Background We present a case concerning a 64 year old female with complaints of palpitations, chest pain and an anomalous right coronary artery (RCA) from the opposite sinus (R-ACAOS) with a suspected malignant trajectory on computed tomography. She was referred to our clinic for a second opinion to re-asses suggested treatment of coronary surgery. Case summary A coronary angiogram was performed demonstrating a RCA with a tapered ostium typical for an inter-arterial course. Dobutamine and adenosine stress test during simultaneous intracoronary flow, pressure and ultrasound assessment, was performed to determine the functional significance. After 120 mcg adenosine intracoronary baseline flow velocity increased from 14 cm/sec to a peak flow velocity of 37 cm/sec, demonstrating a sufficient coronary flow velocity reserve (CFVR) of 2.6. No intracoronary pressure drop during maximal hyperaemia was found. After maximum dobutamine stress CFVR was measured 2.5. Fractional flow reserve measured 0.99. Cross sectional area measurement through intravascular ultrasound demonstrated a diameter reduction from 14.6 mm2 to 8.5mm2. Therefore we concluded this aberrant trajectory was not of any functional relevance and should be considered non-malignant. Discussion There are several anatomic coronary anomalies which may contribute to coronary compression during exercise and are therefore correlated with sudden cardiac death. R-ACAOS is correlated with low mortality rate of 0.2% in comparison to Left-ACAOS at 6.3% over 20 years in participants of competitive sport. Therefore strong evidence of ischemia must be present before opting for surgery. Our pragmatic approach provided in our opinion enough evidence for a conservative treatment strategy.
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