Presentation
Chest pain without ST elevation. Multiple co-morbidities.
Patient Data
Left coronary system:
The left main coronary artery originates from the right anterior sinus with a course between the RVOT/main pulmonary artery and the aorta. The left main coronary artery is long and of medium diameter. The left anterior descending artery originates from the left main. This artery is medium in size and mildly calcified. This artery has one diagonal. The proximal left anterior descending coronary artery has a non-flow-limiting (<50%) stenosis. The mid-left anterior descending coronary artery has a non-flow-limiting (<50%) stenosis. The circumflex coronary artery originates from the left main coronary artery. This artery is medium in size and without calcification. This artery has three major obtuse marginals. The circumflex coronary artery is free of stenosis in its proximal, and distal segments.
Right coronary system:
The right coronary artery originates from the right anterior sinus. This artery is medium in size and without calcification. The proximal right coronary artery has severe (70-90%) stenosis. The distal right coronary artery has a non-flow-limiting (<50%) stenosis.
Opinion:
Right dominant system with anomalous origin of left main from the right coronary sinus, with a course between the right ventricular outflow tract/main pulmonary artery and aorta, severe stenosis of proximal RCA, non-obstructive disease of LAD, CAD RADS 4a/P2/E.
Case Discussion
This patient is experiencing chest pain without ST elevation and had undergone catheter coronary angiography. The left system was challenging to cannulate due to an anomalous origin from the right coronary sinus. CT coronary angiography was performed to image the anomalous origin of LMCA & LCX lesions.
The right coronary artery and left main artery both originate from the right coronary sinus with separate adjacent openings, i.e. an anomalous left coronary artery origin from the right coronary sinus. The left main coronary artery has an interarterial course between the RVOT/main pulmonary artery and the aorta. This can be associated with sudden death and myocardial ischemia in younger adults, however it can also be a benign incidental finding especially in the absence of specific anatomical and dynamic features 3. Chest pain in this individual may be due to right coronary artery stenosis or a non-cardiac cause.
Case courtesy of Dr Safwat Almoghazi, MD, radiologist, Dr Shreeram Kannan Consultant Radiologist Dr Ahmed Nabil Consultant Cardiologist.
Unable to process the form. Check for errors and try again.