Hindawi Publishing CorporationCase Reports in MedicineVolume 2013, Article ID 195026, 3 pageshttp://dx.doi.org/10.1155/2013/195026

Case ReportAnomalous Right Coronary Artery from Left MainCoronary Artery and Subsequent Coursing betweenAorta and Pulmonary Trunk

Deephak Swaminath, Ragesh Panikkath, Jason Strefling, Alvaro Rosales,Roshni Narayanan, and Jason Wischmeyer

Department of Internal Medicine, TX Tech Health Sciences Center, Lubbock, TX 79430, USA

Correspondence should be addressed to Deephak Swaminath; deephak.swaminath@ttuhsc.edu

Received 6 July 2013; Accepted 18 November 2013

Academic Editor: Frank A. Pigula

Copyright © 2013 Deephak Swaminath et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Anomalous origin of left main coronary artery or right coronary artery from the aorta with subsequent coursing between the aortaand pulmonary trunk is rare and can be sometimes life threatening. After hypertrophic cardiomyopathy, coronary artery anomaliesare the second most common cause of sudden cardiac deaths among young athletes. This is a case presentation of an anomalousorigin of right coronary artery from left main coronary artery coursing between the pulmonary trunk and aorta. Patient presentedwith STEMI and had coronary bypass surgery.

1. Case Description

The patient is a 33-year-old male with an unremarkable pastmedical history and was transferred from an outside facilitywith an acute inferior myocardial infarction and ventriculartachycardia. Patient initially presented to the outside facilitywith complaints of chest pain. ECG showed lateral STelevation and subtle inferior ST elevation. At the outsidefacility, patient developed ventricular tachycardia, and CPRwas initiated with cardioversion 4 times before return ofspontaneous circulation. The patient was subsequently intu-bated and transferred to our facility for further management.

Upon transfer, the patient was taken for left heart cath-eterization (LHC) and selective coronary angiography. Leftheart catheterization and angiography showed an 80% longtubular stenosis of the proximal to mid left anterior descend-ing coronary artery (LAD) as well as an anomalous takeoffof the right coronary artery (RCA) from a left main coronaryartery (Figures 2(a), 2(b), and 2(c)). LHC revealed markedlyelevated left ventricular end diastolic pressure (LVEDP). Thepatient was aggressively diuresed after LHC revealed anelevated LVEDP. Dynamic ST changes improved with dual

antiplatelet therapy, heparin, nitrates, and aggressive diuresis.Cardiac CT angiography with 3D reconstruction (Figures1(a) and 1(b)) showed an anomalous origin of the rightcoronary artery coursing from the left main coronary arterybetween the aorta and pulmonary trunk. There was morethan 70% narrowing at the origin of the right coronary arteryfrom an apparent impingement from a plethoric pulmonarytrunk. Cardiovascular surgery was consulted for surgicalintervention. Aortocoronary bypass was performed with aleft internal mammary artery bypass to the left anteriordescending coronary artery and saphenous vein graft bypassto the right coronary artery. Postoperatively, the patientrecovered and was discharged home.

2. Discussion

Coronary artery anomalies are found in 0.9%–1.3% of pa-tients undergoing coronary angiography [1, 2]. Anomalousorigin of the left main coronary artery or right coronaryartery from the aorta coursing between the aorta and pul-monary trunk is rare and can be sometimes life-threatening.

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Aorta

RCALM

LeftPA

RightPA

LAD

(a)

RCA

(b)

Figure 1: (a) Cardiac CT angiography with 3D reconstruction with digital subtraction of pulmonary arteries. (b) Cardiac CT angiography.

RCA LCX

LAD

(a)

LAD with stenosis

RCALCX

(b) (c)

Figure 2: (a) Anomalous right coronary artery AP caudal projection with nonselective left coronary ostia angiogram. (b) Anomalous rightcoronary takeoff from left coronary artery in a RAO caudal projection of nonselective left coronary ostia angiogram. (c) Aortogram utilizingthe JR4 catheter showing no separate right coronary ostium.

After hypertrophic cardiomyopathy, coronary artery anoma-lies are the second most common cause of sudden cardiacdeaths among young athletes. Coronary artery anomaliesare also the most common cause of nontraumatic suddendeaths in young American military recruits [2–4]. In a recentstudy, coronary artery anomalies were the cause of deathin up to 19% of young athletes who died during or shortlyafter strenuous physical activity [3]. An interarterial course isclinically significant and carries a high risk for sudden cardiacdeath in young adults [5].

This is a case presentation of an RCA originatingfrom the common left main coronary artery and cours-ing between the pulmonary trunk and aorta. The patientpresented with ST segment elevation and life-threateningarrhythmia. Reduction of the right coronary blood flowsecondary to impingement from a plethoric pulmonary trunkis likely attributed to the acute presentation. Notably, thepatient did have anterolateral ST changes, suggestive of ahemodynamically significant LAD lesion, which may havecontributed to the elevated LVEDP on presentation. Inother presentations of compromising coronary anomalies,reduction in the coronary blood flow could be due to com-pression of the first segment of the coronary artery duringits interarterial course, acute takeoffs, or slit-like orifices ofthese arteries. Anomalous coronary origin with interarterialcoursing causes compromise in the coronary blood flow,which is evident during increases in pressure in the greatvessels during exercise. Ischemic compromise of anomalouscoronary arteries manifests as angina, syncope, congestiveheart failure, arrhythmias, and sudden death [6–10].

However, coronary anomalies are often asymptomaticandmight be discovered as an incidental finding.Thephysicalexam, ECG, and stress test are generally unremarkable. Ananomalous origin of a coronary artery and its route maybe diagnosed by coronary angiography or more definitivelyby multislice computed tomography. Intravascular ultra-sound provides high-resolution images to precisely evaluatecoronary anomalies and luminal irregularity. The role ofintravascular ultrasound was recently demonstrated in asmall study that diagnosed an extrinsic compression of ananomalous coronary artery originating from the oppositesinus of Valsalva [11].

A study of two large registries composed of 27 youngcompetitive athletes who died of sudden cardiac death (SCD)revealed that 23 had left main coronary artery from the rightaortic sinus and 4 had a right coronary artery from the leftsinus [12]. Estimates on rates of SCD with this conditioncome almost exclusively from autopsy data. Multiple studiesfocused on identifying specific factors that correlate with ahigher likelihood of SCD in patient with coronary anomaliesrevealed that angle of take off, intramural course, slit-likeostium, interarterial course, vessel spasm, and intussuscep-tion of the anomalous vessel are the contributing factors [13].However, in an attempt to identify specific features that werethought to contribute to risk of death, Taylor et al. lookedat 30 pathology cases of anomalous coronary arteries andconcluded that there were no anatomic features that could aidin risk assessment [14].This assertion produces a quandary inrisk assessment and likely means that these cases should beassessed individually on a case by case basis.

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Anomalous origin of the right coronary artery from theleft coronary sinus is 6 timesmore common than the contrarysituation of the left coronary artery originating from theright coronary sinus. However, fortunately this presentationis believed to be more benign than its counterpart whichis more malignant. Consequently, although surgical repairis advisable for all patients with the left coronary arteryoriginating from the right coronary sinus, this is not thecase with the right coronary artery originating from theleft coronary sinus, where it might it be advisable to onlya selected subgroup of patients [15]. The surgical optionsfor anomalous coronary origins from contralateral sinusinclude bypass grafting, reimplantation of the anomalousvessel into its appropriate sinus, patch augmentation withor without pulmonary artery translocation, and unroofingthe anomalous vessel [16]. Nonsurgical strategies include theuse of beta blockers and avoidance of participation in allcompetitive sports for patients [15].

Conflict of Interests

The authors declare that they have no conflict of interests.

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