.4%) cases. Sinoatrial node artery (SNA) originated in the right coronary in 134 (60.6%) cases, 77 (34.9%) from circumflex artery (CxA) and from both in 10 (4.5%). Posterior right diagonal artery (PRDA) was noted in 38 (17.2%) hearts, but only 6% of the sample with long PIA, concomitantly presented the PRDA (P = 0.001). In right dominance SNA were originated from RCA in 54.7% and form CxA in 46.3% (P = 0.06). Conclusions: Caliber of the RCA and its branches is lesser than the majority of previous studies, while the PRDA frequency is slightly higher than the reported in literature. Clinical and pathological scenarios by these variations should be taken into account: hemodynamic procedures, cardiac surgery and arrhythmias from coronary occlusive disease.

To assess the ability of transthoracic high-frequency two-dimensional echocardiography to detect atherosclerotic lesions in the descending portion of the left coronary artery, 30 consecutive patients with suspected coronary artery disease underwent two-dimensional echocardiographic examination 24 to 96 hours before coronary angiography. The descending portion of the left coronary artery was arbitrarily divided into a mid segment (the portion of the coronary vessel embedded in the anterior interventricular sulcus) and an apical segment (the portion turning around the cardiac apex into the posterior interventricular sulcus). The mid segment was imaged in 24 and the apical segment in 25 of the 30 patients for a total of 49 out of 60 segments (82%). Comparison of the echocardiographically visualized segments with the corresponding angiographic segments indicated that a correct echocardiographic diagnosis of significant stenosis was made in 11 out of 12 segments. There were no false positive results. Thus the sensitivity and specificity of high-frequency transthoracic echocardiography in the detection of significant stenosis in the imaged segments were 92% and 100%, respectively. Compared with angiography, additional information concerning the status of the arterial wall, the presence of calcific plaques, and the cross-sectional extent of the obstructive lesions was obtained by echocardiography in eight patients.

The great cardiac vein is the longest venous vessel of the heart; in the majority of our cases it originated at the lower third of the anterior interventricular sulcus (58%). The great and the middle cardiac veins merge at the apex of the heart, forming together with the coronary sinus into which they both empty, a complete venous ring around the left ventricle (13%). On reaching the area of the coronary sulcus, the great cardiac vein crosses the anterior interventricular branch and the circumflex branch of the left coronary artery forming the triangle of Brocq and Mouchet in which the vein is mainly superficial (61%). One, two or three anterior ventricular branches of the left coronary artery traverse this triangle; the relations of the vein and these arteries are very variable and practically unpredictable in 30% of the cases.

Type IV dual anterior interventricular artery (AIVA) is a rare variant that involves bilateral connection of this vessel to the left main coronary artery and right coronary artery or right aortic sinus. We present a case of such a variant where the ectopic branch traveled an intraseptal course, i.e., through the superior aspect of the crista supraventricularis in a subendocardial position and then intramyocardially inside the upper interventricular septum to reach the anterior interventricular sulcus and descend toward the apex. In a left anterior oblique view, this course lacked the typical caudal anterior loop but it was recognized by virtue of emergence of a septal branch as the first branch of the ectopic AIVA. Recognition of this variant and differentiation among the possible courses of the ectopic branch is important for patient management.

Congenital coronary artery anomalies are uncommon. Dual left anterior descending coronary artery (LAD) is defined as the presence of two LADs within the anterior interventricular sulcus (AIVS), and is classified into four types. Type IV is a rarely reported subtype and differs from the others, with a long LAD originating from the right coronary artery (RCA). Dual LAD is a benign coronary artery anomaly, but should be recognised especially before interventional procedures. With the increasing use of multidedector computed tomography (MDCT), it is essential for radiologists to be aware of this entity and the cross-sectional findings.

The anterior interventricular branch of the left coronary artery has the most constant distribution in the human heart and rarely gives off right ventricular branches. Here we report a case with a right ventricular branch which diverged from the anterior interventricular branch and descended on the anterior right ventricular wall parallel to the anterior interventricular sulcus; we termed it the “right ventricular descending branch.” This artery gave a collateral artery to the occluded anterior interventricular branch at the apex, and had prevented anterior myocardial infarction. The right ventricular descending branch should be precisely identified in order to perform successful myocardial revascularization procedures such as coronary artery bypass grafting and percutaneous coronary intervention, especially in a patient with anterior interventricular branch occlusion.

Assessment of coronary flow reserve (CFR) is a valuable clinical tool in the cardiac catheterization laboratory; however, CFR and endothelial function also can be assessed noninvasively using Doppler transthoracic echocardiography (TTE). Consider the anatomy of the left anterior descending coronary artery (LAD), which travels within the epicardial fat of the anterior interventricular sulcus. Initial attempts to visualize coronary artery anatomy with echocardiography concentrated on proximal artery anatomy; however, the distal LAD courses just a few centimeters from the chest wall and is readily accessible for evaluation with TTE.

In normal participants, the left anterior descending (LAD) artery arises from the left coronary artery (LCA) and courses along the anterior interventricular sulcus (AIVS) until it reaches the apex. Dual LAD circulation is an uncommon coronary anomaly in which there are two LAD arteries. A type 4 dual LAD circulation is an extremely rare variant of a dual LAD in which one of the LAD arteries arises from the right coronary artery (RCA). A 75-year-old man presented to us with angina on exertion of recent onset. The resting ECG was normal and echocardiogram showed normal left ventricular function. He underwent a coronary angiogram which revealed a rare coronary anomaly. There were two LAD arteries. One LAD artery originated …

The left anterior descending artery (LADA) is defined as the vessel that travels in the anterior interventricular sulcus (AIVS) supplying septal branches to the anterior interventricular septum. Duplication of the LADA entails that two vessels are located in the AIVS. This report presents some comments regarding a case of the so called "parallel LADA" which has been erroneously recognized as dual LADA.

Summary Coronary artery anomalies are seen in about 1.3% of patients undergoing coronary angiography. However, the dual type of left anterior descending (LAD) artery is a rare form of coronary artery anomaly. There are four types of dual LAD; type IV describes the anomaly of a rudimentary LAD artery terminating in the mid-portion of the anterior interventricular sulcus, and the presence of another LAD originating from the right coronary artery and continuing to the anterior interventricular sulcus.

To the Editor, Dual left anterior descending coronary artery (Dual LAD) is a quite rare coronary anomaly that can be discovered in about 1% of patients undergoing coronary angiography with normal hearts [1]. Although anomalies associated with the origin, course, branching pattern, and distribution of the coronary arteries have been described in autopsy specimens, these findings have become more relevant since the widespread application of coronary percutaneous revascularization for atherosclerotic coronary artery disease. Usually these kind of coronary anomalies, which can be differentiated in 4 types depending on the origin of major septal and diagonal branches and course within the anterior interventricular sulcus [2] ,h as no clinical consequences but it may be difficult to choose the correct strategy to revascularize this anomaly when both vessels are severely diseased [3,4], especially in emergent

We read with great interest a report by Gallo et al. [1] on a very rare coronary artery anatomy. In a classification of single coronary artery (SCA) by Lipton et al. [2] with modifications by Yamanaka and Hobbs [3], this case refers to the R-IIIC type of SCA. Indeed, there is little discrepancy between terminology and anatomy in this type of SCA, which is very apparent in the present case. According to the foregoing classification, the R-IIIC type of SCA is an anomaly where the left anterior descending artery (LAD) and left circumflex artery (LCx) arise separately from the proximal part of the normal right coronary artery (RCA). Then, LCx passes the great vessels posteriorly and LAD crosses anteriorly the infundibulum of the right ventricle to reach their usual locations [2, 3]. This LAD supplies only the middle and distal portions of the anterior interventricular sulcus (AIVS), and the proximal portion of the AIVS receives blood from the ‘LCx’ (it is clearly seen in Fig. 2A from [1]). Thus, AIVS has two sources of blood supply and this anatomy refers to Type IV dual LAD [4]. In more detail, we have discussed this anatomy in a recent similar case by Saxena et al. [5, 6]. Hence, the R-IIIC type of SCA is a combination of two anomalies: Type IV dual LAD and left main stem (LM) originating from the RCA, and the correct description of coronary arteries in this type should apply the terms long LAD, short LAD and LM. Correct diagnosis of dual LAD in SCA may be important in planning the strategy of revascularization in the case of atherosclerotic lesions in the LM or short LAD.

A newborn girl who was delivered vaginally at 37 weeks of gestation exhibited double-outlet right ventricle, pulmonary stenosis and persistent left superior vena cava accompanied with ectopia cordis (online video 1: shows her heart beating outside the body and the anterior interventricular sulcus). The case fulfilled the diagnostic criteria …

A 76-year-old woman was admitted to the emergency department of the Ondokuz Mayis University Hospital due to palpitation. She had ventricular tachycardia, and normal sinus rhythm was restored by electrical cardioversion. Teleradiography showed a large, bilobular, cystic and calcific structure on the cardiac silhouette. Three-dimensional cardiac computed tomography revealed that the cyst was 4 cm × 4 cm × 3 cm, and was located between the epicardium and the myocardium at the anterior interventricular sulcus, just beneath the proximal left anterior descending (LAD) coronary artery (Figure 1). Coronary angiography determined no severe coronary artery stenosis, but interestingly, the cyst caused a change in the normal route of the LAD coronary artery (ie, the LAD coronary artery had been ‘jumping over’ the cyst) (Figure 2). The cyst was thought to be responsible for the arrhythmia, and the patient underwent surgical resection. Cardiac cysts are often discovered incidentally. They may lead to complications such as rupture, allergic reaction, embolization, cardiac tamponade, pericarditis, myocardial ischemia, rhythm disturbances and valve dysfunction (1). In most cases, surgery is the preferred method of treatment (2). Figure 1) Three-dimensional cardiac computed tomography (arrow shows left anterior descending coronary artery; asterisk shows cyst) Figure 2) Coronary angiography at right anterior oblique caudal view (arrow shows ‘jumping’ left anterior descending coronary artery; asterisk shows cyst)

Assessment of flow in the left anterior descending coronary artery by Doppler echocardiography appeared to be possible in some patients in which the coronary artery system might be wide and/or the displacement of the coronary artery might be reduced because of cardiac enlargement or of impaired cardiac function. A study of this possibility was carried out in 78 patients, 20 cases with hypertrophic cardiomyopathy, 10 with dilated cardiomyopathy, 20 with aortic valve disease, and 28 following valve replacement for aortic valve disease. The anterior interventricular sulcus was a helpful landmark to search for the left anterior descending artery. The characteristic feature of the coronary flow pattern, that the flow ran mainly during diastole, was also helpful in finding the coronary artery. Complementary roles of ultrasonic imaging and Doppler ultrasound evaluation should be emphasized for identifying a thin echo-free space in the sulcus as the coronary artery. The left anterior descending coronary artery was imaged in 26 of the 78 patients. The peak velocity ranged 24 cm/s to 75 cm/s in different patients. Because the present study was carried out in patients with some particular diseases, these results do not indicate that current techniques can be routinely used for assessing the coronary flow. The detection rate will be increased with improvements in image resolution and the Doppler sensitivity. Although the detection rate of the coronary artery was not satisfactory in the present stage, the effect of sublingual administration of nitroglycerin on coronary circulation was noninvasively assessed in some patients, where reduction of the flow velocity by about 27% was observed in real time.

The anatomy of the coronary arteries is well known, but there is a wide variety in their origin and distribution. The dual left anterior descending artery is defined as the presence of two left anterior descending arteries within the anterior interventricular sulcus and is classified into four types. It is a benign anatomical variant that should be recognized, especially before interventional procedures. We report a patient with type I dual left anterior descending artery, with acute anterior wall ST elevation myocardial infarction, referred for primary percutaneous coronary intervention.

Twenty-three cases of an anatomic variant of the left anterior descending artery (LAD) are described. This variant is termed "dual LAD" and consists of two branches which supply the usual distribution of the LAD. One branch (short LAD) terminates in the proximal aspect of the anterior interventricular sulcus (AIVS). A second, longer branch has a variable course outside the AIVS and returns to the AIVS distally. The long LAD arose from the LAD proper in 21 cases and from the RCA in two cases. The initial course of the long LAD was on the epicardial surface of the left ventricle (17 cases), right ventricle (three cases), or within the interventricular septum (three cases). Recognition of these variants is important for correct surgical identification of the short and long LADs.

Our previous study provided a new 2-dimensional echocardiographic technique to detect peripheral right coronary artery aneurysms in Kawasaki disease, with use of the subcostal approach. An additional study was performed to detect peripheral left coronary artery aneurysms. Because the left anterior descending artery runs along the anterior interventricular sulcus and the left circumflex artery along the mitral valve ring, these regions were searched for coronary aneurysms by use of the subcostal imaging approach. Among 143 patients with Kawasaki disease, 44 left coronary aneurysms were visualized in 22 patients. Three aneurysms at the origin of the obtuse marginal artery and 1 in the further peripheral site of the left circumflex artery were observed in 3 patients. Two aneurysms at the origin of the second diagonal branch of the peripheral left anterior descending artery were detected. These echocardiographic studies were done prospectively, and their features coincided well in size, shape, and anatomic location with confirmatory angiographic appearances.