Anomalous origin and interarterial course of right coronary artery associated with angina and proven ischemia

Abstract

Clinical 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 artery (RCA) originating from the left sinus of Valsalva coursing between the aorta and pulmonary artery. This was associated with demonstrable stress ischemia with nuclear perfusion scan. The patient underwent surgery with a bypass graft to the anomalous RCA with complete relief of her angina.

Keywords: angina; computed tomography; coronary anomaly; coronary artery disease; ischemia.

Fig. 1

A 64-slice CT coronary angiograph. (A) Anomalous origin of the RCA from the left sinus and proximal course between the aorta and pulmonary artery.(B) Reconstructed image revealing common ostia of both the right and left coronary arteries, slit like orifice of RCA, proximal interarterial course, and intramural location in the aortic wall of the RCA. (C) The difference in the luminal diameter between the proximal interarterial segment and the distal normal segment of the RCA is clearly seen. Ao, aorta; PA, pulmonary artery; RCA, right coronary artery; LCx, left circumflex artery; LAD, left anterior descending artery.

Fig. 2

Stress and rest bull's-eye representation (top row) and vertical long axis (bottom row) images of myocardial perfusion revealing stress induced and reversible perfusion defect in the inferior segments. INF, inferior.