Sudden Death with Single Coronary Artery Ostium vices in college died while attending a picnic party. She had a lunch and climbed a mountain for almost two hours. She then rested for an hour. After resting, she suddenly lost con- sciousness while too competitively playing the stretch-the- legs game as a team member, Resuscitation was performed by her colleagues. She was then immediately taken to a hospital where she failed to recover and died. Her family reported that she had previously been in good health. How- ever, her colleagues stated that she had one recent episode of exertional dyspnea while rafting and was absent from school for three days. Unfortunately, we have no any her medical records for further evaluation or treatment of this symptom. Autopsy findings She was approximately 160 cm tall and weighed 66 kg. Upon external examination, there were defibrillator related bruises on the chest and two needle punctures in the cubital fossa. Internally, the lungs weighed 904 g and 923 g, respec- tively. There were petechial subpleural hemorrhages on the interlobular surfaces. The heart showed slightly hypertro- phic (weighed 349 g). There were petechial hemorrhages on the posterior interventricular groove. The right and left coronary arteries simultaneously opened to a single bifur- cated ostium on the left sinus of Valsalva (Fig. 1). The left coronary artery was dominant. The left coronary artery and subsequent branches followed a normal route and distribu- tion. However, the right coronary artery arose from the left sinus of Valsalva and proceeded between the ascending aorta and the pulmonary artery (Fig. 2). Both coronary arteries had neither arteriosclerotic change nor thromboemboli in the lumen, and acute myocardial lesions like infarction or myocarditis were not observed. Histologically, every organ showed congested, although there were neither pathological changes nor congenital abnormalities that could possibly be the cause of her death. In the wall of the coronary arteries, no pathological lesions such as atherosclerosis, angiitis or fibro- muscular dysplasia were observed. There was no evidence of any specific disease or injury. No toxic agents or alcohol components were detected in the blood or gastric contents. DISCUSSION Coronary artery anomalies are rare and detected incidental- ly in less than 0.3% of autopsies. The incidence of these anomalies is estimated to range from 0.2% to 1.2%.3,4 Coro- nary artery anomalies that entail a risk of sudden death cause non-specific symptoms and are rarely detected by angiogra- phy. Types of coronary artery anomalies include the follow- ing: a coronary artery originating from the wrong aortic si- nus, the emission of a single coronary artery from the aortic sinus, the left coronary artery originating from the pulmo- nary trunk, a high take-off coronary ostium from the aortic wall, and a stenosis of the coronary ostium. Most coronary anomalies are usually of little or no clinical significance. However, several types can result in sudden death. Among single coronary artery anomalies, a left coronary artery originating from the right sinus of Valsalva has more frequently been reported. However, the present case had an even rarer variant; a right coronary artery originating from Fig. 1. Internal view of the aortic sinuses shows the single coronary artery ostium (arrow) arising from the left aortic sinus of Valsalva. Aorta L. Circ. LAD Aorta L. Circ. LAD Aorta L. Cor. R. Cor. P. A. R. Cor. R. Cor. P. A. A B C Fig. 2. Projectional diagrams of the base of the heart illustrating basic anatomical distribution patterns. (A) normal pattern, (B) single left coronary artery ostium, (C) single right coronary artery ostium. P.A., pulmonary artery; L. Circ., left circumflex coronary artery; LAD, left anterior descending coronary artery; R. Cor., right coronary artery. Yonsei Med J http://www.eymj.org Volume 52 Number 5 September 2011 857