Prepulmonic coronary course

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A prepulmonic course refers to a coronary artery course anterior to the right ventricular outflow tract or main pulmonary artery and is considered as a ‘benign course’.

Epidemiology

Associations

Clinical conditions associated with a prepulmonic course of a coronary artery include :

  • other congenital coronary artery anomalies
    • ectopic origin of the left main coronary artery (LMCA)
    • ectopic origin of the right coronary artery (RCA)
    • single coronary artery
  • other forms of congenital heart disease
  • tetralogy of Fallot

Clinical presentation

A prepulmonic anomalous course is thought to pose no hemodynamic consequences and will be probably found as an incidental finding on invasive coronary angiography,  cardiac CT or cardiac MRI.

However, it has been associated with angina in some case reports.

Complications

A prepulmonic anomalous course has been rarely reported to lead to coronary vasospasm and thus myocardial ischemia .

Radiographic features

A prepulmonic course is associated with an ectopic origin of either left main coronary artery, left anterior descending artery or right coronary artery and can be visualized on invasive coronary angiography (ICA) coronary CTA or coronary MRA as a major coronary artery coursing anterior to the right ventricular outflow tract or main pulmonary artery, where normally no major coronary arteries are found .

Radiological report

The radiological report should include a description of the following features:

Treatment and prognosis

A prepulmonic course is considered benign and hemodynamic irrelevant. Patient management will entirely depend on symptoms and on associated findings.

In the setting of tetralogy of Fallot, it might have an impact on the surgical approach for pulmonary outflow tract correction .