Multimodality Imaging of Anomalous Origin of Right Coronary Artery From Pulmonary Artery (ARCAPA)

J INVASIVE CARDIOL 2017;29(9):E104.

Key words: ARCAPA, cardiac imaging, anomalous coronary anatomy

A 55-year-old man presented with altered mental status and hypoxia due to opiate drug abuse. Due to elevated cardiac troponin, he underwent coronary angiogram. Findings included a large tortuous left anterior descending (LAD) artery and left circumflex (LCX) artery that collateralized to a large right coronary artery (RCA), which drained into the pulmonary artery (PA). Computed tomography angiographic and fluoroscopic images confirmed anomalous RCA from PA (ARCAPA) (Figure 1 and Video 1). Epicardial coronaries were without any significant obstructive disease. Oximetry was performed to determine the significance of left to right shunt; however, there was no hemodynamically significant step-up in oxygen saturation from right ventricle to PA, suggesting that the shunt was not significant. The cardiac enzyme elevation was attributed to hypoxia-related stress on myocardium in the presence of ARCAPA. Cardiothoracic surgical consultation was done at our center and the patient was referred to another center to an adult congenital heart disease surgeon. ARCAPA is exceedingly rare, with reported incidence of 0.002% in the literature. Coronary steal phenomenon can occur in ARCAPA due to differences in diastolic pressure between systemic and pulmonary arterial beds, with risk of myocardial ischemia during increased myocardial oxygen demand. Surgical correction with implantation of anomalous RCA into the aorta is recommended.

The literature on adult patients suggest that these patients can have angina, and when they have hypoxia for any reason, it can cause ischemia, angina, and troponin elevation. Our patient had history of hypoxia from sleep apnea. After discussing the risks and benefits, including the risk of sudden cardiac death, our patient decided to wait before he undergoes surgery.

From Carle Foundation Hospital, University of Illinois at Urbana Champaign, Urbana, Illinois.

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 accepted April 5, 2017.

Address for correspondence: Sanjay S. Mehta, MD, FACC, FSCAI, Carle Foundation Hospital, University of Illinois at Urbana Champaign, Urbana, IL 61801.Email: sanjay.mehta@carle.com