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Anomalous Origin of the Right Coronary Artery With Intramural Aortic Course Causing Exercise-Induced Cardiac Arrest
A 25-year-old athletic man had a ventricular fibrillation arrest while running. Electrocardiogram after defibrillation showed ST-segment elevations in leads V1 and V2 and incomplete right bundle branch block, which then normalized. Personal and family history was unremarkable. Echocardiogram showed mild RV dilatation with borderline RV and LV function. Troponin I peaked at 5.55. The patient made a complete recovery. Cardiac MRI demonstrated mild thinning of the RV free wall, without stigmata of arrhythmogenic RV cardiomyopathy. Coronary angiography showed a normal left coronary system with opacification of the RCA on 
injection of the left coronary circulation (Figure 1; Video 1, available at www.invasivecardiology.com). A coronary CT angiogram (CCTA) showed an ectopic RCA originating from the left coronary sinus traversing between the pulmonary artery and aorta (Figures 2 and 3).
The patient was referred for surgical exploration and correction of the coronary anomaly. He was found to have an RCA that originated from the left sinus in a narrowed, slit-like ostium, coursed intramurally for 1.5 cm within a thickened portion of the aorta, 
and exited the aorta at the right coronary sinus. The RCA was dissected from the thickened aortic wall. The ostium of the RCA was reconstructed, and a pericardial patch was used to repair the aortic wall. The surgical repair was imaged postoperatively with CCTA demonstrating the reconstructed RCA and aorta (Figure 4). The patient did well and was discharged home. CCTA can be a useful imaging modality in evaluating the presence of anomalous coronary arteries. In this case, direct surgical inspection revealed an intramural course of 
the RCA that was not clearly visualized on CCTA.
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From the 1Department of Internal Medicine and 2Division of Cardiology, California Pacific Medical Center, San Francisco, California.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted April 9, 2012 and accepted May 29, 2012.
Address for correspondence: Ilana Spokoyny, MD, Department of Internal Medicine, California Pacific Medical Center, 2351 Clay Street, Suite 360, San Francisco, CA 94115. Email: Ilana.Spokoyny@gmail.com
