A prepulmonic course refers to a coronary artery course anterior to the right ventricular outflow tract or main pulmonary artery and is considered a ‘benign course’.
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Epidemiology
Associations
Clinical conditions associated with a prepulmonic course of a coronary artery include 1-4:
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other congenital coronary artery anomalies
ectopic origin of the left main coronary artery (LMCA)
ectopic origin of the right coronary artery (RCA)
other forms of congenital heart disease
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 2.
Complications
A prepulmonic anomalous course has been rarely reported to lead to coronary vasospasm and thus myocardial ischemia 3.
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 1-6.
Radiology report
The radiological report should include a description of the following features:
right coronary artery origin, course, segments
left main coronary artery origin and variant anatomy
left anterior descending artery with course branches and segments
circumflex artery with course, branches and segments
coronary artery disease and stenosis with location based on the AHA coronary artery segment model
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 1.
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