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Can We Better Understand the Known Variations

in Coronary Arterial Anatomy?
Ing-Sh Chiu, MD, PhD, and Robert H. Anderson, BSc, MD
Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei,
Taiwan; Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South
Carolina; and Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom

Coronary arterial anatomy is remarkably diverse. Identification of surgical risk factors, however, requires
description in a uniform fashion. Such description
mandates that account be given of both aortic sinusal
origin and variability in aortopulmonary relationships.
Currently, however, it is rare to find all this information provided either in clinical reports or published
reviews. In this review, therefore, we summarize why

both these features are important, emphasizing the

marriage of convenience between the aortic root position within the cardiac base and the arrangement of the
epicardial coronary arteries. The inductive approach
accounts for all potential variations.

ing requires knowledge not only of the sinusal origin

[13, 15] but also of the marriage of convenience between the aortic valvar sinuses and the epicardial
course of the coronary arteries [16, 17].

Address correspondence to Dr Chiu, Department of Surgery, National

Taiwan University Hospital, No. 7 Chung-Shan S. Road, Taipei, Taiwan
100; e-mail: ingsh@ntu.edu.tw.

2012 by The Society of Thoracic Surgeons

Published by Elsevier Inc

What Determines the Anatomy of the Coronary

Arteries?
The major coronary arteries occupy the atrioventricular
and interventricular grooves [18]. Although there are 4
such groovesright and left atrioventricular and anterior
and inferior interventricularwe describe only 3 major
coronary arteries. This is because the inferior interventricular artery, usually described incorrectly as the posterior descending artery [19], takes its origin from 1 or the
other, or sometimes both, of the 2 arteries located within
the atrioventricular grooves. These arteries, the right
coronary artery (RCA) and the circumflex coronary artery
(CXA), extend around the orifices of the tricuspid and
mitral valves, respectively. The third major coronary
artery is located in the anterior interventricular groove
(anterior interventricular artery [AIVA]), also known as
the left anterior descending (LAD) artery. The arteries
take their proximal origin from the aortic valvar sinuses
that are adjacent to the pulmonary trunk [18, 20, 21],
with the right-sided adjacent aortic sinus giving rise to
the RCA and the left-sided adjacent sinus to the CXA and
AIVA, usually through a short common stem. This normal pattern can be described as dual sinus origin. Its
essential feature is that irrespective of the relationship of
the arterial roots to each other, coronary arteries enter
the aortic root from each side. An alternative description
therefore is bilateral root entry (Fig 1A). One wellrecognized variation is seen when the CXA extends
through the transverse pericardial sinus, taking its origin
from the right-sided adjacent aortic sinus (Fig 1B). Another important variation is found when either the RCA
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ariations from the normal distribution of the coronary arteries are known to be of major clinical
significance. For example, the so-called intramural
course of a proximal coronary artery in the otherwise
normal heart is known to be a harbinger of sudden
cardiac death [1, 2]. Surgeons have long been aware of
the problems produced by inadvertent intraoperative
damage to the coronary arteries, especially during
reentry. At present, the surgeon ideally should enter
the operating room with a full appreciation of the
arrangement to be encountered, including features
such as intramural origin [2 4] or passage of a significant coronary artery across an obstructed ventricular
outflow tract [5]. There is as yet however no consensus
as to how the potential variations in coronary arterial
anatomy can best be categorized [6]. Classifications are
manifold yet none has achieved uniform acceptance,
nor do they provide all the information required to
produce meaningful analysis of potential risk. The
situation with greatest anatomic variability is transposition. However, some well-accepted classifications for
this lesion, such as that proposed by Yacoub and
Radley-Smith [7], do not permit inclusion of all the
known variables. Others [8] are so complicated as to
defeat all but the most dedicated users [9 11]. The
system proposed by Quaegebeur and colleagues [12,
13], which is well accepted by surgeons, is found
wanting when information is needed concerning epicardial course [4, 9]. Attempts to provide new, and
perhaps more complicated, classifications [11, 14] have
not been greeted with enthusiasm. An alternative
approach therefore is to emphasize the factors that
underscore the potential variations. That is our goal in
this review, in which we argue that such understand-

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Fig 1. Anatomy of normal coronary arteries is well shown by computed tomography. (A) The aortic root as viewed from above. Right and left
coronary arteries arise from the aortic valvar sinuses adjacent to the subpulmonary infundibulum, which has been transected to provide this
image. (B) Variant in an otherwise normal heart in which the circumflex coronary artery arises from the right coronary artery and then extends through the transverse sinus. The anterior interventricular artery takes origin from sinus #2 (not seen). ([A] Courtesy of Dr Tony Hlavacek, Medical University of South Carolina.)

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or the main stem of the left coronary artery runs between

the subpulmonary infundibulum and the aortic root,
taking origin from the opposite adjacent aortic sinus [1,
22]. This produces an interarterial variation, which can
exist with or without an additional intramural variant
(Fig 2) [23]. Other variations include those in which a
single coronary artery takes its origin from either side of
the aortic root, or all major coronary arteries arise from
the same sinus in the absence of interarterial coursing.
These patterns, with their variations [22, 24, 25], can
collectively be described as unilateral root entry, thus
distinguishing the arrangements from the more usual
situations in which the coronary arteries take origin from
each side of the aortic root, in other words bilateral root
entry. As we will show, these differences are crucial in
understanding the overall variations in coronary arterial
anatomy.

proximal parts of the coronary arteries budded out

from the aortic sinuses. It is now accepted that the
coronary arteries develop within the epicardial atrioventricular and interventricular grooves and that their
proximal parts grow into the aortic valvar sinuses [27].

Embryologic Development of the Coronary

Arteries
In the past, concepts based on embryology have been
said to serve as a hindrance rather than a help in
analyzing normal and abnormal anatomic arrangements [26]. Nonetheless, advances in the understanding of the mechanisms of development require reevaluation of this opinion. Thus all of the normal patterns
for coronary artery disposition, along with their variations, can now readily be understood on the basis of
recent findings concerning their embryologic development [20, 2730]. The major epicardial coronary arteries attain their aortic connections relatively late in
development, subsequent to the process of aortopulmonary rotation [28, 30]. It used to be thought that the

Fig 2. Computed tomographic image shows intramural origin of

the right coronary artery (RCA). The aortic root is viewed from
behind. The RCA crosses the commissure (white arrow) between
the leaflets of the aortic valve supported within sinuses adjacent
to the subpulmonary infundibulum and takes its origin from the
left-hand sinus #2. The left coronary artery is also seen taking its
origin from sinus #2. (Courtesy of Dr Tony Hlavacek, Medical
University of South Carolina.)

The existence of arteries coursing anterior or posterior

to the arterial roots also supports the notion that a
crown-like configuration of arterial primordia is to be
found around the developing aortic and pulmonary
roots [29]. Since the major coronary arteries hardly
ever take origin from the nonadjacent aortic sinus, and
when arising anomalously from the pulmonary trunk
also frequently arise from adjacent sinuses [31], factors
related to the separation of the arterial roots by fusion
of the major outflow cushions almost certainly guide
their proximal in-growth toward the valvar sinuses
[20]. This notion is further supported by the marked
variability in sinusal origin of the coronary arteries in
the setting of a common arterial trunk [32, 33], which
exists because of failure of septation of the developing
outflow tract [34]. An exaggeration of this guiding
pattern would also be sufficient to direct one or the
other of the right and left coronary arteries beyond its
intended site of origin, producing the intramural variant with single-sinus origin but bilateral root entry [35,
36]. We can expect therefore that these intramural
patterns will be seen as variants of the patterns already
well recognized for dual sinus entry [11, 36]. It is also
intuitive to suggest that part of the guiding mechanism
depends on the proximity of the 2 adjacent aortic
sinuses to the atrioventricular and anterior interventricular groove. Since the coronary arteries must perforce pierce the sinusal wall only subsequent to the
establishment of aortic position, it is the final location
of the aortic root relative to the cardiac base that is
responsible for producing the marriage of convenience
between the major coronary arteries and their sinuses
of origin [11, 16, 17, 37, 38].

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Evidence From Previous Descriptions

Fig 3. The 5 basic options for dual sinus origin of coronary arteries recognized thus far in the setting of regular transposition, illustrating the arterial relationships most frequently seen with the
different patterns [11]. (a) Usual pattern. (b) As aortic root rotates more obliquely toward the right, the circumflex coronary
artery (CXA) tends to move posteriorly and can originate, along
with the right coronary artery (RCA), from sinus #2, the anterior
ventricular artery (AIVA) retaining its origin from sinus #1. (c)
When the aortic root moves further rightward and lateral, it is
more frequent for the RCA and the AIVA to arise from sinus #1,
the CXA originating from sinus #2 but taking a retropulmonary
course. (d) When arterial trunks are normally related in transposition, however, the origin of the coronary arteries is as usually
seen in the normal heart. (e) Should the aortic root be rotated to
a left lateral location, the AIVA, along with the RCA, often takes
its origin from sinus #2, with the RCA running in an anteropulmonary position, the CXA taking origin from sinus #1. (A !
AIVA; L ! CXA; R ! RCA.)

Review of publications describing the patterns of the

coronary arteries in transposition, congenitally corrected transposition, and tetralogy of Fallot shows that
the coronary arteries are not always arranged in their
anticipated fashion and that this fact also holds for the
otherwise normal heart [1, 2, 9]. In tetralogy of Fallot,
eg, the rightward location of the aorta reduces the
distance between sinus #1 and the AIVA, thus explaining why an AIVA is often found crossing the narrowed
subpulmonic infundibulum (Fig 3c) [39]. Furthermore,
the anomalous course in this setting is more frequent
when the aortic root is rotated and located even more
anteriorly [40]. Nonetheless, the greatest variation in
coronary artery arrangement [8, 14] is found when
transposed arterial trunks exist in the setting of concordant atrioventricular connections [41], in other
words regular transposition (Fig 3). In this setting,
the right-sided aortic valvar sinus, known as sinus #2,
is the one that is closest to the right atrioventricular
groove. An artery exiting from this sinus will enter the
right-sided atrioventricular groove directly. The leftsided aortic valvar sinus, sinus #1, is directly adjacent
to the anterior interventricular groove. An artery exiting from this sinus is able not only to enter the anterior

groove but also to give a branch that passes directly

into the left atrioventricular groove. It is not surprising
therefore that the most frequent arterial relationship in
transposition (when the aorta is positioned rightward
and anterior) is associated with the origin of the AIVA
and CXA from sinus #1 and the RCA arising from sinus
#2 (Fig 3a). There are nonetheless multiple alternate
patterns. Most existing classifications were devised in
attempts to cater for description of these variations. No
single classification has achieved universal acceptance.
The classification of Yacoub and Radley-Smith [7, 42],
eg, accounts for relatively few of the known variations.
It also mixes the features used for classification, with 4
of the described patterns accounting for varying sinusal origin of the main coronary arteries, but 2 of
them (types B and C) showing the same sinusal anatomy. This classification was subsequently expanded to
include details of the course of the proximal coronary
arteries relative to the arterial pedicle, a feature of
obvious surgical significance [43 45]. In this regard,
the feature of the second most common pattern is for
the CXA to run a retropulmonary course, passing

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Fig 4. Numeric-alphabetic classification devised by Shaher and Puddu [8], combining information concerning sinusal origin and the epicardial
course of the coronary arteries. All variants drawn in a fixed aortic position rightward and anteriorly have been modified to show the more
typical locations of the aortic root for the various patterns identified [11]. Type 9, the arrangement seen in the normal heart, is a mirror image
of type 1. Types 3, 5, and 7 illustrate variants of single coronary artery, whereas types 2, 4, 6, and 8 elucidate various types of unusual circumflex coronary artery.

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through the transverse pericardial sinus to reach the

left atrioventricular groove (Fig 3b). This retropulmonary passage of the CXA can also be found when both
the RCA and AIVA arise from sinus #1 (Fig 3c).
Furthermore, the latter patterns with retropulmonary
CXA are known to be more frequent when the arterial
trunks are rotated from the oblique orientation toward
a more side-by-side arrangement [10, 42 44]. One of
the oldest classifications, that proposed by Elliott and
colleagues [46], had previously emphasized this effect
of rotation of the aortic root. The clockwise rotation of
the aortic root from the anticipated right anterior
location takes the left-handed aortic sinus into a posterior position and closer to both the transverse pericardial sinus and the left atrioventricular groove (Fig
3b, 3c). This influence of the location of the aortic root
relative to the cardiac base also offers an explanation
for why, when the aorta arises from the right ventricle
but in a posterior position (Fig 3d) (the arrangement
known as posterior transposition), the coronary arteries arise in the fashion expected for the normal heart
[11, 47]. It also explains why, when the aorta is anterior
but leftward located in so-called regular transposition,
the RCA has to cross in front of the pulmonary trunk to
take origin, along with the AIVA, from sinus #2 (Fig 3e)
[11, 48].

Taken together, these associations point to the significant influence of aortic position in determining
sinusal origin of the coronary arteries [12, 37, 48 50].
There are nonetheless other subtle variations to be
found in arterial anatomy, such as duplication or
absence of the major epicardial branches. An attempt
to incorporate all this information into one system [8]
produced huge complexity (Fig 4). Another system,
devised by Gittenberger-de Groot and colleagues [12],
with its roots in the doctoral thesis of Quaegebeur [13],
removed the necessity for describing the location of
the aortic root. These studies showed that irrespective
of arterial relationships, the 2 aortic sinuses adjacent to
the pulmonary root could always be designated as
being to the right or left of the observer standing in the
nonadjacent sinus and codified as #1 and #2. Although
the system is now well accepted by the surgical community [4, 1315, 37, 51, 52], it fails to provide for each
individual patient the crucial information concerning
the location of the aortic root. It is only when we take
note of the location of the aortic root in addition to
sinusal origin that we can explain one of the conundrums that remains concerning the arrangement of the
coronary arteries in the setting of transposed arterial
trunks.

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The Missing Option in Patients With

Transposition
When one of us (RHA) was working with the archive of
congenitally malformed hearts housed at Childrens
Hospital of Pittsburgh, a selection was made at random
of 100 hearts with concordant atrioventricular and
discordant ventriculoarterial connections. At the time,
RHA was convinced that the system proposed by
Quaegebeur [13] was the optimal means of describing
coronary arterial anatomy, so as discussed earlier, he
neglected to note the specific relationship of the transposed aortic root relative to the ventricular base when
describing the sinusal origins. It remains impressive,
nonetheless, that 7 of the 8 possibilities predicted on
the basis of 3 coronary arteries arising from only 2
aortic sinuses [15, 41] were present within the small
group of hearts selected from the archive (Fig 5, first 2
rows). The question was not posed, however, as to why
one of the patterns had not been encountered. Our
subsequent review of the salient published literature
providing details on more than 6,000 patients [3, 4, 79,

11, 12, 35, 42 44, 46, 48 50, 53, 54] now shows that this
option was not only missing in the 100 hearts selected
at random from Pittsburgh but also that it has never
been described in the setting of regular transposition. The missing option exists when the RCA and the
CXA are supposed to arise from sinus #1 and the AIVA
is supposed to arise from sinus #2 (Fig 5, third row
middle). We are now able, based on marriage of
convenience, to explain the lack of this option. As
already discussed, usually the aorta is anterior and
right-sided in patients with typical transposition. In
this situation, sinus #2 is located rightward and posterior relative to the heart itself. If the AIVA was taking
origin from this sinus, as would be necessary to produce the missing option, this artery would need to
cross the epicardial territory of either the RCA or the
CXA to reach the anterior interventricular groove (Fig
5, gray figure in third row left). This is unlikely to
happen. The only situation that would favor the missing
option on the basis of marriage of convenience is when
the aortic root is positioned posterior and leftward rela-

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Fig 5. Eight theoretical possibilities for sinusal origin of the coronary artery patterns on the basis of 3 major coronary arteries taking origin
from the 2 adjacent aortic valvar sinuses. The numbers show the frequency of the various patterns discovered within a cohort of 100 hearts
selected from the archive of congenitally malformed hearts held at Childrens Hospital of Pittsburgh. The 8 potential patterns in three rows
include the 2 variations with origin of a solitary coronary artery, which is shown in the middle and right panels, middle row. These 2 patterns
then have multiple variations in terms of epicardial branching, which are grouped together here on the basis of identical sinusal origin. The
remaining 6 possibilities are those with bilateral root entry. (Left-hand panel, bottom row) The missing option is impossible when the aorta is
anterior and rightward. (Right hand panel, bottom row) The missing option is possible if the aorta is positioned posteriorly and leftward. This
aortic position, however, has never been encountered in patients with regular transposition. (A ! anterior ventricular artery; L ! circumflex
coronary artery; PT ! pulmonary trunk; R ! right coronary artery.)

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Fig 6. (A) Missing option for coronary artery arrangement in the setting of regular transposition has been observed in patients with congenitally corrected
transposition with a left posterior aortic root. There was retropulmonary coursing of the right-sided circumflex coronary artery (CXA) to sinus #1, the leftsided right coronary artery (RCA) taking a retroaortic course, also to take origin from sinus #1, whereas the anterior ventricular artery (AIVA) took direct
origin from sinus #2. (B) This option was also discovered in the setting of arterial trunks arising concordantly and in parallel fashion from the ventricular
mass, but with the aorta posteriorly located relative to the pulmonary trunk. In this instance, the retroaortic CXA arose from the RCA, which itself took origin from sinus #1, whereas the AIVA took origin from sinus #2. (C) This pattern is a more frequent finding in the otherwise normal heart, as shown in Figure 1B. In this setting, an almost directly posterior aortic position produces greater adjacency between the left atrioventricular groove and sinus #1.

tive to the pulmonary trunk so that both the RCA and the
CXA could arise from sinus #1, which would be located
posteriorly, whereas the AIVA would arise from the
anteriorly located sinus #2. This aortic position has yet to
be described in regular transposition but does exist when
congenitally corrected transposition coexists with a posterior aorta (Fig 6A) [16] or when the arterial trunks arise
concordantly in parallel fashion from the ventricular
mass [17] but with the aorta posteriorly located relative to
the pulmonary trunk (Fig 6B). It cannot be coincidental,
therefore, that this missing option has been encountered
in both these situations, as well as in a relatively common
variation in the otherwise normal heart (Figs 1B, 6C).
Furthermore, this variation is advantaged when the aorta
is more posteriorly located than is usually the case [55], in
this way bringing sinus #1 closer to the left atrioventricular groove (Fig 6C). These findings further reinforce the
notion of marriage of convenience.

How Should We Describe the Variations in

Coronary Artery Pattern?
The sophistication in diagnostic techniques is now sufficiently great for nearly all the crucial information relating
to coronary artery patterns to be provided preoperatively
[22, 56]. This information should now include analysis of
the precise relationship of the aorta to the pulmonary
trunk, as well as the location of the facing commissure
and sinuses [8, 57]; the sinusal origin of the 3 major
coronary arteries; information relating to ectopic location, including eccentric origin and high or low takeoff [1,
21, 35, 36, 57]; intramural course of their orifices; their
epicardial course relative to the arterial pedicles; and
salient information concerning the individual branching
of the arteries themselves, such as dual origin of
anterior interventricular arteries. Ideally, descriptions
should also include details of the origin of the artery to

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the sinus node [50, 58], which may need to be redirected if it originates directly from an aortic valvar
sinus (Fig 4), albeit current resolution of computed
tomography still makes the identification of this detail
difficult. The diagnostician will hopefully, nonetheless,
seek to provide as much information as possible for
each patient being discussed for corrective surgery.
When we compare the accounts given by different
groups, all this information may prove to be of clinical
significance. It is the information regarding the location of the aortic root, however, that currently is most
often ignored [4, 14, 15, 51, 52].

Patterns With Origins From Two Aortic Sinuses and

With Bilateral Entry to the Aortic Root
Sinusal origin and aortic position are closely related in
terms of the development of the given patterns to the
arrangements seen in those patients in whom 2 aortic
sinuses give rise to 3 major coronary arteries, these
sinuses almost without exception being adjacent to the
pulmonary trunk. It was recognition of this association
that underscored the system proposed by our group
working in Taiwan, which uses the concept of 2 " 3 to
produce a unifying system for the various patterns seen
in transposition [11, 54, 59] and other congenitally malformed hearts [16, 17, 40]. We now recognize the need to
construct 2 circles to provide full understanding of the

potential patterns (Fig 7). The first circle accounts for the
marriage of convenience between the rotated aortic root
and the proximal orifices of the coronary arteries located
in 3 anatomic grooves in the setting of right-hand ventricular topology, whereas the second circle accounts for
left-hand topology [16, 59]. Both circles are proposed
because in the presence of left-handed topology, the
morphologically right and left atrioventricular grooves
are on the opposite side of the heart relative to the facing
aortic coronary sinuses (Fig 6A). In the setting of lefthand topology, the CXA, occupying the right-sided atrioventricular groove, is closest to sinus #2, as in the usual
variant of congenitally corrected transposition, and
therefore usually arises from this sinus, along with the
AIVA (Fig 7B, illustrated at the 3 oclock position). Appreciation of the orientation of the aortic root within our
2 suggested circles can therefore provide a rational explanation for all the known anomalous patterns of the
major coronary arteries in the setting of dual sinus origin
with bilateral root entry.

Patterns in Which the Coronary Arteries Arise From a

Single Aortic Sinus but With Bilateral Entry to the
Aortic Root
Appreciation of the orientation of the aortic root relative to the cardiac base inside the circle in Figure 8A
also provides a rational explanation for the anomalous

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Fig 7. The 6 potential options for bilateral root entry illustrated relative to most likely locations of the aortic root. (A) Options for right-hand (RH) ventricular topology. (B) Left-hand (LH) topology. The patterns reported most frequently for transposition (TGA), tetralogy of Fallot (TF), congenitally corrected
transposition (CCT), and concordant ventriculoarterial connection with parallel arterial trunks (Conc VA conn with PAT) and otherwise normal heart each
occupy a different portion of the horizontal circle representing the location of the aortic root within the cardiac base. The gap between panels (d) and (e) in
Figure 3 is now filled by the missing option in Figure 6. In patients with left-hand ventricular topology, the left-sided atrioventricular groove contains the
morphologic right coronary artery (RCA), whereas the right-sided groove contains the morphologic circumflex coronary artery (CXA). (A ! anterior interventricular artery; L ! circumflex coronary artery; R ! right coronary artery.)

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Fig 8. Variants for single coronary artery can also be understood on the basis of marriage of convenience. (A) Variants with bilateral root entry, with the 6 established options for dual sinus origin inside the circle, and the small black images positioned outside the circle representing
the options passing interarterially into the opposite sinus to produce the variants of bilateral root entry with single sinus origin. (B) Potential
variations for unilateral root entry are shown in blue outside the circle, these being the variants with single coronary arteries. The specific
types discovered in each disease entity labeled in the center have occupied different portions of the circle, suggesting that these abnormal patterns are also influenced by the location of the aortic root. (AVG ! atrioventricular groove; CCT ! congenitally corrected transposition;
IVG ! interventricular groove; TF ! tetralogy of Fallot; TGA ! transposition.)

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coronary artery patterns observed when both arteries

take their origin from the same sinus but with the
arteries entering from opposite sides of the aortic root,
one or the other then taking an interarterial course (Fig
8A, outside the circle). The pattern illustrated between
the 10 and 11 oclock positions outside the circle in
Figure 8A is the interarterial and intramural variant
shown in Figure 2, known now to be a harbinger of
sudden cardiac death.

Patterns With Unilateral Entry to the Aortic Root

Our review of the salient literature indicates that aortic
position varies not only for the different patterns seen
when coronary arteries enter through both sides of the
aortic root but also when all the coronary arteries enter
the aortic root from the same side (Fig 8B), these being
the variants for single coronary artery. For example, the
single artery above the right circle at the 11 oclock
position in Figure 8B is reported in tetralogy of Fallot [60].
However, this type has not yet, to the best of our
knowledge, been reported in regular transposition.
Our analysis to date therefore suggests that the potential
patterns for single sinus origin with unilateral entry to
the aortic root are also influenced by the location of the
aortic root itself.

Surgical Implications
It could be argued that the full clinical significance of the
multiple variations we have reviewed has yet to be

established. It might also be thought that intraventricular

anatomy also influences coronary artery arrangements.
We are unaware of any convincing evidence supporting
this latter notion. Indeed, evidence supporting such a
suggestion could not be assembled unless a unified
concept is constructed to provide the basis for understanding all the variations. Our hope is that our review
might provide the impetus for agreement on such a
concept. Nonetheless, in the current surgical climate,
information concerning the origins and course of the
coronary arteries, and their orientation to the aortic root,
is of most significance to those performing the arterial
switch procedure, in which optimal redirection of all the
coronary arteries in situ remains the cornerstone of
surgical success [61, 62]. All known patterns are amenable to transfer [3, 53], although the late recurrence of
coronary artery obstruction, which has been reported to
be as high as 3% to 7.8 % [63, 64], may well be related to
variations in coronary arterial anatomy [50, 53]. We have
already proposed diagnostic techniques for the recognition of potentially dangerous coronary artery patterns
and surgical techniques for their correction [36, 57, 62]. In
particular, when redirecting the origin of coronary arteries adjacent to the facing commissure, or an artery
passing intramurally across this commissure, we consider it advantageous to create a single arterial button by
means of a superiorly based trapdoor. In addition to the
short axis rotation, which reflects the juxtacommissural
origin of the coronary artery [36], it is also frequently
necessary to be aware of additional rotation in the long

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axis should the abnormal coronary artery also show high

takeoff [50, 57], this being a frequent additional finding in
the setting of intramural origin.

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Conclusions
We suggest that in the future when charting details of
surgical correction of coronary artery anomalies or describing the operative procedure for the arterial switch,
information should be provided not only of sinusal origin
but also of the location of the aortic root relative to the
cardiac base. Emphasis should also be given to whether
the coronary arteries enter the aortic root from both sides
or whether there is unilateral entry. Only when all this
information is widely available will we be able to judge
whether it is truly possible to provide a universally
acceptable classification for coronary arterial anatomy.
Irrespective of whether we achieve a suitable classification, the provision of information concerning aortic position as well as sinusal origin will make it easier to assess
the remaining surgical risk factors for procedures such as
the arterial switch.

10.
11.

12.

13.
14.
15.
16.
17.

We are indebted to all our colleagues in Taiwan who contributed

to earlier studies establishing the importance of the aortic root
position in determining the options for coronary artery patterns
in congenitally malformed hearts, and to Drs Tony Hlavacek and
Marios Loukas, and Mrs Diane Spicer, who worked extensively
with us to establish the arrangement of the normal coronary
arteries. We also thank Dr Hlavacek for permitting us to reproduce Figures 1 and 2. We are grateful to Miss Chang-Ying Lin for
the preparation of Figures 3 through 8. This study was supported
by a grant from the National Science Council in Taiwan
(NSC972314 B 002 043MY3).

18.

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