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Vol. 69. Issue 4.
Pages 458-460 (April 2016)
Letter to the Editor
DOI: 10.1016/j.rec.2015.12.016
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Could Descending Septal Artery Be Another Variant of the Dual Left Anterior Descending Artery?
¿Podría ser la arteria septal descendente otra variante de la doble arteria descendente anterior?
Francisco L. Moreno-Martíneza,
Corresponding author

Corresponding author:
, Hugo Spindola-Francob, Omaida J. López-Bernalc
a Unidad de Hemodinámica y Cardiología Intervencionista, Cardiocentro Ernesto Che Guevara, Villa Clara, Cuba
b Department of Radiology, Montefiore Medical Center, New York, United States
c Departamento de Anatomía Patológica, Hospital Pediátrico Universitario José Luis Miranda, Villa Clara, Cuba
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Rev Esp Cardiol. 2015;68:1029-3110.1016/j.rec.2015.07.010
Jose M. Montero-Cabezas, Aly M. Tohamy, Ioannis Karalis, Victoria Delgado, Martin J. Schalij
Rev Esp Cardiol. 2016;69:460-110.1016/j.rec.2016.01.005
José M. Montero-Cabezas, Victoria Delgado, Ioannis Karalis, Martin J. Schalij
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To the Editor,

We read with great interest the article by Montero-Cabezas et al,1 which prompted us to ask the question forming the title of this letter.

Absence of the first septal branch of the left anterior descending artery (LAD) on left coronary angiography not only raises the suspicion of the presence of a descending septal artery, or Bonapace's branch, as mentioned by the authors themselves mention,1 but also clearly demonstrates the existence of a congenital coronary anomaly of the LAD.

According to Spindola-Franco et al,2 the LAD is the coronary artery with the most constant origin, course, and distribution in the human heart; however, many anatomical variants have been described in the literature.2–10

Such congenital coronary anomalies are rare. Their incidence is between 0.64% and 1.3% but can reach almost 6%. Dual LAD represents 1.2% to 6.1% of all coronary anomalies.3

Notably, the definition of the descending septal artery by Montero-Cabezas et al1 has similarities to the updated classification of type IV dual LAD,3 except that it could be considered the opposite: in the description by Montero-Cabezas et al, it is the short LAD (in this case the descending septal artery) that originates from the right coronary artery, or close to it, and the long LAD continues normally as a branch of the left coronary artery (Figure 1).

Figure 1.

Type V left anterior descending artery. Modified with permission from Moreno-Martínez et al,3 showing a graphical representation of the other types of dual left anterior descending artery. Cx, circumflex artery; LAO, left anterior oblique; LCA, left coronary artery; L-LAD, long left anterior descending artery; RAO, right anterior oblique; RCA, right coronary artery; RV, right ventricle; S-LAD, short left anterior descending artery.


In such cases, the descending septal artery could be considered a new type of dual LAD, rather than an isolated variant of coronary anomalies. The types proposed by Montero-Cabezas et al1 would constitute its anatomical variants; therefore, the classification of dual LAD would remain as described in Figure 2.

Figure 2.

Classification of the types and subtypes of dual left anterior descending artery (respecting the classic description by Spindola-Franco from 19832) Modified with permission from Moreno-Martínez et al.3 AIVS, anterior interventricular sulcus; DSA, descending septal artery; LAD, left anterior descending artery; LCA, left coronary artery; LV, left ventricle; RCA, right coronary artery; RV, right ventricle.


The possibility of combining these types of anomaly of the origin, course, and distribution of the LAD could have important implications in clinical practice.

J.M. Montero-Cabezas, A.M. Tohamy, I. Karalis, V. Delgado, M.J. Schalij.
La arteria septal descendente: descripción de esta variante anatómica coronaria poco frecuente en tres escenarios clínicos diferentes.
Rev Esp Cardiol., 68 (2015), pp. 1029-1031
H. Spindola-Franco, R. Grose, N. Solomon.
Dual left anterior descending coronary artery: angiographic description of important anatomic variants and surgical implications.
Am Heart J., 105 (1983), pp. 445-455
F.L. Moreno-Martínez, I.F. Aladro-Miranda, R.S. Ibargollín-Hernández, L.F. Vega-Fleites, J.R. Nodarse-Valdivia, N.R. Lara-Pérez, et al.
Angioplastia de circunfleja en paciente con doble arteria descendente anterior tipo IV.
Propuesta para actualizar la clasificación de Spindola-Franco. Arch Cardiol Mex., 82 (2012), pp. 297-302
C. Tuncer, Y. Gumusalan, A. Sokmen, G. Sokmen, S. Koroglu, A. Suner.
A previously undescribed anomaly of left anterior descending artery: type V dual left anterior descending artery.
Int J Cardiol., 134 (2009), pp. 141-143
E. Tutar, S. Gulec, G. Pamir, A. Alpman, K. Omürlü, D. Oral.
A case of type IV dual left anterior descending artery associated with anomalous origin of the left circumflex artery in the presence of coronary atherosclerosis.
J Invasive Cardiol., 11 (1999), pp. 631-634
F.L. Moreno-Martínez, L.F. Vega, H.A. Fleites, R. Ibargollín, R. González, O. López.
Dual left anterior descending coronary artery.
The Internet Journal of Thoracic and Cardiovascular Surgery., 7 (2004),
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A.Y. Andreou, P.C. Avraamides.
Short branch of type IV dual left anterior descending coronary artery running as an aberrant obtuse marginal branch: a previously undescribed arrangement.
Clin Anat., 22 (2009), pp. 873-875
C. Cruz, D. McLean, M. Janik, P. Raggi, A.M. Zafari.
A rare coincidence of two coronary anomalies in an adult.
Cardiol Res Pract., 2010 (2010), pp. 376067
A. Manchanda, A. Qureshi, A. Brofferio, D. Go, J. Shirani.
Novel variant of dual left anterior descending coronary artery.
J Cardiovasc Comput Tomogr., 4 (2010), pp. 139-141
J. Maroney, L.W. Klein.
Report of a new anomaly of the left anterior descending artery: type VI dual LAD.
Catheter Cardiovasc Interv., 80 (2012), pp. 626-629
Copyright © 2016. Sociedad Española de Cardiología
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