Coronary Conundrum: Anomalous Pan-Coronary Origin from the Right Sinus with a “Type X” Dual LAD

A 49-year-old male presented with chest pain that continued for 5 hours. On examination, his blood pressure was 90/60 mm Hg, with a heart rate of 110/minute. Electrocardiography showed new-onset right bundle branch block with ST-segment depression in the inferior leads. Echocardiography showed mild hypokinesia of the apex with an ejection fraction of 45%. Coronary angiography revealed that all three coronaries were arising from the right coronary sinus and appeared normal in caliber and TIMI 3 flow (Figure 1A, 1B). We then probed the left sinus and found the stump of an obstructed accessory left anterior descending (LAD) artery (Figure 1C). When probing this vessel with a workhorse wire, we established antegrade flow. Subsequently, after balloon dilatations, we deployed a drug-eluting size 3 stent (28 mm), achieving TIMI 3 flow distally (Figure 1D). Dual LAD “Type X” anatomy was later confirmed with computed tomography angiography (Figure 1E, 1F).

Figure 1

Coronary artery anomalies are identified in approximately 1% of diagnostic angiograms. A dual LAD represents a small subset but may have profound implications during interventional procedures. The Type X variant of dual LAD, with a long LAD from the right coronary cusp and a shorter LAD from the left sinus, is the least common version.¹