Anomalous origin of left main coronary artery from the right sinus of Valsalva presenting as non ST elevation acute coronary syndrome: A case report

Abstract

Congenital anomalies of the coronary arteries are a cause of sudden cardiac death. Of the known anatomic variants, anomalous origination of a coronary artery from an opposite sinus of Valsalva (ACAOS) remains a major clinical issue and a challenging condition to treat. Congenital coronary anomalies are likely to be under-recognized, as completing an anatomic assessment in a very large portion of the population would seem unfeasible. However, we present a case report with image of a 49 year old male presented with acute non-ST elevation ACS for which he underwent diagnostic angiography of the coronary system which revealed a common origin of both right and left main coronary artery from right sinus of Valsalva with significant obstructive lesion in the mid segment of right coronary artery. However, due to financial constraints CT angiography could not be done in this patient to identify the detail anatomy and the course of the anomalous left coronary artery origin (L-ACAOS). He was managed medically with dual antiplatelets, beta blockers, nitrates and ACE inhibitors.

Anomalous origin of the left main from the right coronary sinus presenting with sudden cardiac death: utility of mechanical circulatory support

“…Work up of patients with anomalous coronary arteries is similar to acute coronary syndrome with few points to consider. Electrocardiographic findings in symptomatic patients are nonspecific, ranging from STEMI abnormalities, implying ischemic changes, to ventricular tachycardia or fatal fibrillation [6,7].…”

“…Of note, transesophageal echocardiography is of limited benefit as this modality does not provide a clear picture of coronary origin and pathway. On the other hand, owing to its fast results and clear depiction of cardiac anatomy, coronary computed tomography angiography (CTA) has shown promising features rendering it the first-line imaging modality in most centers to outline the origin and full pathway of anomalous coronary arteries in patients of interest [6,8]. Moreover, angiographic view of coronary CTA assists in evaluating high-risk anatomical features including the slit-like origin, acute take-off angle, intramural and elliptical luminal vessel shape, and proximal narrowing of anomalous coronary arteries [9,10].…”

Anomalous Origin of Left Main Coronary Artery from the Right Sinus of Valsalva: A Case Series-based Review

“…Unfortunately, in the vast number of cases, sudden cardiac death is the initial and frequently terminal presentation [7]. Electrocardiographic findings in symptomatic patients are nonspecific and could vary from ST-wave abnormalities suggesting ischemia to ventricular tachycardia or fibrillation [10,11]. An echocardiogram is typically obtained to assess left ventricular systolic function, but it does not provide any additional diagnostic information.…”

Inferior Myocardial Infarction and Total AV Block in a Patient with Single Ostium in the Right Sinus of Valsava (A Rare Congenital Coronary Anomaly)

“…With exercise or physical activity, the blood flow through major vessels such as aorta and pulmonary artery as well as myocardial contractility increases, predisposing these anomalously coursing arteries for compression. [8][9][10] In nearly 15% of patients with SCA, myocardial ischemia can develop in the absence of acute (non-orthogonal) angle of take-off and kinking of the coronary artery as it exits from the aorta; c.) hypoplasia and/or stenosis of the intramural segment, particularly at the level of the valvar commissure. [6,11,12] Angiography can definitely distinguish between the intramural and the intraseptal course and the coexistence of atherosclerotic [13,14] .…”