J INVASIVE CARDIOL 2019;31(9):E279.
Key words: acute coronary syndrome, anomalous origin of right coronary artery, cardiac computed tomography, coronary angiography, coronary artery anomaly
A 52-year-old woman was admitted for acute coronary syndrome without persistent ST elevation (NSTEMI). She had no cardiovascular risk factors and practiced running regularly. Electrocardiogram was normal and echocardiogram showed hypokinesia of the left ventricular posterior wall with normal ejection fraction.
Coronary angiography showed normal left coronary artery (Figure 1A). However, the right coronary artery (RCA) originated from the left sinus of Valsalva (very close to the left main coronary artery) and ran toward the acute margin of the heart (Figure 1B). The caliber of the RCA was regular and the posterolateral branch showed a tight stenosis (culprit lesion). We performed percutaneous coronary intervention with drug-eluting stent implantation; a good angiographic result was obtained. The patient was discharged after 3 days. Cardiac computed tomography (CCT) confirmed the RCA anomaly and showed that the proximal segment of the vessel ran between the ascending aorta and pulmonary artery (Figure 1C).
Coronary artery origin from the opposite sinus is a rare coronary anomaly; the incidence is about 1.07% (between 0.12% and 0.9% for the RCA). Three types of RCA ectopic origin are described: retroaortic, interatrial, and anterior to the pulmonary trunk. Although clinically consequential in about 20% of cases, diagnosis is usually incidental. When the ectopic artery runs between the aorta and pulmonary artery or when intussusception occurs in the aortic wall, myocardial ischemia and sudden death during extreme exercise can occur.
In adult patients, coronary angiography is the standard procedure for the assessment of coronary artery disease; unfortunately, only two-dimensional images are acquired and do not provide adequate spatial resolution. In contrast, CCT is a sensitive diagnostic method that reconstructs three-dimensional images, enabling exact views of anomalous arteries, as well as their origins, courses, and anatomical correlations to other great vessels and structures. A limitation of CCT is the lack of hemodynamic information. Surgical correction (transposition of the anomalous origin or coronary artery bypass) is recommended in symptomatic patients with interatrially coursing RCA.
From the Unità Operativa Complessa di Cardiologia, Ospedale San Francesco, Nuoro, Italy.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted February 2, 2019.
Address for correspondence: Dr Giovanni Lorenzoni, Ospedale San Francesco, Unità Operativa Complessa di Cardiologia, via Mannironi 1, Nuoro, Italy. Email: firstname.lastname@example.org