Background
Coronary artery anomalies are characterized by an abnormality in the course or origin of three main coronary arteries. There needs to be more scientific evidence to promptly treat coronary artery anomalies with poorly understood prognostic implications, especially anomalous aortic origin of the right coronary artery from the left coronary cusp.
Case presentation
A 58-year-old Caucasian female presented multiple times over 6 months with atypical chest discomfort and palpitations. The treadmill exercise test demonstrated exercise-induced non-sustained ventricular tachycardia. A coronary angiogram revealed no obstructive coronary artery disease and an anomalous aortic origin of the right coronary artery from the left coronary cusp with an interarterial course. She was managed conservatively with medications, despite persistent recurrent symptoms.
Conclusion
It is essential to identify subtle symptoms and insidious onset of anomalous aortic origin of the right coronary artery symptoms as seen in our patient, which can contribute to significant morbidity. There are discrepancies in existing guidelines between different cardiovascular societies in managing selected subgroups of patients with anomalous aortic origin of the right coronary artery who do not have high-risk features, but continue to remain symptomatic.
Background:
The incidence of anomalous aortic origin of the right coronary artery (AAORCA) is between 0.026% and 0.25%. There is limited data regarding medical versus surgical management. We present a case of AAORCA which did not “qualify” for surgical intervention but remained symptomatic on medical management.
Presentation:
A 58-year-old female with paroxysmal atrial fibrillation presented for the eighth time in the past two years with recurrent atypical chest pain and lightheadedness. Vital signs and cardiac biomarkers were normal.
Work-up:
EKG showed normal sinus rhythm. TTE revealed EF 68%. Myocardial perfusion imaging was normal but exercise stress test showed ventricular ectopy, ventricular bigeminy, short bursts of ventricular tachycardia (VT) at peak exercise, and a 7-beat run of VT. A 30-day event monitor revealed a 17-beat run of VT at a rate of 173 bpm (Figure A).
Management:
Cardiac catheterization showed the dominant right coronary artery (RCA) arising from the left coronary cusp with a shared ostium to the left coronary system (Figure B-D). A coronary CT scan confirmed dominant RCA arising from left coronary cusp (Figure E) with an interarterial course (Figure F) and slit-like appearance of the proximal RCA, with a likely intramural course (Figure G).She was managed conservatively with restriction of vigorous exercise, up-titration of beta-blockers, addition of anti-anginal agents and implantation of loop recorder.
Conclusion:
The most updated consensus statement for AAORCA recommends surgical intervention for those with signs or symptoms of myocardial ischemia (true angina, findings on provocative testing, aborted sudden cardiac arrest or non-vagally-mediated arrhythmia).Although our patient did not “qualify” for surgical intervention, she continued to experience refractory symptoms. Hence, it is of utmost importance to consider surgical intervention in patients who have failed medical management, for improved quality of life.
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