Super dominant left anterior descending artery with origin of both posterior descending artery and posterior left ventricular artery from septal branch.

To cite: Patra S, BC S, Agrawal N, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013010303 DESCRIPTION The posterior descending artery (PDA) arises from the right coronary artery (RCA) in approximately 85% of people in right dominant circulation. Whereas only in 10–15% of cases, it arises from the circumflex artery (LCX) or from both RCA and LCX. Rarely the posterior descending artery can arise from the left anterior descending (LAD) coronary artery. 3 A 65-year-old man presented with new onset effort angina of Canadian Cardiovascular Society class II severity. He was hypertensive and a smoker. Exercise treadmill test was positive in 9.1 metabolic equivalents of task (METS). Blood investigations revealed only the presence of hyperlipidaemia (low density lipoprotein 141 mg/dL). ECG was normal and echocardiography was found to have normal left ventricular ejection fraction with concentric left ventricular hypertrophy with no regional wall motion abnormality. Coronary angiography showed a normal left main coronary artery. LAD artery showed luminal irregularities and it was giving rise to large first septal branch. This first septal branch after its septal course divides into large posterior left ventricular branch (PLV)) and a small PDA. The PDA ends after meeting an ascending branch from LAD in the posterior atrioventricular grove (figures 1 and 2; videos 1 and 2). LCX is giving rise to left atrial circumflex branch and obtuse marginal (OM) branches (figure 2). RCA is originated normally from right coronary sinus and found to be non-dominant (figure 3). This anomalous LAD supplied the most of the heart by giving origin of PDA and PLV through septal branch. Though, CT coronary angiogram is the best noninvasive test to detect coronary artery anomalies but the patient was not willing to undergo.