Anomalous right coronary artery with interarterial course depicting an unusual case of an electrical storm: a case presentation.

BACKGROUND: The condition of anomalous aortic origin of the right coronary artery (AAORCA) with an interarterial course leads to few, if any, clinical problems. Malignant presentation of the often non-significant AAORCA associated with conduction system abnormalities is a rare finding. Surgical repair, even for highly symptomatic patients, is still controversial. However, in this case, the surgery brought a paradigm shift in treatment modality, improving the symptoms of this patient. CASE PRESENTATION: We report a case of a 52-year-old man with severe chest pain and recurrent electrical storms with an implanted cardiac resynchronization therapy defibrillator (CRT-D) device. Coronary angiography and computed tomography (CT) revealed the rare anomalous aortic origin of the right coronary artery (AAORCA) with a high interarterial course between the aorta and the pulmonary trunk. As symptoms typically develop on exertion, placing the patient at an increased risk of ischemic distress, a stress myocardial perfusion imaging study helped to identify his high-risk status. Although patient-specific, a surgical repair was the only concrete step agreed upon after multiple collaborative discussions with the cardiac surgeons. Surgery significantly improved the symptoms, with the patient reporting resolution of his chest pain, as well as no documented inappropriate defibrillator activity on follow-up appointments. CONCLUSION: One purpose of reporting the case study was to underscore the risk factors associated with AAORCA, challenging claims of its benign nature. This case complements existing findings demonstrating that ischemic distress consequent to the right coronary artery (RCA) compression may precede the rare incidence of an electrical storm. Importantly, the case-study emphasizes the significance of integrated multimodality imaging in clinical practice as well as providing real-world evidence for the efficacy of surgical repair in highly symptomatic patients with AAORCA with an interarterial course.

Anomalous Coronary Arteries: A Cause for Malignant Arrhythmias.

Anomalous aortic origin of a coronary artery (AAOCA) is a congenital condition that can lead to sudden cardiac death (SCD), particularly among young individuals. The cause of SCD is thought to be ischemia, primarily related to the course of the anomalous coronary artery. Surgical intervention, such as unroofing or coronary revascularization, is the preferred management modality for patients with evidence of ischemia or concomitant fixed obstruction. Herein, we presented a case of a 24-year-old male admitted to the emergency department with a history of palpitations, dyspnea, diaphoresis, and syncope. The patient had no prior medical diseases and was eventually diagnosed with an anomalous right coronary artery (ARCA) originating from the left coronary sinus. The patient underwent surgical unroofing of the ARCA to prevent further episodes of ischemia and ventricular arrhythmias. The case highlights that coronary artery anomalies can be life-threatening and lead to SCD, especially in young individuals with no risk factors. Investigating coronary anomalies in medically free patients presenting with cardiac symptoms and arrhythmias is crucial.

Anomalous Origin of the Right Coronary Artery From the First Septal Perforator.

A 68-year-old white male presented to the clinic for chest pain and shortness of breath with exertion. Through coronary angiography, the patient was found to have an anomalous origin of the right coronary artery off the first septal perforator branch of the left anterior descending artery. The patient was treated with conservative medical therapy as symptoms had resolved, and the patient did not wish to undergo further procedures.

Anomalous Coronary Origin and Malignant Course in a Young Patient With Palpitation and Demand Ischemia: A Serendipity or a Syndrome Without a Name?

Anomalous coronary artery remains the second most common cause for sudden cardiac death (SCD) in young athletes. The anomaly most commonly associated with SCD is the one that courses between the aorta and pulmonary artery, the malignant course. We present a case of a young gentleman who presented with symptomatic palpitations and was found to have anomalous right coronary artery from ostial left main coronary artery coursing between the aorta and pulmonary artery.

Rare malignant anomalous right coronary artery incidentally detected by dual source computed tomography angiography in an adult referred for transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is a safe treatment option for elderly patients with aortic stenosis (AS) with high or intermediate surgical risk. The anomalous origin of coronaries from a single Valsalva sinus has a higher risk of coronary obstruction during the TAVI procedure, so prior knowledge of these anatomical variants is of paramount importance as it can change the surgical strategy. In this report, we present the case of an adult patient suffering from severe aortic stenosis and incidentally diagnosed with an anomalous malignant variant of right coronary artery (RCA) by pre-procedural Computed Tomography (CT) Angiography. In TAVI planning, the use of electrocardiography (ECG) gated Dual Source CT (DSCT) enables accurate coronary and aorto-iliac vascular study, useful for detecting congenital coronary anomalies.

Spontaneous Coronary Artery Dissection of an Anomalous Right Coronary Artery in a Young Male.

Spontaneous coronary artery dissection (SCAD) is a tear in the coronary artery layers that presents clinically as an acute coronary syndrome (ACS), ventricular arrhythmias, or sudden cardiac death (SCD). It is uncommon for young healthy males with no comorbid conditions to have SCAD. We report an interesting case of SCAD in an anomalous right coronary artery (RCA) in a young 33-year-old male. The patient presented with episodes of midsternal chest pain and had elevated troponins on laboratory workup. A left heart catheterization revealed anomalous RCA, originating from the left aortic sinus. The left heart catheterization also demonstrated a SCAD of the anomalous RCA. Cardiothoracic surgery was consulted, and the patient had placement of saphenous vein graft to the proximal RCA. While this patient's presentation of ACS in the setting of SCAD is relatively common, it was atypical due to gender and lack of precipitating stressors. One of the risk factors this patient did have was the anomalous RCA arising from the left aortic sinus. There is scarce literature involving guidance for therapeutic intervention for RCA ostial lesion, let alone an anomalous one. Although coronary artery bypass grafting (CABG) remains the most clinically sound decision, in this case, further development of guidelines for RCA lesions would aid in decision-making.

Sudden Cardiac Death in a Patient with Anomalous Origin of Right Coronary Artery with Concomitant Sinus of Valsalva Aneurysm.

Anomalous origin of right coronary artery (ARCA) arising from the left sinus of Valsalva (a congenital cardiac abnormality) and sinus of Valsalva aneurysm (SOVA) are rare and often have asymptomatic conditions. However, symptoms could range from chest pain, shortness of breath, palpitations, syncope to sudden cardiac death (SCD). The co-existence of these two anomalies (ARCA + SOVA) could lead to potential adverse outcomes in the absence of early intervention. The presence of these two conditions together increases the risk of SCD as reported in our case of a young male who presented to the emergency department with chest pain.