Anomalous Origin and Interarterial Course of Right Coronary Artery Associated with Angina and Proven Ischemia

Abstract

In April 2012, a 25-year-old lady was seen in our clinic with the chief complaint of chest pain on exertion. The pain was central, crushing like, radiating to her neck, and was typically occurring on exertion. The patient noted that she experienced the pain especially in the mornings when she was rushing to catch her bus to work; the pain was worse when the weather was cold and if she had her breakfast. She was consistently experiencing the pain on exertion for the last 2 years. She did not have any risk factors for atherosclerotic coronary artery disease. Echocardiography findings were within normal limits. A treadmill exercise stress test was performed where she reached the target heart rate and complained of chest pain at peak exercise, but only nondiagnostic subtle upsloping ST depressions were observed. Because of low pretest probability of an obstructive coronary artery stenosis a conventional coronary angiography was not performed at that stage. With the possibility of a coronary artery anomaly the patient was referred for a computed tomography (CT) coronary angiography. The CT scan demonstrated anomalous origin of the right coronary artery (RCA) from the left sinus of Valsalva and the proximal course of the RCA between the aorta and pulmonary artery (►Fig. 1).When requestioned in depth, the patient did not report any history of syncope-presyncope or palpitations.While the patients symptoms were typical of angina, to aid in therapeutic decision making an objective criteria for ischemia was searched. A nuclear perfusion scan was performed that revealed a mild stress induced perfusion defect in the inferior segment of the left ventricle (►Fig. 2) (the interpreting physician was aware of patient's typical anginal symptoms and the presence of coronary anomaly, but not of the exact anatomy to avoid any bias). The decision was to refer patient for surgery. Robotic surgery through a minithoracotomy was performed and the right internal mammary artery was anastomosed to the distal RCA, the proximal RCA was tied off to prevent steal phenomenon. After an uneventful surgery, the patient recovered and her chest pain on exertion subsided completely. Two months after the operation, an exercise stress test was performed which confirmed complete relief of symptoms. A further nuclear perfusion study was not performed at that stage not to expose the patient to further radiation.Anomalous coronary arteries are rare congenital abnormalities; however, they may be life threatening. Keywords► coronary anomaly ► ischemia ► computed tomography ► coronary artery disease ► angina AbstractClinical significance of coronary arteries with anomalous origin and/or course is highly heterogeneous. Anomalies with the origin from the opposite sinus and interarterial course can be associated with angina, syncope, and sudden cardiac death. However, there are no clear guidelines for diagnosis and treatment of such cases. We present the case of a young lady who presented with typical angina, and later proved to have an anomalous right coronary ar...

Approaches to the treatment of the premature ventricular contractions in a young patient with anomalous origin of the right coronary artery from the left sinus of Valsalva

“…Оценка необходимости реваскуляризации при аномалиях ПКА зависит от наличия симптомов ишемии миокарда, а именно доказанной ишемии, проявляющейся подъемом сегмента ST, увеличением маркеров ишемического повреждения миокарда. Подобные пациенты были пролечены хирургически с превосходным долгосрочным результатом [6].…”

Anomalous origin of right coronary artery causing myocardial ischemia in a young patient

“…Cases with no documented cardiac ischemia have been reportedly treated medically with excellent long-term follow-up. [ 6 ] The asymptomatic incidentally diagnosed patients with low risk of sudden cardiac death can possibly closely followed up with exercise restriction as per current guideline. [ 7 ] The risk of sudden death is increased in symptomatic patients, as well as in the presence of some risk factors such as intense physical activity, young age <35 years, aggravating anatomical features such as intramural inter-arterial course, slit-like ostium, and acute angle of takeoff.…”