A 46-year-old man emergently presented after developing chest pain while running for a taxi. He reported no associated shortness of breath, palpitations, or dizziness. His vital signs were stable, and the results of respiratory and cardiovascular examination were normal. An electrocardiogram showed ST-segment elevation in leads V 2 through V 6 (Fig. 1). An urgent coronary angiogram revealed narrowing at the origin of the left main coronary artery (LMCA) that did not resolve after intracoronary nitroglycerin was administered (Fig. 2). However, there was no evident atherosclerotic disease.To better characterize the lesion, we performed dual-source, 64-slice computed tomographic scanning (Siemens Medical Solutions USA, Inc.; Mountain View, Calif ) with retrospective cardiac gating (0.6 × 0.3-mm image slices); postprocessing image reconstruction was done on independent workstations. We found that the LMCA anomalously originated at an acute angle from the right coronary sinus (Fig. 3) and took a malignant course between the proximal ascending aorta and the pulmonary
Images in Cardiovascular Medicine