Home | About | FAQ | Reviews | Search

Illustrated Encyclopedia of Human Anatomic Variation: Opus II:

Cardiovascular System: Arteries: Head, Neck, and Thorax

Coronary Arteries
Ronald A. Bergman, PhD
Adel K. Afifi, MD, MS
Ryosuke Miyauchi, MD
Peer Review Status: Internally Peer Reviewed

A TV star sued his cardiac surgeon because, in a by-pass operation, he negligently

removed the healthy coronary artery leaving the defective one behind. The surgeon
was an experienced cardiac surgeon. The attorney for the surgeon argued in court that
the mix-up was a natural result of "abnormalities in the patient's heart". The lawyers
put the patient's arteries on trial. Their defense was that the patient had "freakish
anatomy". The case was settled out of court in favor of the patient. Information
source: People (Weekly). 612/00. Variations of the coronary arteries are numerous,
well known and are easily accessed.
Branches of the coronary arteries may vary in origin, distribution, number, and size.
The left coronary artery is more variable than the right. The branches may arise as a
common trunk, or both arise from the same aortic sinus. The anterior interventricular
and terminal branches of the left coronary sometimes arise separately from the aortic
sinus. In some cases, a single coronary artery serves the entire heart; either the right or
the left coronary artery is absent. One coronary artery may be larger than usual and
the other correspondingly smaller. Very rarely, an extra coronary artery arises from the
pulmonary artery. Occasionally, there are two interventricular branches, or two or
more posterior interventricular branches. There may be three or even four independent
coronary arteries which are, generally, quite small. A conus artery arising from the
aorta was found in 50% of 651 subjects. Coronary artery preponderance occurs in
about 30% of cases; left coronary is preponderant in 12% of cases and the right
coronary in about 18%. Left coronary artery dominance is eight times more frequent

in males (18.2%) than in females (2.6%), while right coronary artery preponderance is
almost twice as common in females (23.1%) as in males (14.6%).In some unusual
circumstances, the left coronary circumflex branch may be the dominant artery.
The right coronary artery occasionally arises from the pulmonary trunk, usually
without adverse consequences. Cases have also been reported of the left coronary
arising from the pulmonary trunk, but this is usually associated with myocardial
ischemia, with patients dying at 13 months or younger. In one case, however, a female
patient survived 60 years; in another case, a male survived 34 years (cause of death
unrelated to heart disease). In 14,000 consecutive autopsies, this condition was found
three times. When both coronary arteries arise from the pulmonary trunk, death occurs
shortly after birth.
It has been reported that in 50% of hearts, the sinoatrial and atrioventricular nodes
were supplied by the right coronary, and in 7% of hearts, these nodes were supplied
by the left coronary. In the remainder (43%), one artery supplied one node and the
other artery supplied the other, in either combination. Spalteholz, however, reported
the sinoatrial node to be supplied in 68% of cases by the right coronary, in about 32%
by the left coronary, and very rarely by an extracardiac artery.
The left coronary circumflex branch may be larger and longer than usual, giving off
the posterior interventricular artery before anastomosing with a smaller right coronary
artery on the posterior surface of the heart. Mavi, et al reported that from among
10,042 adult Turkish patients only 27 (0.3%) had variations in the origin of the left
circumflex coronary (LCC) artery. The LCC arose from the left coronary sinus of
Valsalva in 15 (55.5% of the total of 27 patients), from the right coronary sinus of
Valsalva in 7 (25.9%) patients, and from the proximal part of the right coronary artery
in 8 (29.6%) patients. Lack of knowledge of these variations may have dire
consequences in catheterization, valve replacement, or bypass surgery.
The Incidence of Variations of the Left Circumflex Coronary Artery (CCA)
Found at Coronary Angiography or from Autopsy Studies
Author

# of
Patients

Incidence

Type (see below)

Population

Cieslinski et al 4016

26 (0.6%)

A12,B2,C12

German

Garg et al

4100

14 (0.3%)

B12,C2

India

Kaku et al

17731

7 (0%)

B7

Japan

By Angiography:

Kardos et al

7694

83 (1.1%)

A54,B C29

Central European

Mavi et al

10042

27 (0.3%)

A12,B7,C8

Turkish

Topaz et al

13010

22 (0.2%)

B9,C13

Hispanic

Yamanaka &
Hobb

126595

984 (0.8%)

A513,BC467,D4

American

By Autopsy:
Frescura, et al

0.2%

Italian

Kurjia, et al

0.8%

Iraqi

A. Number of circumflex coronary artery (CCA) originating from left sinus of

Valsalva
B. Number of CCA originating from right sinus of Valsalva
C. Number of CCA originating from right coronary artery
D. Number of absent CCA.
Modified from Mavi et al., Saudi Med. J., vol. 23(11):1390-1393, 2002.
An infrequent branch of the right coronary is a septal branch that supplies the middle
part of the septum and both limbs of the conduction system.
Occasionally, a coronary artery arises from the common carotid, later giving rise to
right and left branches. "Large and direct" anastomoses between the right and left
coronary arteries have been reported in 9% of individuals. Smaller anastomoses
between the two vessels occur in most hearts. The absence of right/left coronary
anastomoses was said to occur in 3% of hearts.
The anterior interventricular (descending) coronary artery and vein have been reported
to arise from the left internal thoracic (mammary) artery and vein (Robicsek, et al.).
Coronary Artery Anomalies Found in Angiographic Studies
Author

No. Patients

Variations

Incidence

Baltaxe

1000

0.9%.

Chaitman

3750

31

0.83%.

Donaldson

9153

82

0.9%.

Engle

4250

51

1.2%.

Hobbs

38703

601

1.55%.

Kimbiris

7000

45

0.64%.

Liberthson

21

0.6%.

Wilkins

10661

83

0.78%.

Yamanaka

126595

1686

1.3%.

The incidence of congenital coronary artery anomalies, in angiographic studies is

about 1.3%, based on 126,595 cases where 1,686 were found (Yamanaka and Hobbs).
These authors classified coronary artery variations as 1) benign and 2) potentially
serious. The classification follows:
1) BENIGN CORONARY ANOMALIES
a) Separate origin of left anterior descending artery and left circumflex from the left
sinus Valsalva (513 cases, 0.41% incidence, 30.4% of all anomalies).
b) Absent left circumflex (with maximally dominant right coronary artery) (4 cases,
0.003% incidence, 0.24% of all anomalies).

c) Origin of left circumflex from right coronary or right sinus of Valsalva (467 cases,
0.37% incidence, 27.7% of all anomalies).
d) Ectopic origin of right coronary artery or left main trunk from posterior sinus of
Valsalva (Left main trunk; 16 cases, 0.0008% incidence, 0.95% of all anomalies.
Right coronary; 4 cases, 0.003%, 0.24% of all anomalies).
e) Ectopic coronary origin from the ascending aorta (Left main trunk; 16 cases,
0.013% incidence, 0.95% of all anomalies. Right coronary; 188 cases, 0.15%
incidence, 11.2% of all anomalies).
f) Intercoronary communication (3 cases, 0.002% incidence, 0.18% of all anomalies).
g) Small coronary artery fistulae (163 cases, 0.12% incidence, 9.7% of all anomalies).
Total No. Anomalies...1359, Incidence...1.07%, Of all anomalies...80.6%.
2) POTENTIALLY SERIOUS CORONARY ANOMALIES
a) Ectopic coronary origin from the pulmonary artery (Bland-White-Garland
syndrome) (Left main trunk from pulmonary; 10 cases, 0.008 % incidence, 0.59% of
all anomalies).
Left anterior descending; 1 case, 0.0008% incidence, 0.06% of all anomalies.
Right coronary artery from pulmonary artery; 2 cases, 0.002% incidence, 0.12% of all
anomalies).
b) Ectopic origin of the left coronary artery from the right sinus of Valsalva Left main
trunk from right sinus of Valsalva; 22 cases, 0.017 % incidence, 1.3% of all
anomalies.
Left anterior descending from right sinus of Valsalva; 38 cases, 0.03% incidence,
2.3% of all anomalies.
Right coronary artery from left sinus of Valsalva; 136 cases, 0.107% incidence, 8.1%
of all anomalies.
Note: Shirani and Roberts reported four cases of the ectopic origin of the left main
coronary artery from the right aortic sinus with a retroaortic course. In none of the
four patients did the unusual origin and course of the left coronary artery factor in
causing their death (32, 45, 57, and 69 years of age). These same authors reported that
anomalous origin of the left circumflex coronary from the right aortic sinus or from

the right coronary artery with a retroaortic course is the most common congenital
coronary artery anomaly; it occurs in about one in three hundred human hearts or
0.33%. The discovery of coronary artery variations in patients undergoing coronary
angiography is about 1%.
c). Ectopic origin of right coronary artery from the left sinus of Valsalva (data, see
above).
d). Single coronary artery.
The level of the orifices of the coronary arteries in the sinuses of Valaslva varies in
both the vertical and horizontal directions. Commonly they lie at the level of the free
edge of the cusp, but they are often above this level and in some cases below. While
most commonly at the center of the sinus they are often found nearer their anterior
margin. Two coronary arteries have been found to arise from a common trunk or both
to arise from one sinus of Valsalva. Frequently the number of coronary arteries are
increased to three or four. These supplementary vessels are generally small. Symmers
(1907) reported the following;
In 100 Hearts
1 right accessory coronary artery

26

2 right accessory coronary arteries

3 right accessory coronary arteries

4 right accessory coronary arteries

1 left accessory coronary artery

Total

39

These arteries arise from the aorta near the main coronary trunk. They occur on both
sides but more frequently on the right. In rare instances, an additional coronary artery
may arise from the pulmonary trunk.
Note: "Pistol" Pete Maravich ran the basketball courts in high school, college, and was
an NBA professional for a total of 30 years despite having a congenitally absent left
coronary artery. Reported in Cardiovascular News, pp. 16-19, April, 1988.
It has been found that when variations of the coronary arteries occur, and these are
infrequent, they are most commonly associated with the left coronary artery.
According to Vieweg, Alpert and Hagan the sinoatrial node artery arose from the right
coronary artery in 53%, the left coronary artery in 35%, and from both in 11% of 118
patients. The artrioventricular node artery arose from the right coronary in 84%, the
left coronary in 8%, and from both in 8% of the same 118 patients with normal
coronary arteriograms.
Variations in Origin of Coronary Arteries with Relationship to the Aorta in 4,250
patients undergoing Coronary Arteriography.
From Engel, Torres and Page, 1975.

Origin

Number of
Patients

Course of Ectopic Artery in

relationship to the aorta

RCA from LSV

Anterior

LAD and CX separate from

8
LSV

---

CX from RSV or RCA

30

Posterior

LAD from RSV

Anterior

LAD and CX from RSV

(separate ostia)

CX posterior, LAD anterior

MLCA from RSV

Anterior

MLCA from PA

---

LAD from PA (CX from

RSV)

CX posterior

RCA = right coronary artery; LSV = left sinus of Valsalva; LAD = left anterior
descending; CX =circumflex; RSV = right sinus of Valsalva; MLCA= main left
coronary artery; PA = pulmonary artery.
The unusual origin of either the left main coronary artery (LMCA) or right coronary
artery (RCA) from the aorta with subsequent coursing between the aorta and
pulmonary trunk is rare - and may lead to a clinically important outcome.
Image 12,
Image 271,

Image 91,

Image 147A,

Image 147B,

Image 196,

Image 273

Circumflex:
See Image 12
Left Coronary:
Image 155,
259D,

Image 259A,

Image 259E

Left Anterior Descending:

See Image 12
Origin of:

Image 259B,

Image 259C,

Image

Image 223,

Image 438

Preponderance:
See Image 91, See Image 259A-E,

Image 274,

Image 275

Right Coronary:
Image 135, See 259A-E
Replacing:
Image 397
Single:
See Image 397,

Image 409,

Image 432

References
Abbott, M.E. (1908) Anomalous origin from the pulmonary arteries. In Osler, W., Ed.
Osler's Modern Medicine, Its theories and practice. Lea & Febiger, Philadelphia.
Abrikosoff, A. (1911) Aneurysm des linken Herzventrikels mit abnormer Abgangstella
der linken Koronararterie von Pulmonalis bei einem fnfmonatlichen Kinde. Arch. f.
Path. Anat. u. Physiol. u. f. Klin. Med. 203:413-420.
Adachi, B. (1928) Das Arteriensystem der Japaner. Band 1, p. 17. Kyoto.
Agustsson, M.H., Gasul, B.M., Fell, E.H., Graettinger, J.S., Bicoff, J.P. and D.F.
Waterman. (1962) Anomalous origin of left coronary artery from pulmonary artery:
diagnosis and treatment of infantile and adult types. JAMA. 180:95-101.
Ahmed, S.H., El-Rakhawy, M.T., Abdalla, A. and R.G. Harrison. (1973) A new
conception of coronary artery preponderance. Acta Anat. 83:87-94.

Alam, M., Brymer, J. and S. Smith. (1993) Transesophageal echocardiographic

diagnosis of anomalous left coronary artery from the right aortic sinus. Chest
103:1617-1618.
Alexander, R.W. and G.C. Griffith (1956) Anomalies of the coronary arteries and their
clinical significance. Circulation 14:800-805.
Anson, B.J., Ed. (1966) Morris' Human Anatomy, 12th ed. The Blakiston Division,
McGraw-Hill Book Company, New York.
Antopol, W. and M.A. Kugel (1933) Anomalous origin of the left circumflex coronary
artery. Am. Heart J. 8:802-806.
Ayer, A.A. and Y.G. Rao (1957) A radiographic investigation of the coronary arterial
pattern in human hearts. J. Anat. Soc. India. 6:63-66.
Babb, J.D. and J.M. Field. (1977) Double coronary arteriovenous fistula. Chest
72:656-658.
Baim, D.S., Kline, H. and J.F. Silverman. (1982) Bilateral coronary artery-pulmonary
artery fistulas: Report of five cases and review of the literature. Circulation 65:810815.
Baltaxe, H.A., Amplatz, K. and D.C. Levine. (1973) Coronary Angiography. CC
Thomas, Springfield.
Baltaxe, H.A. and D. Wixon (1977) The incidence of congenital anomalies of the
coronary arteries in the adult population. Radiology 122:47-52.
Barbour, D.J. and W.C. Roberts. (1985) Origin of the right from the left main
coronary artery (single coronary ostium in aorta). Am. J. Cardiol. 55:609.
Barresi, V., Susmano, A., Colandrea, M.A. and J.J. Muenster. (1973) Congenutal
absence of the circumflex artery. Clinical and cinearteriographic observations. Am.
Heart J. 86:811-816.
Barth, III., C.W., Bray, M. and W.C. Roberts. (1986) Sudden death in infancy
associated with both left main and right coronary arteries from a common ostium
above the left sinus of Valsalva. Am. J. Cardiol. 57:365-366.

Barth, III., C.W. and W.C. Roberts. (1986) Left main coronary originating from the
right sinus of Valsalva and coursing between the aorta and pulmonary trunk. JACC (J.
of the Am. College of Cardiol.). 7:366-373.
Bassis, M.L. and J.A. Sheinkopf. (1955) Anomalous origin of the left coronary artery
from the pulmonary artery. Ann. Int. Med. 42:983- 994.
Benge, W., Martins, J.B., and D.C. Funk. (1980) Morbidity associated with anomalous
origin of the right coronary artery from the left sinus of Valsalva. Am. Heart J. 99:96100.
Benson, P.A. (1970) Anomalous aortic origin of coronary artery with sudden death:
Case report and Review. Am. Heart J. 79:254-257.
Bergman, R.A., Thompson, S.A., Afifi, A.K. and F.A.Saadeh. (1988) Compendium of
Human Anatomic Variation: Catalog, Atlas and World Literature. Urban &
Schwarzenberg, Baltimore and Munich.
Bett, J.H.N., O'Brien, M.F. and P.J.S. Murray. (1985) Surgery for anomalous origin of
the right coronary artery. Br. Heart J. 53: 459-461.
Bianchi, A. (1904) Morfologia delle arteriae coronariae cordis. Arch. Ital. Anat.
Embriol. 3:87-164.
Blake, H.A., Manion, W.C., Mattingly, T.W. and G. Baroldi. (1964) Coronary artery
anomalies. Circulation 30:927-940.
Bland, E.F., White, P.D. and J. Garland. (1933) Congenital anomalies of the coronary
arteries. Report of an unusual case associated with cardiac hypertrophy. Am. Heart J.
8:787-801.
Bochdalek, Jr., -. (1867) Anomaler Verlauf der Kranzarterien des Herzens. Arch.
Pathol. Anat. Physiol. Klin. Med. 41:260.
Brandt, III., B., Martins, J.B. and M.L. Marcus. (1983) Anomalous origin of the right
coronary artery from the left sinus of Valsalva. N. Eng. J. Med. 309:596-598.
Bregman, D., Brennan, F.J., Singer, A., Vinci, J., Parodi, E.N., Cassarella, W.J. and
R.N. Edie (1976) Anomalous origin of right coronary artery from the pulmonary
artery. J. Thorac. Cardiovasc. Surg. 72:626-630.

Brooks, -. (H.St.J.) (1885) Anomalous coronary artery of the heart. Dublin J. Med.
Sci. 80:257-258.
Brooks, H.St.J. (1886) Two cases of an abnormal coronary artey of the heart arising
from the pulmonary artery; With some remarks upon the effect of this anomaly in
producing cirsoid dilatation of the vessels. J. Anat. Physiol. 20:26-29.
Burchell, H.B. and A.I Brown. (1962) Anomalous origin of coronary artery from
pulmonary artery masquerading as mitral insufficiency. Am. Heart J. 63:388-393.
Bustamante, R., Prez-Stable, E., Guerra, R. and B. Milans. (1950) Visualizacion
radiologica de las arterias coronarias. Archivos del Instituto de Cardiologia de Mexico
20:350-356.
Cambell, J.S. (1929) Stereoscopic radiography of the coronary system. Quart. J. Med.
22:247-267.
Campbell, J. (1928) The coronary arteries of the heart. Thesis. Queen's University,
Belfast.
Canter, C.E., Gutierrez, F.R., Spray, T.L. and T.C. Martin. (1988) Diagnosis of
anomalous left coronary artery from the pulmonary trunk by color Doppler
echocardiography. Am. Heart J. 116:885-886.
Chaitman, B.R., Lesprance, J., Saltiel, J. and M.G. Bourassa (1976) Clinical,
angiographic, and hemodynamic findings in patients with anomalous origin of the
coronary arteries. Circulation 53:122-131.
Chander, S. and I. Jit. (1957) Single coronary artery. J. Anat. Soc. India. 6:116-118.
Cheitlin, M.D., DeCastro, C.M. and H.A. McAllister. (1974) Sudden death as a
complication of anomalous left coronary origin from the anterior sinus of Valsalva: A
not-so-minor congenital anomaly. Circulation 50:780-787.
Chinn, J. and M.A. Chinn. (1961) Report of an accessory coronary artery arising from
the pulmonary artery. Anat. Rec. 139:23-28.
Cielinski, G., Rapprich, B. and G. Kober. (1993) Coronary anomalies: incidence and
importance. Clin. Cardiology 16:711-715.
Cohen, L.S. and L.D. Shaw. (1967) Fatal myocardial infarction in an eleven year od
boy associated with a unique coronary artery anomaly. Am. J. Cardiol. 19:420-423.

Correia, M. (1933) Contributions a l'etude de la circulation artrielle du coeur. Assoc.

Anatomistes Comptes Rendus 28:200-204.
Davis, J.E., Green, D.C., Cheitlin, M.D., DeCastro, C.M. and W.H. Brott. (1984)
Anomalous left coronary artery origin from the right coronary sinus. Am. Heart J.
108:165-166.
Denko, J.V. and C.S. Hagerty. (1953) Anomalous origin of the left coronary artery
from the pulmonary artery (Bland-White-Garland Syndrome). Arch. Path. 56:142-147.
Didio, L.J.A. and T.W. Wakefield. (1975) Coronary arterial predominance or balance
on the surface of the human cardiac ventricles. Anat. Anz. 137:147-158.
Dietrich, W. (1939) Ursprung der vorderen Kranzarterie aus der Lungenschlagader mit
ungewhnlichen Verderungen des Herzmuskels und der Gefsswnde. Arch. Pathol.
Anat. Physiol. Klin. Med. 303:436-456.
Donaldson, R.M., Raphael, M., Rodley-Smith, R., et al. (1983) Angiographic
identification of primary coronary anomalies causing impaired myocardial perfusion.
Cathet. Cardiovasc. Diagn. 9:237-249.
Dubrueil, J.M.(1847) Des Anomalies Artrielles. Balliere, Paris.
Dutra, F.R. (1950) Anomalies of coronary arteries; Report of two cases, with comment
on the dynamics of development of the coronary circulation. Arch. Intern. Med.
85:955-965.
Edwards, J.E. (1958) Anomalous coronary arteries with special reference to
arteriovenous-like communications. Editoral. Circulation 17:1001-1006.
Edwards, J.E. (1960) Congenital malformations. F. Malformations of the coronary
vessels. [In] Gould, S.E., Ed. Pathology of the Heart., 2nd ed. CC Thomas,
Springfield.
Edwards, J.E. (1964) The direction of blood flow in coronary arteries arising from the
pulmonary trunk. Circulation 29:163-166.
Eidlow, S. and E.R. Mackenzie. (1946) Anomalous origin of the left coronary artery
from the pulmonary artery. Am. Heart J. 32:243-249.

Elliot, L.P., Amplatz, K. and J.E. Edwards. (1966) Coronary artery patterns in
transposition complexes: anatomic and angiographic studied. Am. J. Cardiol. 17:362378.
El-Said, G.M., Ruzyllo, W., Williams, R.L., Mullins, C.E., Hallman, G.L., Cooley,
D.A. and D.G. McNamara. (1973) Early and late results of saphenous vein graft for
anomalous origin of the left coronary artery from the pulmonary artery. Circulation 47
and 48 (Suppl. III):2-6.
Engle, H.J, Tomes, C. and H.L. Page. (1975) Major variations in anatomical origin of
the coronary arteries: angiographic observations in 4,250 patients without associated
congenital heart disease. Cathet. Cardiovasc. Diagn. 1:157-169.
Engelman, G. (1898) Ein fall von mangel einer Coronararterie. Anat. Anz. 14:348350.
Esente, P., Gensini, G.G., Biambarolmei, A. and D. Bernstein. (1983) Bidirectional
blood flow in angiographic normal coronary arteries. Am. J. Cardiol. 51:1237-1238.
Eugestes, G.S. and P.B. Oliva. (1973) Anomalous origin of the right coronary artery
from the pulmonary artery. Chest 63:294-296.
Fernandes, F., Alam, M., Smith, S. and F. Khaja. (1993) The role of transesophageal
echocardiography in identifying anomalous coronary arteriesophageal echoees.
Circulation 88:2532-2540.
Frescura, C., Basso, C., Thiene, G., Corrado, D., Pennelli, T., Angelini, A., et al.
(1998) Anomalous origin of coronary arteries and risk of sudden death: A study based
on an autopsy population of congenital Heart disease. Hum. Pathol. 29:689-695.
Friedman, S., Ash, R., Klein, D. and J. Johnson. (1960) Anomalous single coronary
artery complicating ventriculotomy in a child with cyanotic heart disease. Am. Heart
J. 59:140.
Fulton, W.F.M. (1965) The coronary arteries. Charles C Thomas, Publisher,
Springfield.
Gaither, N.S., Rogan, K.M., Stajduhar, K., Banks, A.K., Hull, R.W., Whitsitt, T. and
M.N. Vernalis. (1991) Anomalous origin and course of coronary arteries in adults:
Identification and improved imaging utilizing transesophageal echocardiography. Am.
Heart J. 122:69-75.

Gallavardin, L. and P. Ravault. (1925) Anomalie d'origine de la coronary antrieure.

Lyon Md. 135:270-272.
Garg, N., Tewari, S., Kapoor, A., Gupta, D.K., and N. Sinha. (2000) Primary
congenital anomalies of the coronary arteries: A coronary arteriographic study. Int. J.
Cardiol. 74:39-46.
Gasul, B.M. and E. Loeffler. (1949) Anomalous origin of the left coronary artery from
the left pulmonary artery (Bland-White-Garland Syndrome). Report of four cases.
Pediatrics 4:498-507.
Gobel, F.L., Anderson, C.F., Baltaxe, H.E., et al. (1970) Shunts between the coronary
and pulmonary arteries with normal origin of the coronary arteries. Am. J. Cardiology
25:655-661.
Gouley, B.A. (1950) Anomalous left coronary artery arising from the pulmonary
artery (adult type). Am. Heart J. 40:630-637
Grace, R.R., Angelini, P and D.A. Cooley. (1977) Aortic implantation of anomalous
coronary artery arising from the pulmonary artery. Am. J. Cardiology. 39:606-613.
Granitsianu, A. (1922) Anatomische studien ber die coronarterien und experimentelle
untersuchungen ber ihre durchangigkeit. Virchow's Arch. Path. Anat. 238:1-75.
Grayzel, D.M. and R. Tennant. (1934) Congenital atresia of tricuspid orifice and
anomalous origin of coronary arteries from pulmonary artery. Am. J. Path. 10:791794.
Gross, L. and M.A. Kugel. (1933) The arterial blood vascular distribution to the left
and right ventricles of the human heart. Am. Heart J. 9:165-177.
Di Guglielmo, L. and M. Guttadauro (1954) Anatomic variations in the coronary
arteries. An arteriographic study in living subjects. Acta Radiologica. 41:393-416.
Guikahue, M., Sidi, J., Kachaner, J., Villain, E., Cohen, L., Piechaud, J.F., Bidos, J.,
Pedroni, E., Vouhe, J.Y. and J.Y. Neveux. (1988) Anomalous left coronary artery
arising from the pulmonary artery in infancy: Is early operation better? Br. Heart J.
60:522-526.
Hackensellner, H.A. (1954-55) Koronaranomalien unter 1000 auslesefrei untersuchten
Herzen. Anat. Anz. 101:123-130.

Halbertsma, H.J. (1863) Ontleedkundige Aanteekeningen. Nederlandsch Tijdschrift

voor Geneeskunde 7:693-702.
Hallman, G.L., Cooley, D.A. and D.B. Singer. (1966) Congenital anomalies of the
coronary arteries: anatomy, pathology, and surgical treatment. Surgery 59:133-134.
Hamilton, D.I., Ghosh, P.K. and R.J. Donnelly (1979) An operation for anomalous
origin of the left coronary artery. Br. Heart J. 41:121-124.
Harthorne, J.W., Scannel, J.G. and R.E. Dinsmore (1966) Anomalous origin of the left
coronary artery: remediable cause of sudden death in adults. N. Engl. J. Med.
275:660-663.
Henson, K.D., Geiser, E.A., Billett, J., Alexander, J.A., Akins, E.W. and C. Bopitiya.
(1992) Use of transesophageal echocardiography to visualize an anomalous right
coronary artery arising from the left main coronary artery (single coronary artery).
Clin. Cardiol. 15:462-465.
Hepburn, D. (1895) Rare abnormal arrangement of the coronary arteries. J. Anat.
Physiol. 29:459-462.
Heuser, R.R., Achuff, S.C. and J.A. Brinker, Jr. (1982) In advertent division of an
anomalous left anterior descending coronary artery during complete repair of
tetrology of Fallot: 22-year follow-up. Am. Heart J. 103:430-432.
Hobbs, R.E., Millit, H.D., Raghavan, P.V., Moody, D.S. and W.C. Sheldon. (1982)
Coronary artery fistulae: a ten-year review. Cleve. Clin. Q. 49:191-197.
Hsieh, Y-K., Fu, M., Wu, C-J., Chua, S.O. and K-H. Yeh. (1996) Anomalous origin of
left coronary artery from right coronary artery (single coronary artery). J. Ultrasound
Med. 15:169-171.
Huber, G.C., Ed. (1930) Piersol's Human Anatomy, 9th ed. L.B. Lippincott Co.,
Philadelphia.
Hutchinson, M.C.E. (1978) A study of the atrial arteries in man. J. Anat. 125:39-54.
Hutton, W.K. (1915) Some anomalous coronary sinus. J. Anat. Physiol. 69:407-413.
Ihekwaba, F.N., Davidson, K.G., Ogilview, B. and P.k. Caves (1976) Anomalous
origin of the left subclavian artery from the pulmonary artery with coronary artery
steal in adults: report of two cases and review of the literature. Thorax 31:337-345.

Ishikawa, T. and P.W. Brandt. (1985) Anomalous origin of the left main coronary
artery from the right anterior aortic sinus: angiographic definition of anomalous
course. Am. J. Cardiol. 55:770-776.
Isner, J.M., Shen, E.M., Martin, E.T. and R.V. Fortin. (1984) Sudden unexpected death
as a result of anomalous origin of the right coronary artery from the left sinus of
Valsalva. Am. J. Med. 76:155-158.
Jain, S.P. and S. Hazary. (1958) Coronary arterial pattern in man and some other
animals. J. Anat. Soc. India. 7:1-4.
James, T.N. (1960) The arteries of the free ventricular walls in man. Anat. Rec.
136:371-384.
James, T.N. (1972) Anatomy of the Coronary Arteries. Harper & Row, New York.
James, T.N. and G.E. Burch (1958) The atrial coronary arteries in man. Circulation
17:90-98.
Jokl, E., McClellan, J.T. and G.D. Ross. (1962) Congenital anomaly of the left
coronary artery in a young athlete. J A M A. 182:572-573.
Jordan, R.A., Dry, T.J. and J.E. Edwards. (1950) Anomalous origin of the right
coronary artery from the pulmonary trunk. Proc. Staff Meeting Mayo Clin. 25:673678.
Kaku, B., Shimizu, M., Yoshio, H., Ino, H., Mizuno, S., Kanaya, H., et al. (1996)
Clinical features of prognosis of Japanese patients with anomalous origin of the
coronary artery. Jpn. Circ. J. 60:731-741.
Karcz, R., Kohmann, A. and S. Kohmann. (1971) Varieties of the pulmonary trunk,
aorta, and coronary arteries of the heart. Folia Morphol. Warsaw 30:341-345.
Kardos, A., Babai, L., Gaal, T., Horvath, T., Talosi, L. et al. (1997) Epidemiology of
congenital coronary artery anomalies: A coronary arteriography study on a central
European population. Cathet. Cardiovasc. Diagn. 42:270-275.
Kaunitz, P.L. (1947) Origin of left coronary artery from pulmonary artery. Review of
the literature and report of two cases. Am. Heart J. 33:182-206.
Kelly, V.C., Wilkins, W.S. and R.B. Scott. (1953) Syndrome of anomalous left
coronary artery. J. Pediatr. 42:731-733.

Kimbris, D. (1985) Anomalous origin of the left main coronary artery from the right
sinus of Valsalva. Am. J. Cardiol. 55:765-769.
Kimbris, D., Iskandrian, A.S., Segal, B.L. and C.E. Bemis. (1978) Anomalous aortic
origin of coronary arteries. Circulation 58:606-615.
Kopsch, F. (1908) Rauber's Lehrbuch und Atlas der Anatomie des Menschen. Georg
Thieme, Leipzig.
Kragel, A.H. and W.C. Roberts. (1988) Anomalous origin of either the right or left
main coronary artery from the aorta with subsequent coursing between aorta and
pulmonary trunk: Analysis of 32 necropsy cases. Am. J. Cardiol. 62:771-777.
Krumbhaar, E.B. and W.E. Ehrich. (1938) Varieties of single coronary artery in man,
occurring as isolated cardiac anomalies. Am. J. Med. Sci. 196:407-413.
Kucera, R.F., Bowden, W.D., Thomas, H.M. and P.W. Blue. (1986) Anomalous origin
of the right coronary artery from the left sinus of Valsalva: a case report. Cathet.
Cardiovasc. Diagn. 12:334-336.
Kuchinka, A. (1942) Ueber Koronaranomalie. Zentralb. f. Allgem. Path. u. Path. Anat.
79:110-111.
Lardini, H. and W.C. Sheldon. (1976) Ectopic origin of the left anterior descending
coronary artery from the right coronary sinus: report of a case simulating anterior
descending obstruction. Chest 69:548-549.
Latarjet, A. (1948) Testut's Traite D'Anatomie Humaine, 9th ed. G. Doin & Co., Paris.
Latarjet, M. and P.E. Duroux. (1956) Les branches auriculaires des artres coronaires
du coeur. Assoc. Anatomistes Comptes Rendus. 43:450-465.
Lee, T.M., Chen, W.J., Chen, M.F., Liau, C.S., and Y.T. Lee. (1995) Anomalous origin
of left circumflex artery in a scimitar syndrome. A case report. Angiology 46:957-961.
Lerberg, D.B., Ogden, J.A., Zuberbuhler, J.R. and H.T. Bahnson. (1979) Anomalous
origin of the right coronary from the pulmonary artery. Ann. Thorac. Surg. 27:87-94.
Leroy, F., Germain, S., Bauters, C., Lablanche, J.M. and M.E. Bertrand. (1992)
Abnormal origin of the left circumflex coronary artery: Clinical, angiographic and
prognotic aspects. Apropos of 30 cases. Arch. Mal. Coeur Vaiss. 85:993-999.

Levin, D.C. and H.A. Baltaxe. (1972) Angiographic demonstration of important

anatomic variations of the posterior descending coronary artery. AJR (Am J.
Roentgenology, Radium Therapy and Nuclear Medicine) 116:41-49.
Levin, D.C., Fellows, K.E. and H.L. Abrams. (1978) Hemodynamically significant
primary anomalies of the coronary arteries: angiographic aspects. Circulation 58:2534.
Lewis, F.T. (1904) The question sinusoids. Anat. Anz. 25:261-279.
Liberthson, R.R., Dinsmore, R.E., Bharati, S., Rubenstein, J.J., Caulfield, J., Wheeler,
E.O., Harthorne, J.W. and M. Lev. (1974) Aberrant coronary artery origin from the
aorta: diagnosis and clinical significance. Circulation 50:774-779.
Liberthson, R.R., Dinsmore, R.E. and J.T. Fallon. (1979) Aberrant coronary artery
origin from the aorta: report of 18 patients, review of literature and delineation of
natural history and management. Circulation 59:748-754.
Limbourg, M. (1937) ber den Ursprung der Kranzarterien des Herzens aus der
Arteria pulmonalis. Beitr. zu path. Anat. u. zu allg. Path. 100:191-194.
Longnecker, C.G., Reemstma, K. and O. Creech. (1961) Anomalous coronary artery
distribution associated with tetralogy of Fallot: a hazard in open heart surgery. J.
Thoracic Cardiovasc. Surg. 42:258-262.
Lippert, H. und T. Werner. (1969) Arcus aortae dexter als Zufallsbefund. Med. Klin.
64:382-387.
Lipton, M.J., Barry, W.H., Obrez, I., Silverman, J.F. and L. Wexler (1979) Isolated
single coronary artery: diagnosis, angiographic classification, and clinical
significance. Radiology 130:39-47.
Lucio, G. and M. Guttadauro. (1954) Anatomic variations in the coronary arteries.
Acta Radiologica 41:393-416.
Limbourg, M. (1937) Ueber den Ursprung der Kranzarterien des Herzens aus der
Arteria pulmonalis. Beitr. z. path. Anat u. z. allg. Path. 100:191- .
Lundquist, C. and K. Amplatz. (1965) Anomalous origin of the left coronary artery
from the pulmonary artery. Am. J. Roentgenol. 95:611-620.

Lyon, R.A., Johansmann, R.J. and K. Dodd. (1946) Anomalous origin of the left
coronary artery. Am. J. Dis. Childhood. 72:675-690.
Mahowald, J.M., Blieden, L.C., Coe, J.L. and J.E. Edwards. (1986) Ectopic origin of a
coronary artery from the aorta: sudden dearth in 3 of 23 patients. Chest 89:668-672.
Marion, B.J., Leon, M.B., Swain, J.A., Cannon, III, R.O. and A. Pelliccia. (1991)
Prospective identification by two-dimensional echocardiography of anomalous origin
of the left main coronary artery from the right sinus of Valsalva. Am. J. Cardiology
68:140-142.
Marion, P. and J. Papillon. (1950) Aortographic thoracique rtrograde
intracarotidienne (application l'artriographie des coronaries) Presse Md. 58:14741477.
Mavi, A., Serelik, A., Ayalp, R., Pestemalci, T., Batyraliev, T., Gmsburun, E., and
H.I. El-Shanti. (2002) Variants in origin of the left circumflex coronary artery with
angiography. Saudi Med. J. 23(11):1390-1393.
May, A.M. (1960) Surgical anatomy of the coronary arteries. Diseases Chest 38:645657.
McAlpin, W.A. (1975) Heart and Coronary Arteries. Springer-Verlag, New York.
McKinley, H.I., Andrew, J. and C.A. Neill. (1951) Left coronary artery from
pulmonary artery: three cases, one with cardiac tamponade. Pediatrics 8:828-840.
McManus, B.M., Waller, B.F., Jones, M., Epstein, S.E. and W.C. Roberts. (1982) The
case for preoperative coronary angiography in patients with tetralogy of Fallot and
other complex congenital heart disease. Am. Heart J. 103:451-456.
Moises, V.A., Maciel, B.C., Swensson, R.E., Valdes-Cruz, L.M., Daily, P.O. and D.J.
Sahn. (1989) Left coronary artery-to-pulmonary artery communication (a late postoperative complication after the Takeuchi procedure for repair of anomalous origin of
left coronary artery from pulmonary artery) detected by color Doppler flow maping.
Am. Heart J. 118:407-410.
Maloney, Jr., J.V. and A. Blalock. (1954) Problems in cardiovascular surgery. Ann. Int.
Med. 40:1- .
Monckeberg, J.G. (1914) ber eine seltene Anomalie des Koronararterienabgangs.
Zentralbl. Herzen Gefsskr. 6:441-445.

Moodie, D.S., Gill, C., Loop, F.D. and W.C. Sheldon (1980) Anomalous left main
coronary artery originating from the right sinus of Valsalva. J. Thoracic Cardiovasc.
Surg. 80:198-205.
Moodie, D.S., Fyfe, D., Gill, C.C., Cook, S.A., Lytle, B.W., Taylor, P.C., Fitzgerald,
R. and W.C. Sheldon. (1983) Anomalous origin of the left coronary artery from the
pulmonary artery (Bland-White-Garland Syndrome) in adult patients: long-term
follow-up after surgery. Am. Heart J. 106:381-388.
Mouchet, A. and A. Noureddine (1926) L'artre du pilier antieur du ventricle droit ou
artre de la branche droite du fasceau de His. Assoc. Anatomistes Comptes Rendus
21:415-421.
Mouchet, A. and A. Noureddine. (1929) Note sur les artres auriculaires du coeur chez
l'homme. Assoc. Anatomistes Comptes Rendus 24:367-376.
Murphy, D.A., Roy, D.L., Sohal, M. and B.M. Chandler. (1978) Anomalous origin of
the left main coronary artery from anterior sinus of Valsalva with myocardial
infarction. J. Thorac. Cardiovasc. Surg. 75:282-285.
Nerantzis, C.E., Antonakis, E.B. and D.G. Avgoustakis (1978) A new corrosion
casting technique. Anat. Rec. 191:321-325.
Ogden, J.A. (1970) Congenital anomalies of the coronary arteries. Am. J. Cardiology
25:474-479.
Page, Jr., H.L., Engel, H.J., Campbell, W.B. and C.S. Thomas, Jr. (1974) Anomalous
origin of the left circumflex coronary artery: recognition, angiographic and clinical
significance. Circulation 50:768-773.
P'an, M.T. (1934b) The coronary arteries of the Chinese heart. The Chinese Med. J.
XLVIII: 1247-1266.
Pearce, F.B., Sheikh, K.H., deBruijn, N.P. and J. Kisslo. (1989) Imaging of the
coronary arteries by transesophageal echocardiography. J. Am. Soc. Echo 2:276-283.
Petrn, T. (1930) Ein Fall von Mangel der A. coronaria dextra. Arch. Pathol. Anat.
Physiol. Klin Med. 278:158-164.
Pinsky, W.W., Fagan, L.R., Mudd, J.F. and V.L. Willman (1976) Subclavian coronary
anastomosis in infancy for the Bland-White-Garland Syndrome. J Thorac. Cardiovasc.
Surg. 72:15-20.

Piringer-Kuchinka, A. (1951-1952) Typische Variett der Koronararterien. Anat. Anz.

98:97-104.
Quain, R. (1844) Anatomy of the arteries of the Human Body. Taylor and Walton,
London.
Richter, O. (1937) ber das Fehlen einer Kranzarterie. Arch. Pathol. Anat. Physiol.
Klin. Med. 229:637-642.
Roberts, J.T. and S.D. Loube. (1947) Congenital single coronary artery in man: Report
of 9 new cases, one having thrombosis with right ventricular and atrial (auricular
infarction) Am. Heart J. 34:188-208.
Roberts, W.C. (1986) Major anomalies of coronary arterial origin seen in adulthood.
Am. Heart J. 111:941-963.
Roberts, W.C. and A.G. Morrow (1969) Compression of anomalous left circumflex
coronaries by prosthetic valve fixation rings. J. Thorac. Cardiovasc. Surg. 57:834-838.
Roberts, W.C., Dicicco, B.S., Waller, B.F., Kishel, J.C., McManus, B.M., Dawson,
S.L., Hunsaker, J.C and J.L. Luke. (1982) Origin of the left main from the right
coronary artery or from the right aortic sinus with intramyocardial tunneling to the left
side of the heart via the ventricular septum: the case against clinical significance of
myocardial bridge or coronary tunnel. Am. Heart J. 104:303-305.
Roberts, W.C., Siegel, R.J. and D.P. Zipes. (1982) Origin of the right coronary artery
from the left sinus of Valsalva and its functional consequences: analysis of 10
necropsy patients. Am. J. Cardiology 49:863-868.
Roberts, W.C. and M. Robinowitz. (1984) Anomalous origin of the left anterior
descending coronary artery from the pulmonary artery in an adult. Am. J. Cardiol.
54:1381-1383.
Robicsek, F., P.W. Sanger, H.K. Daugherty, and V. Gallucci. (1967) Origin of the
anterior interventricular (descending) coronary artery and vein from the left mammary
vessels: A previously unknown anomaly of the coronary system. J. Thorac.
Cardiovasc. Surg. 53:602-604.
Sack, N. (1907) Ein Fall von anormalen Verlauf der carotis interna im Rachen.
Monatsschrift fr Ohrenheilkunde sowie fr Kehlkopf-, Nasen-, Rachenkrankheiten
41:277-278.

Schlesinger, M.J. (1940) Relation of anatomic pattern to pathologic conditions of the

coronary arteries. Arch. Pathol. 30:403-415.
Schesinger, M.J., Zoll, P.M. and S. Wessler. (1949) The conus artery; a third coronary
artery. Am. Heart. J. 38:823-836.
Schey, J. (1925) Abnormer Urspung der rechten Kranzarterie aus der Pulmonalis bei
einem 61jhrigen Mann. Frankfurter Z. Pathol. 32:1-7.
Serota, H., Barth,III, C.W., Seue, C.A., Vandormael, M. Aguirre, F. and M.J. Kern.
(1990) Rapid identification of the course of anomalous coronary arteries in adults: the
"dot and eye" method. Am. J. Cardiol. 65:891-898.
Sewell, W.H. (1966) Roentgenographic anatomy of human coronary arteries. AJR
(Am. J. Roentgenol.) 97:359-368.
Sheth, M., Dovnarsky, M., Cha, S.D., Kini, P. and V. Maranhao. (1988) Single
coronary artery : right coronary artery originating from distal left circumflex. Cathet.
Cardiovasc. Diagn. 14:180-181.
Shirani, J. and W.C. Roberts. (1992) Origin of the left main coronary artery from the
right aortic sinus with retroaortic course of the anomalistically arising artery. Am.
Heart J. 124(4):1077-1078.
Singer, R. (1959) The coronary arteries of the Bantu heart. S. African. Med. J. 33:310315.
Smith, G.T. (1962) The anatomy of the coronary circulation. Am. J. Cardiology 9:327342.
Smith, J.C. (1950) Review of single coronary artery with report of 2 cases. Circulation
1:1168-1175.
Smolin, M.R., Gorman, P.D., Gaither, N.S. and D.C. Worthham. (1992) Origin of the
right coronary artery from the left main coronary artery identified by transesophageal
echocardiography. Am. Heart J. 123:1062-1065.
Snow, P.J.D. (1953) A case of single coronary artery with stereographic demonstration
of the arterial distribution. Br. Heart J. 15:261-263.

Soloff, L.A. (1942) Anomalous coronary arteries arising from the pulmonary artery.
Report of a case in which the left artery arose from the pulmonary artery. Am. Heart J.
24:118-127.
Speziale, G., Fattouch, K., Ruvolo, G., Fiorenza, G., Papalia, U., and B. Marino.
(1998) Myocardial infarction caused by compression of anomalous circumflex
coronary artery after mitral valve replacement. Minerva Cardioangiol. 46:455-456.
Stelmasiak, M. and J. Osemlak. (1972) Relation of the coronary arteries to the areas
supplied by them in man. Folia Morphol., Warsaw 31:457-467.
Swann, W.C. and S. Werthammer. (1955) Aberrant coronary arteries: Experiences in
diagnosis with report of three cases. Ann. Int. Med. 42:873-884.
Symers, W.St.C. (1907) Note on accessory coronary arteries. J. Anat. Physiol. 41:141142.
Takeuchi, S., Imamura, H., Katsumoto, K., Hayashi, I., Katohgi, T., Yozu, R., Ohkura,
M. and T. Inoue. (1979) New surgical method for repair of anomalous left coronary
artery from pulmonary artery. J. Thorac. Cardiovasc. Surg. 78:7-11.
Tamer, D.F., Mallon, S.M., Garcia, O.L. and G.S. Wolff. (1984) Anomalous origin of
the left anterior descending coronary artery from the pulmonary artery. Am. Heart J.
108:341-345.
Taussig, H.B. (1947) Congenital Malformations of The Heart. The Commonwealth
Fund, New York.
Taussig, H.B. (1960) Congenital Malformations of the Heart, 2nd ed. Harvard
University Press, Cambridge.
Taylor, A.J., Rogan, K.M. and R. Virmani (1992) Sudden cardiac death associated
with isolated congenital coronary artery anomalies. J. Am. Coll. Cardiology (JACC)
20(3):640-647.
Trivellato, M., Angelini, P. and R.D. Leachman. (1980) Variations in coronary artery
anatomy: normal versus abnormal. Cardiovasc. Dis. Bull. Texas Heart Inst. 7:357-370.
Turner, F.C. (1885) Case of abnormal development of the coronary arteries of the
heart. J. Anat. Physiol. 19:119.

Tyrrell, M.J., Duncan, W.J., Hayton, R.C. and B.B. Bharadwaj. (1987) Anomalous left
coronary artery from the pulmonary artery: effect of coronary anatomy on clinical
course. Angiology 38:833-839.
Ullah, Q.W., Waheed, N., Saleem, S., Qamar, K. (2015) Variation in the number and
location of coronary ostia - a cadaveric study. Int. J. Pathol 2015; 13(3): 95-100
Urwitz, S. (1937-38) Arteria septi cortis dextra. Anat. Anz. 85:97-110.
Vesterlund, T., Thosen, P.E.B. and O. Hansen. (1985) Anomalous origin of the left
coronary artery from the pulmonary artery in an adult. Br. Heart J. 54:110-112.
Veinot, J.P., Acharya, V.C. and P. Bedard. (1998) Compression of anomalous
circumflex coronary artery by a prosthetic valve ring. Ann. Thoracic Surg. 66:20932094.
Vieweg, W.V.R., Smith, D.C. and A.D. Hagen. (1975) A clinically useful coding
system for normal coronary artery anatomy. Catheterization and Cardiovascular
Diagnosis 1:171-182.
Vieweg, W.V.R., Alpert, J.S. and A.D. Hagen. (1975) Origin of the sinoatrial node and
atrioventrivular node arteries in right, mixed, and left inferior emphasis systems.
Catheterization and Cardiovascular Diagnosis 1:361-373.
Virmani, R., Chun, P.K., Goldstein, R.E., Robinowitz, M. and H.A. McAllister. (1984)
Acute takeoffs of the coronary arteries along the aortic wall and congenital coronary
ostial valve-like ridges: association with sudden death. J. ACC. 3:766-771.
Vlodaver, Z., Neufield, H.N. and J.E. Edwards. (1975) Coronary arterial variations in
the normal heart and in congenital heart disease. Academic Press. New York.
Wesselhoeft, H., Fawcett, J.S. and A.L. Johnson. (1968) Anomalous origin of the left
coronary artery from the pulmonary trunk: its clinical spectrum, pathology,
pathophysiology, based on a review of 140 cases with seven further cases. Circulation
38:403-425.
White, N.K. and J.E. Edwards. (1948) Anomalies of the coronary arteries: Report of
four cases. Archives Pathol. 45:766-771.
White, R.L., Frech, R.S., Casteneda, A. et al. (1972) The nature and significance of
anomalous coronary arteries in tetralogy of Fallot. AJR (Am. J. Roentgenology)
114:350-354.

Wilkins, C.E., Betancourt, B., Mathur, V.S., et al. (1988) Coronary artery anomalies: a
review of more than 10,000 patients from the Clayton Cardiovascular Laboratories.
Texas Heart Institute J. 15:166-173.
Wilson, C.L., Diabal, P.W. and S.A. McGuire. (1979) Surgical treatment of anomalous
left coronary artery from pulmonary artery: follow-up in teen-agers and adults. Am.
Heart J. 98:440-446.
Wilson, P.M. (1965) An unusual variation of the coronary arteries. Anat. Anz.
116:299-302.
Wthrich, R. (1951) ber den Abgang der Art. coronalis sinistra aus der Art.
pulmonalis, Zugleich ein Beitrag zum Problem des ploetzlichen Todes. Cardiologia
18(4):153-212.
Yamanaka, O. and R.E. Hobbs. (1990) Coronary artery anomalies in 126,595 patients
undergoing coronary arteriography. Cathet. Cardiovasc. Diagn. 21:28-40.
Zwicky, P., Daniel, W.G., Mgge, A. and P.R. Lichtlen. (1988) Imaging of coronary
arteries by color-coded transesophageal doppler echocardiography. Am. J. Cardiol.
62:639-640.

Variability in coronary circulation

Despite the position of the heart within the chest and the position of the great arteries as they arise from the
heart, aortic and pulmonary valves normally have a single point of contact, with commissural apposition at this
point. Coronary arteries almost always arise normally from the "facing" sinuses of Valsalva on either side of this
point of commissural contact. Coronary arteries do not normally arise from "nonfacing" or most distant sinus;
however, variations in coronary anatomy are common. Variations that occur in less than 1% of the general
population may be considered abnormal or anomalies.[1, 2] Coronary artery development, both normal and
abnormal, has been reviewed in recent years. [3]

Number and size of coronary ostia

Normally, an individual has two or, sometimes, three coronary ostia. Often, the conal branch of the RCA may
arise separately from the right sinus. The Cx or LAD may, on occasion, arise directly from the aortic root.
Coronary ostia are typically equal to, or larger than, the vessel they supply.

Positioning within sinuses

Coronary arteries arise more or less perpendicular to the aortic wall. Ostia are located in the middle of the
sinus, just above the free leaflet margin of the aortic leaflet and below the sinotubular junction. Coronary
arteries that arise ectopically usually course tangentially to the aortic wall or arise in close relationship to the
commissure of the aortic valve.

Course of coronary arteries

The course of named coronary arteries is mostly epicardial, although the proximal LAD may have an intramural
or subepicardial course in 5-25% of the general population. Branches of epicardial vessels generally proceed in
a perpendicular course to supply myocardial arterioles and capillaries. This uniquely designed pattern of
epicardial (reservoir) and intramyocardial (nutrient) supply optimizes blood flow to the heart.

Anomalies of origination and course

Anomalies of origination and course include the following:

Absent left main trunk (split origination of LCA)

Anomalous location of coronary ostium within aortic root or near proper aortic sinus of Valsalva (for
each artery): High, low, commissural
Anomalous location of coronary ostium outside normal "coronary" aortic sinuses: (1) Right posterior
aortic sinus, (2) ascending aorta, (3) left ventricle, (4) right ventricle, (5) pulmonary artery variants (LCA
arising from posterior-facing sinus, Cx arising from posterior-facing sinus, LAD arising from posterior-facing
sinus, RCA arising from anterior right-facing sinus, ectopic location (outside-facing sinuses) of any coronary
artery from the pulmonary artery (from anterior left sinus, pulmonary trunk, pulmonary branch), (6) aortic arch,
(7) innominate artery, (8) right carotid artery, (9) internal mammary artery, (10) bronchial artery, (11)
subclavian artery, and (12) descending thoracic aorta
Anomalous origination of the coronary ostium from opposite, facing "coronary" sinus (which may
involve joint origination or adjacent double ostia). Variants of the anomalous origination of the coronary
ostium from opposite, facing "coronary" sinus include the following: (1) the RCA arising from left anterior
sinus, with anomalous course (posterior atrioventricular groove or retrocardiac, retroaortic, between the
aorta and pulmonary artery, intraseptal, anterior to pulmonary outflow or precardiac, posteroanterior
interventricular groove)(2) The LAD arising from right anterior sinus, with anomalous course (between the
aorta and pulmonary artery, intraseptal, anterior to pulmonary outflow or precardiac, posteroanterior
interventricular groove)(3) The Cx arising from right anterior sinus, with anomalous course (posterior
atrioventricular groove, retroaortic)(4) The LCA arising from right anterior sinus, with anomalous course
(posterior atrioventricular groove or retrocardiac, retroaortic, between the aorta and pulmonary artery,
intraseptal, anterior to pulmonary outflow or precardiac, posteroanterior interventricular groove) If a
single, common ostium is present, the pattern is considered to represent "single" coronary artery.
Single coronary artery

Anomalies of intrinsic coronary arterial anatomy

Anomalies of intrinsic coronary arterial anatomy include the following:

Congenital ostial stenosis or atresia (LCA, LAD, RCA, Cx): Coronary ostial dimple, coronary ectasia or
aneurysm
Absent coronary artery
Coronary hypoplasia
Intramural coronary artery (muscular bridge)
Subendocardial coronary course
Coronary crossing

Anomalous origination of posterior descending artery from anterior descending branch or septal
penetrating branch
Absent PD (split RCA): Variants include proximal and distal PDs, both arising from the RCA
Absent LAD (split LAD): Variants include (1) LAD and a first large septal branch and (2) double LAD
Ectopic origination of first septal branch

Anomalies of coronary termination

Anomalies of coronary termination may include inadequate arteriolar/capillary ramifications as well as fistulas
from the RCA, LCA, or infundibular artery to the following:

Right ventricle
Right atrium
Coronary sinus
Superior vena cava
Pulmonary artery
Pulmonary vein
Left atrium
Left ventricle
Multiple, right and left ventricles

http://emedicine.medscape.com/article/895854-overview#a6