Hyperdominant Right Coronary Artery Occlusion Presenting with Acute Anterior Wall Myocardial Infarction

Madhu Shukla; Jagdish Chander Mohan

doi:10.4103/jiae.jiae_64_22

INTERESTING CASE REPORT

Year : 2023 | Volume : 7 | Issue : 2 | Page : 182-184

Hyperdominant Right Coronary Artery Occlusion Presenting with Acute Anterior Wall Myocardial Infarction

Madhu Shukla, Jagdish Chander Mohan
Department of Cardiology, Institute of Heart and Vascular Diseases, Jaipur Golden Hospital, New Delhi, India

Date of Submission	21-Dec-2022
Date of Decision	06-Jan-2023
Date of Acceptance	08-Jan-2023
Date of Web Publication	05-Apr-2023

Correspondence Address:
Jagdish Chander Mohan
A51, Hauz Khas, New Delhi - 110 016
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_64_22

Abstract

This case report describes a 69-year-old male who presented with acute anterior myocardial infarction and was detected to have a hyperdominant right coronary artery (RCA) with a large posterior descending branch coursing from the posterior interventricular groove into the apical part of the anterior interventricular space and posterior left ventricular branch coursing in the left atrioventricular groove and supplying the entire free wall. Primary percutaneous intervention of the proximally occluded posterior descending artery resulted in resolution of ST-segment elevation in anterior and inferior leads and also revealed the large vascular territory of the RCA. The occurrence of superdominant RCA and intact left circumflex artery presenting with acute anterior wall myocardial infarction has not been described earlier. Precise morphological and physiological knowledge and evaluation of such a variation assists in opting for the best available therapeutic modality and prognosis.

Keywords: Acute myocardial infarction, coronary anomalies, hyperdominant right coronary artery

How to cite this article:
Shukla M, Mohan JC. Hyperdominant Right Coronary Artery Occlusion Presenting with Acute Anterior Wall Myocardial Infarction. J Indian Acad Echocardiogr Cardiovasc Imaging 2023;7:182-4

How to cite this URL:
Shukla M, Mohan JC. Hyperdominant Right Coronary Artery Occlusion Presenting with Acute Anterior Wall Myocardial Infarction. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2023 [cited 2023 Sep 27];7:182-4. Available from: https://jiaecho.org/text.asp?2023/7/2/182/373607

Introduction

Although the right coronary artery (RCA) is the dominant vessel in most hearts (giving origin to the posterior descending branch and posterior left ventricular branch), it is usually the left anterior descending (LAD) artery that supplies the majority of the left ventricular myocardium as well as the anterior and mid-thirds of the interventricular septum.^[1] Dominance has implications in patients with ischemia and infarction. Hyperdominant RCA with absent or atretic left circumflex (LCX) artery found incidentally or in patients with ischemic heart disease has been reported infrequently in the literature.^{[2],[3],[4],[5],[6],[7],[8]} Typically, an RCA which courses along in the left atrioventricular groove after giving off posterior descending artery (PDA) at the crux and supplies posterolateral left ventricle (giving off branches akin to obtuse marginals) is labeled superdominant or hyperdominant artery. We herein report a 69-year-old diabetic male who presented with acute chest pain and marked ST-segment elevation in inferior and anterior electrocardiographic (ECG) leads and was detected to have total occlusion of PDA and a subtotal occlusion of RCA distal to PDA. This was associated with a nondominant LCX artery and a normal course of LAD artery with a borderline stenotic lesion. Percutaneous intervention of the PDA resulted in immediate resolution of ST-segment elevation in all the relevant ECG leads.

Case Report

A 69-year-old average-built diabetic man presented with acute chest pain on the morning of November 25, 2022. His 12-lead electrocardiogram [Figure 1] showed 2–5 mm ST-segment elevation in leads I, II, aVF, and V2-V5 with 1–2 mm ST-segment depression in leads I and aVL. A bedside screening echocardiogram showed akinesis of the entire inferolateral wall and all apical segments [Figure 2]. The patient underwent immediate selective coronary angiography. The left main coronary artery was normal, the LAD artery showed a 50%–75% noncalcific stenosis in the mid-part with brisk flow, and the LCX artery was relatively small but gave off an adequate-sized first obtuse marginal branch [Figure 3]. Thrombotic occlusion of proximal PDA was noted along with a nonobstructive thrombus in the distal RCA [Figure 4]. Following percutaneous intervention and stent implantation in the PDA, there was good flow and disappearance of thrombus from the distal RCA. However, the coronary guidewire in the PDA curved around the apex and entered the anterior interventricular groove. The posterior left ventricular branch coursed in the left atrioventricular groove and gave off large branches to the left ventricular free wall. In an anteroposterior view, RCA encircled almost the entire atrioventricular groove [Figure 5] and [Figure 6], [Video 1].

Figure 1: (a) A 12-lead electrocardiogram at presentation showing ST-segment elevation in inferior and anterior chest leads. (b) Resolution of elevated ST segment with QS pattern in II, III, aVF, and V3-V6. Note prominent R-waves in V1-V2 after reperfusion suggestive of true posterior myocardial infarction. PCI: Percutaneous coronary intervention

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Figure 2: Apical four-chamber view showing apical akinesis in systole (b, white arrows) and also diastolic deformity of apical half of the left ventricle in diastole (a)

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Figure 3: (a) Left coronary angiogram in the anteroposterior cranial view and (b) left coronary artery in anteroposterior view. Note the tubular stenosis in the mid-part of the left anterior descending artery. LMCA: Left main coronary artery, LAD: Left anterior descending artery, LCX: Left circumflex artery

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Figure 4: Right coronary angiogram in the left anterior oblique (a) and anteroposterior views (b) showing occluded posterior descending artery (PDA, white arrow) and a subocclusive thrombus in the posterior left ventricular (PLV, yellow arrow) branch. (b) The results after percutaneous intervention (PCI). RCA: Right coronary artery

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Figure 5: Anteroposterior views of the right coronary angiogram. (a and b) White arrow points to the terminal course of the posterior descending artery which curves around the apex to enter the anterior interventricular groove shown with the location of the coronary guidewire (white arrow in panel a). Also note the posterior left ventricular artery in the left atrioventricular groove giving off large branches that reach the free wall of the left ventricle

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Figure 6: Right coronary artery encircling the entire atrioventricular groove. The yellow curved line completes the atrioventricular groove

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[Additional file 1]

Video 1: Right coronary angiogram in the anteroposterior view after placement of the stent in the posterior descending artery. Note the hyperdominance of the artery which supplies territories of the left circumflex and left anterior descending arteries.

Discussion

Anatomical coronary anomalies are reported in 1% of the reviewed coronary angiograms.^[1] Superdominant RCA is a rare anomaly (0.0008% frequency) with 52 reported cases in the literature until 2021.^[9] In all these reports, hyperdominant or superdominant RCA has been defined as the one wherein LCX is either absent or atretic and the RCA courses in the left atrioventricular groove. The coronary distribution pattern reported in the present case is different, and the presentation with acute anterior wall myocardial infarction has not been reported. Our case has a nondominant LCX which gives off an obtuse marginal branch and a left atrial branch but does not enter the left atrioventricular groove to any significant extent. RCA encircles almost the entire atrioventricular groove and its terminal branch PDA courses from the posterior interventricular groove into the anterior interventricular groove around the apex. This distribution pattern of PDA resulted in ST-segment elevation in anterior ECG chest leads and apical akinesis. The lesion in the mid-LAD was probably not responsible for this presentation as the lesion appeared borderline, nonulcerated with brisk flow, and the resolution of ST-segment elevation after stent implantation in PDA was immediate.

Conclusion

A patient presenting with ST-elevation acute myocardial infarction involving anterior and inferior ECG leads may have either thrombotic occlusion of the distal LAD artery or of the hyperdominant RCA. The latter variant has not been mentioned in the literature. This patient presented with a very unusual hyperdominant RCA with potential therapeutic and prognostic significance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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