A 40-Year-Old Female with Exertional Angina

The incidence of coronary anomalies in patients undergoing coronary angiography is approximately 1.3%.¹ Most of these anomalies are clinically benign, but some of them are associated with a high risk of myocardial infarction and sudden cardiac death. In this report, we describe the case of a patient with exertional angina who was found to have an anomalous right coronary artery arising from the left main trunk. We discuss the clinical importance of this particular anomaly and potential treatment options. Case Report. A 40-year-old female presented to the cardiology out-patient clinic with several months’ history of exertional chest tightness and dyspnea relieved with rest or nitroglycerin. She had presented at an outsidehospital a month prior with similar symptoms and had undergone a stress test, which did not show any evidence of ischemia. However, the stress test was stopped once she attained 85% of her maximal predicted heart rate. She was discharged on antacids and omeprazole with no improvement in her symptoms. Because of the typical nature of her symptoms and relief with rest/nitroglycerin, she underwent a 16-slice CT angiogram to non-invasively rule out any significant obstructive coronary artery disease. The CT angiogram revealed an anomalous origin of the right coronary artery from the left main coronary artery. The right coronary artery traveled between the aorta and the right ventricular outflow tract, and otherwise appeared patent throughout its anomalous course (Figure 1A and 1B). A subsequent coronary angiogram confirmed the anomalous origin and course of the right coronary artery (Figure 2). On the basis of the patient’s symptoms and the reports of sudden death with this abnormality, she was scheduled for coronary artery bypass surgery in which a saphenous vein graft was placed to her mid-right coronary artery, and the proximal portion of the artery was ligated. She tolerated the procedure well and remains asymptomatic at the four month follow-up visit. Discussion. Anomalous origin of the right coronary artery is a relatively rare congenital anomaly initially described by White and Edwards.² An anomalous origin of the right coronary artery can lead to angina pectoris, myocardial infarction, or sudden death in the absence of atherosclerotic stenosis.³ Potential explanations for this include compression of the right coronary artery by the great vessels, the oblique upright angle at the juncture of the anomalous right coronary artery and the left coronary sinus, producing a slit-like orifice in the aortic wall that can collapse during exercise,⁴ and spasm of the proximal portion of the right coronary artery between the aorta and the pulmonary artery.^5,6 One study of 52 patients with anomalous origin of the right coronary artery reported that 25% died suddenly and, in most cases, without prior symptoms.³ Treatment options for this condition include reimplantation of the right coronary artery to the aorta,⁷ ostioplasty, i.e., excision of the common wall between the right coronary artery and the aorta,⁸ and bypass grafting of the right coronary artery with ligation of the native artery proximal to the graft anastomosis to prevent competitive flow.⁹ Medical therapy includes treatment with beta-blockers and may reduce the risk of sudden cardiac death.¹⁰ Our patient preferred the option of surgical revascularization with complete amelioration of her symptoms.

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