Malignant Course of Anomalous Left Coronary Artery Causing Sudden Cardiac Arrest: A Case Report and Review of the Literature

Abstract

Sudden cardiac arrest has been reported to occur in patients with congenital anomalous coronary artery disease. About 80% of the anomalies are benign and incidental findings at the time of catheterization. We present a case of sudden cardiac arrest caused by anomalous left anterior descending artery. 61-year-old African American female was brought to the emergency department after sudden cardiac arrest. Initial EKG showed sinus rhythm with RBBB and LAFB with nonspecific ST-T wave changes. Coronary angiogram revealed no atherosclerotic disease. The left coronary artery was found to originate from the right coronary cusp. Cardiac CAT scan revealed similar findings with interarterial and intramural course. Patient received one-vessel arterial bypass graft to her anomalous coronary vessel along with a defibrillator for secondary prevention. Sudden cardiac arrest secondary to congenital anomalous coronary artery disease is characterized by insufficient coronary flow by the anomalous left coronary artery to meet elevated left ventricular (LV) myocardial demand. High risk defects include those involved with the proximal coronary artery or coursing of the anomalous artery between the aorta and pulmonary trunk. Per guidelines, our patient received one vessel bypass graft to her anomalous vessel. It is important for clinicians to recognize such presentations of anomalous coronary artery.

Coronary Artery Anomalies in Tetralogy of Fallot Patients Undergoing CT Angiography at a Tertiary Care Hospital

“…The course of CAAs has major clinical importance. Retroaortic, prepulmonic, and septal (subpulmonic) course anomalies appear benign, whereas LCA represents most commonly with a malignant course and carries a high risk for sudden cardiac death (SCD) [ 23 , 24 ]. Less frequently associated with SCD is RCA from left coronary sinus is more prevalent (0.1%) [ 25 ].…”

A Case of Anomalous Left Anterior Descending Artery Originating From the Right Sinus of Valsalva

“…CAAs are also the second most leading cause of SCD in athletes at 19% as compared to hypertrophic cardiomyopathy at 36% [12]. Other anatomic characteristics of CAAs predisposing them to grave outcomes include single coronary artery, origin from the pulmonary artery or opposite aortic sinus, intramural course, acute angle takeoff and ostial stenosis or atresia [2][3][4]6,10]. Asymptomatic CAAs rarely need interventions; however, symptomatic individuals with a malignant course often require surgical correction [8].…”

“…Most of the anomalies are incidentally found during coronary angiography, coronary computed tomographic angiography, or coronary magnetic resonance angiography of coronary vessels. About 80% of the anomalies are benign and are asymptomatic; however, malignant outcomes have also been documented [4]. Here, we present the case of a 76-year-old male with non-ST segment elevation myocardial infarction (NSTEMI) who was found to have an asymptomatic anomalous origin of LAD from the RSV.…”

A novel echocardiographic approach for assessing coronary artery origins

“…Although the mechanism of SCD in patients with AAOCA is largely unknown, there are variants of AAOCA that have a higher predisposition for SCD. Patients with a inter‐arterial coronary artery (between the ascending aorta and the pulmonary trunk), ostial abnormalities, compression of an intramural segment during exercise, longer intramural coronary length, and obstruction related to an acute angle of a coronary artery have all been proposed as anatomical features placing patients at higher risk for SCD 10–15 . Identifying the coronary artery origins in young adults can be difficult due to shadowing and attenuation, requiring imaging in multiple planes.…”