{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T14:53:55Z","timestamp":1791212035717,"version":"4.1.0"},"reference-count":26,"publisher":"Oxford University Press (OUP)","issue":"3","license":[{"start":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T00:00:00Z","timestamp":1788393600000},"content-version":"vor","delay-in-days":63,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,7,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Left mainstem coronary artery quadrifurcation (LMQ) is a coronary variant with a wide-ranging estimated prevalence of 1.8\u20139.6%. Although often considered an incidental and benign finding, there is a dearth of literature to support this notion owing to suboptimal clinical characterization of this phenomenon. The aim of the current manuscript was to perform a systematic review of LMQ and to describe its prevalence, associated demographics and reported clinical outcomes. We furthermore propose new nomenclature for this finding. A systematic review was conducted in accordance with the PRISMA 2020 guidelines. Eligible studies were detected for inclusion into the review using web-based sources (i.e. PubMed, Google Scholar) over a 20-year period from January 2005 to September 2025. Search terms included \u2018left mainstem quadrification\/quadrifurcation\/quadfurcation\/tertrafurcation, coronary artery branches, coronary artery anomalies, and coronary intervention\u2019 using left main quadrifurcation and its wording variants. Where available, cardiovascular risk factors and clinical outcomes were recorded. Statistics were performed using SPSS V24 and R V3.4. LMQ prevalence was estimated by pooled analysis of cadaveric series using a DerSimonian\u2013Laird random-effects model. I2, Tau, and Q statistics were also calculated to assess heterogeneity. Publication bias was assessed by Funnel plot and Egger\u2019s regression. In an exploratory analysis, comparative statistics were performed to assess differences between coronary angiography (CAG) and coronary computed tomographic angiography (CCTA) detection using the \u03c72 test, Student\u2019s t-test, and Fisher\u2019s exact test, as appropriate. A P-value &amp;lt; 0.05 was taken to be significant by convention. Nineteen studies were identified, from which two were excluded. The total number of patients evaluated was 757. There were eight cadaveric series (total of 747 cases of which 44 had LMQ quadrification) and the pooled prevalence was 4.5% (95% CI: 2.53\u22126.47%). There was moderate heterogeneity (I = 43.2%, Q = 12.33, P = 0.090, T = 0.00034) with Egger\u2019s regression indicating asymmetry (intercept = \u22122.12, P = 0.001), suggesting small-study effects. Although limited by study numbers (k = 8), the overall risk of bias was low to moderate with consistently low bias in sample selection and measurement reliability and moderate risk in reporting completeness. There was a trend to earlier detection by CCTA compared with CAG (55.3 \u00b1 10.8 years vs. 70 \u00b1 8.5 years, P = 0.056; 95% CI: 0.5\u201331.5). Clinical characterization of LMQ anatomy was inconsistent as was the documentation of clinical outcomes. In conclusion, Pooled analysis of post-mortem studies indicates the prevalence of LMQ anatomy to be 4.5%. Despite several prior reports, clinical characterization of this phenomenon remains poor. We propose a novel name for this phenomenon \u2018LMCA Starfish variant\u2019 along with standardized coronary branch nomenclature to help identify and increase awareness of this variant.<\/jats:p>","DOI":"10.1093\/ehjimp\/qyag157","type":"journal-article","created":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T10:34:08Z","timestamp":1788431648000},"source":"Crossref","is-referenced-by-count":0,"title":["A systematic review of left mainstem quadfurcation anatomy \u2018The Starfish Sign\u2019: an incidental finding or a variant of concern?"],"prefix":"10.1093","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2052-6352","authenticated-orcid":false,"given":"Anas","family":"Musa","sequence":"first","affiliation":[{"name":"Guy\u2019s and St Thomas\u2019 NHS Foundation Trust , London SE1 7EH ,","place":["UK"]},{"name":"Cardiology Department, Rashid Hospital, Dubai Health , 315 Umm Hurair Second, Street 2, Dubai, UAE"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6704-7335","authenticated-orcid":false,"given":"Zoubia","family":"Fathima","sequence":"additional","affiliation":[{"name":"Cardiology Department, Rashid Hospital, Dubai Health , 315 Umm Hurair Second, Street 2, Dubai, UAE"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Azza","family":"Mohamedelamin","sequence":"additional","affiliation":[{"name":"Cardiology Department, Rashid Hospital, Dubai Health , 315 Umm Hurair Second, Street 2, Dubai, UAE"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Usama","family":"Al Bastaki","sequence":"additional","affiliation":[{"name":"Radiology Department, Rashid Hospital, Dubai Health , 315 Umm Hurair Second, Street 2, Dubai, UAE"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0002-1008-7966","authenticated-orcid":false,"given":"Edouard","family":"Long","sequence":"additional","affiliation":[{"name":"Guy\u2019s and St Thomas\u2019 NHS Foundation Trust , London SE1 7EH ,","place":["UK"]},{"name":"School of Biomedical Engineering and Imaging Sciences, King\u2019s College London , London SE1 7EH ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ronak","family":"Rajani","sequence":"additional","affiliation":[{"name":"Guy\u2019s and St Thomas\u2019 NHS Foundation Trust , London SE1 7EH ,","place":["UK"]},{"name":"School of Biomedical Engineering and Imaging Sciences, King\u2019s College London , London SE1 7EH ,","place":["UK"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,9,3]]},"reference":[{"key":"2026100510122563200_qyag157-B1","first-page":"275","article-title":"Anatomic variations and anomalies of the coronary arteries: 64-slice CT angiographic appearance","volume":"15","author":"Ko\u015far","year":"2009","journal-title":"Diagn Interv Radiol"},{"key":"2026100510122563200_qyag157-B2","doi-asserted-by":"crossref","DOI":"10.1161\/CIRCINTERVENTIONS.120.009872","article-title":"Left main trifurcation and its percutaneous treatment: what is known so far?","volume":"14","author":"Kovacevic","year":"2021","journal-title":"Circ Cardiovasc Interv"},{"key":"2026100510122563200_qyag157-B3","first-page":"135","article-title":"Morphological expression of the left coronary artery: a direct anatomical study","volume":"67","author":"Ballesteros","year":"2008","journal-title":"Folia Morphol (Warsz)"},{"key":"2026100510122563200_qyag157-B4","first-page":"1327","article-title":"Clinically relevant morphometric analysis of the left coronary artery","volume":"3","author":"Dombe","year":"2012","journal-title":"Int J Biol Med Res"},{"key":"2026100510122563200_qyag157-B5","first-page":"98","article-title":"Variant termination of the left coronary artery: pentafurcation is not uncommon","volume":"18","author":"Ogeng\u2019o","year":"2014","journal-title":"Eur J Anat"},{"key":"2026100510122563200_qyag157-B6","doi-asserted-by":"crossref","first-page":"1235","DOI":"10.18203\/2320-6012.ijrms20181274","article-title":"Variations in the anatomical and branching pattern of the left coronary artery: a cadaveric study","volume":"6","author":"Lakshmiprabha","year":"2018","journal-title":"Int J Res Med Sci"},{"key":"2026100510122563200_qyag157-B7","author":"Apsara"},{"key":"2026100510122563200_qyag157-B8","first-page":"8","article-title":"Quadrifurcation of left coronary artery\u2014an extremely rare variation that can lead to acute coronary artery syndrome","volume":"19","author":"Nayak","year":"2020","journal-title":"Online J Health Allied Scs"},{"key":"2026100510122563200_qyag157-B9","doi-asserted-by":"crossref","first-page":"17","DOI":"10.26611\/10011921","article-title":"Study of quadrifurcation of left coronary artery and its clinical importance","volume":"19","author":"Jaishree","year":"2021","journal-title":"Medpulse Int J Anat"},{"key":"2026100510122563200_qyag157-B10","doi-asserted-by":"crossref","DOI":"10.33448\/rsd-v13i5.45955","article-title":"Anomalies and anatomical variations in the coronary arteries and their possible implications","volume":"13","author":"Morais","year":"2024","journal-title":"Res Soc Dev"},{"key":"2026100510122563200_qyag157-B11","article-title":"Branching patterns of left coronary artery among North Indians","volume":"2","author":"Agnihotri","year":"2024","journal-title":"Anat J Afr"},{"key":"2026100510122563200_qyag157-B12","first-page":"211","article-title":"A large-sized left main coronary artery with quadfurcation: a rare anatomy","volume":"79","author":"Khalid","year":"2015","journal-title":"Conn Med"},{"key":"2026100510122563200_qyag157-B13","doi-asserted-by":"crossref","first-page":"299","DOI":"10.5603\/KP.2015.0059","article-title":"Quadrifurcation of the left main coronary artery and acute coronary syndrome","volume":"73","author":"Tyczy\u0144ski","year":"2015","journal-title":"Kardiol Pol"},{"key":"2026100510122563200_qyag157-B14","first-page":"5","article-title":"Percutaneous intervention for quadrifurcation lesion of the left main coronary artery","volume":"1","author":"Kantaria","year":"2019","journal-title":"J Clin Case Rep Images"},{"key":"2026100510122563200_qyag157-B15","first-page":"E888","article-title":"Stentless treatment for a left main quadrifurcation lesion","volume":"34","author":"Murasato","year":"2022","journal-title":"J Invasive Cardiol"},{"key":"2026100510122563200_qyag157-B16","doi-asserted-by":"crossref","first-page":"76","DOI":"10.14740\/jmc4037","article-title":"Left main coronary artery aneurysm with rare quadfurcation anatomy","volume":"14","author":"Latyshev","year":"2023","journal-title":"J Med Cases"},{"key":"2026100510122563200_qyag157-B17","first-page":"1421","article-title":"Ultra-low contrast balloon-embedded PCI for acute LMCA occlusion with quadrifurcation anatomy in a resource-constrained setting","volume":"106","author":"Rajendran","year":"2025","journal-title":"Catheter Cardiovasc Interv"},{"key":"2026100510122563200_qyag157-B18","doi-asserted-by":"crossref","first-page":"85","DOI":"10.5603\/KP.2014.0011","article-title":"Quadrofurcation of the left main coronary artery","volume":"72","author":"Ar\u0131bal","year":"2014","journal-title":"Kardiol Pol"},{"key":"2026100510122563200_qyag157-B19","author":"Feger"},{"key":"2026100510122563200_qyag157-B20","author":"Hegab"},{"key":"2026100510122563200_qyag157-B21","doi-asserted-by":"crossref","first-page":"3920","DOI":"10.3390\/jcm13133920","article-title":"Coronary artery anomalies: a computed tomography angiography pictorial review","volume":"13","author":"Baz","year":"2024","journal-title":"J Clin Med"},{"key":"2026100510122563200_qyag157-B22","doi-asserted-by":"crossref","first-page":"765","DOI":"10.3390\/medicina61040765","article-title":"The role of MDCT coronary angiography in the detection of benign varieties and anomalies of coronary blood vessels\u2014a narrative review","volume":"61","author":"Mladenovic Markovic","year":"2025","journal-title":"Medicina (Kaunas)"},{"key":"2026100510122563200_qyag157-B23","doi-asserted-by":"crossref","DOI":"10.1016\/j.ijft.2023.100554","article-title":"The effect of bifurcation angulation on flow characteristics and hemodynamic indicators in an idealized left coronary artery","volume":"21","author":"M\u00fcft\u00fco\u011fullar\u0131","year":"2024","journal-title":"Int J Thermofluids"},{"key":"2026100510122563200_qyag157-B24","first-page":"339","article-title":"Influence of bifurcation angle in left coronary artery with stenosis: a CFD analysis","volume":"31","author":"Kamangar","year":"2020","journal-title":"Biomed Mater Eng"},{"key":"2026100510122563200_qyag157-B25","doi-asserted-by":"crossref","first-page":"5143","DOI":"10.3390\/jcm11175143","article-title":"Evaluation of the relationship between left coronary artery bifurcation angle and coronary artery disease: a systematic review","volume":"11","author":"Geerlings-Batt","year":"2022","journal-title":"J Clin Med"},{"key":"2026100510122563200_qyag157-B26","doi-asserted-by":"crossref","first-page":"93","DOI":"10.5830\/CVJA-2022-031","article-title":"Association between bifurcation angle of the left main coronary artery and severity of stenosis of the proximal left anterior descending artery","volume":"34","author":"Yahia","year":"2023","journal-title":"Cardiovasc J Afr"}],"container-title":["European Heart Journal - Imaging Methods and Practice"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/ehjimp\/advance-article-pdf\/doi\/10.1093\/ehjimp\/qyag157\/70937929\/qyag157.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ehjimp\/article-pdf\/4\/3\/qyag157\/70937929\/qyag157.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ehjimp\/article-pdf\/4\/3\/qyag157\/70937929\/qyag157.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T14:12:35Z","timestamp":1791209555000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ehjimp\/article\/doi\/10.1093\/ehjimp\/qyag157\/8780993"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,2]]},"references-count":26,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2026,7,2]]}},"URL":"https:\/\/doi.org\/10.1093\/ehjimp\/qyag157","relation":{},"ISSN":["2755-9637"],"issn-type":[{"value":"2755-9637","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,8]]},"published":{"date-parts":[[2026,7,2]]},"article-number":"qyag157"}}