Anomalous LAD - septal/subpulmonic course

Case contributed by Yune Kwong


Chest pain for investigation

Patient Data

Age: 45 years
Gender: Male

Note: This case has been tagged as "legacy" as it no longer meets image preparation and/or other case publication guidelines.

The LAD (white arrowhead) is seen to arise from the right coronary artery, and passes within the septum before reaching the interventricular groove. The circumflex (black arrowhead) arises directly from the left coronary sinus.

On sagittals, the LAD course is seen to pass below the right ventricular outflow tract ie subpulmonic course.

Case Discussion

An anomalous coronary artery arising from the opposite sinus usually takes four common courses:

  1. interarterial
  2. retroaortic
  3. prepulmonic
  4. septal (subpulmonic)

In the case above, the course of the LAD is septal (subpulmonic). This can be difficult to differentiate from a malignant interarterial course, but a septal LAD has a more inferior position. Also a septal LAD is usually surrounded by myocardium compared to the interarterial course where it is surrounded by epicardial fat. A septal LAD also has a downwards course giving the 'hammock sign', and usually does not have an oblong or slit-like orifice, unlike the inter-arterial variant.

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