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Year : 2023  |  Volume : 11  |  Issue : 1  |  Page : 52-53

The aberrant continuation of the long or second left anterior descending artery from the ramus intermidius: A novel variant of the Group-I dual left anterior descending artery

Department of Cardiology, Yashoda Hospitals, Hyderabad, Telangana, India

Date of Submission18-Dec-2022
Date of Decision26-Dec-2022
Date of Acceptance09-Jan-2023
Date of Web Publication12-Apr-2023

Correspondence Address:
Pankaj Jariwala
Department of Cardiology, Yashoda Hospitals, Somajiguda, Raj Bhavan Road, Hyderabad - 500 082, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/heartindia.heartindia_58_22

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How to cite this article:
Jariwala P. The aberrant continuation of the long or second left anterior descending artery from the ramus intermidius: A novel variant of the Group-I dual left anterior descending artery. Heart India 2023;11:52-3

How to cite this URL:
Jariwala P. The aberrant continuation of the long or second left anterior descending artery from the ramus intermidius: A novel variant of the Group-I dual left anterior descending artery. Heart India [serial online] 2023 [cited 2023 May 28];11:52-3. Available from: https://www.heartindia.net/text.asp?2023/11/1/52/374103

Dear Editor,

An 80-year-old hypertensive male presented with symptoms of intermittent retrosternal pain at rest for the previous 10 days that worsened with effort. His vital parameters were normal when he arrived at the emergency department. The electrocardiogram indicated 1–1.5 mm ST-segment depression in anterolateral leads (V1-6; I, aVL) with sinus tachycardia. The echocardiography revealed normal left ventricular (LV) function with normal regional wall motion. His troponin I high-sensitivity levels were slightly increased (2.3 pg/dL; Normal range 0–0.12 pg/dL). The rest of the laboratory values were within normal ranges. A clinical diagnosis of non-ST-segment elevation myocardial infarction was made and guideline-directed medical therapy was started in the form of dual-antiplatelet therapy (aspirin and clopidogrel), high-dose statin (atorvastatin), beta-blocker (metoprolol), ramipril, nitrates, and low-molecular-weight heparin.

Coronary angiography demonstrated the left dominant coronary circulation with a normal large left main coronary artery which trifurcated into three main branches: Left anterior descending artery (LAD), ramus intermedius (RI), and left circumflex artery (LCx). The origin of the short LAD or LAD1 terminated in the mid-part of the anterior interventricular sulcus (AIVS) after giving multiple septal perforators and had a borderline lesion of its proximal segment. The large RI branch ran along the LV lateral wall and reached the LV apex before terminating in the distal interventricular sulcus (IVS). The distal course was similar to the LAD; hence, it was designated as LAD2. It had a discrete 90% stenosis of the proximal segment. It gave origin to the intermediate-sized branch which had significant stenosis of the proximal segment and supplied a high lateral wall of the LV. The dominant LCX was normal and the right coronary artery was small and non-dominant. Because the patient chose medical therapy, he was discharged on the 2nd day [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d and [Video 1 [Additional file 1]]. He was recommended to have computed tomography coronary angiography percutaneous coronary intervention, but he refused.
Figure 1: (a-d) Coronary angiography of the left coronary artery in AP and LAO views (a and b) revealed four coronary arteries branching from the left main coronary artery. The artery LAD travelled in the AIVS and terminated in the mid part with terminal bifurcation (Short LAD/LAD1; solid black arrows). After its origin, the RI divided into an intermediate size branch that ran between the LAD and RI and had significant stenosis of its proximal segment, and another larger branch that extended over the lateral wall and had discrete stenosis of its proximal segment. It wrapped distally around the left ventricular apex (curved dashed white line) before entering the distal AIVS (Long LAD/LAD2; dashed black arrows). The left circumflex artery (LCx) was dominant and normal in the AP caudal view, giving rise to the left posterior descending artery and three postero-lateral branches (c). In the LAO caudal view, there was a visible separation of three epicardial coronary arteries: the LAD, the RI, and its branch, and the LCx, which clearly showed the aberrant continuation of the RI to supply the distal AIVS (d). LAO: Left anterior cranial, AP: Anteroposterior, LAD: Left anterior descending, RI: Ramus intermedius,

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A ”Dual LAD” is defined as the aberrant/anomalous LAD which feeds a single territory but gets its supplies from two different main divisions or two different ostial sources. When LAD1 is present, it usually ends in the midst of the AIVS. Although the LAD2 often deviates from the AIVS and goes outside of it, entering the distal AIVS is a constant feature.[1] In our situation, LAD1 fed the mid-septum whereas LAD2 diverged from the large RI branch to supply the distal IVS and antero-lateral wall of the LV.

We divided dual LAD into three groups: Group I dual LAD, in which both LADs originate from the left coronary sinus and/or arteries which is aberrancy; Group II dual LAD, in which one component of the LAD originates from the left coronary sinus/artery and the other anomalously from the right coronary sinus/artery; and Group III dual LAD, in which both LADs anomalously originate from the right coronary sinus and/or artery. Furthermore, the variable course of the LAD2 is to be defined with four letters: A for anterior or prepulmonic, B for interarterial, P for posterior or retro aortic, and S for septal or intramyocardial, each of which is designated as a subgroup.[2] Following the classification into groups and subgroups, additional distinguishing features must be included as part of the classification. Our case should be classified as Group I-A dual LAD with aberrant long LAD/LAD2 continuance from the RI.

An aberrancy of the vessel is a divergence from typical anatomy, while an anomaly is a vessel with an unusual or nonstandard origin.[3] This case presented a novel illustration of dual LAD, which was systematically categorized by using our one-of-a-kind classification approach. Previously, such a case of coronary artery aberrancy had not been encountered in the literature.

Declaration of patient consent

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

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Conflicts of interest

There are no conflicts of interest.

Ethical approval

For the publication of any case report format which do not involve any administration of drug, or intervention, there is no need for the ethical approval.

Authors' contributions

PJ conceived up the study's topic, conducted its research, and drafted the paper.

  References Top

Jariwala P, Jadhav K. Dual left anterior descending artery: Case series based on novel classification and its therapeutic implications. Indian Heart J 2022;74:218-28.  Back to cited text no. 1
Jariwala P, Jadhav KP, Koduganti S. Dual left anterior descending artery: Diagnostic criteria and novel classification. Indian J Thorac Cardiovasc Surg 2021;37:285-94.  Back to cited text no. 2
Gentile F, Castiglione V, De Caterina R. Coronary artery anomalies. Circulation 2021;144:983-96.  Back to cited text no. 3


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