Anomalous origin of the left coronary artery with malignant course

Case contributed by Naim Qaqish
Diagnosis certain


Excertional epigastric pain and dyspnea.

Patient Data

Age: 45 years.
Gender: Male

Native coronary arteries:

Origin: There is evidence of anomalous single ostium arising from the right coronary cusp giving branches to both the right coronary artery and left-main.  Absent ostium of the left main form its normal origin in the left coronary cusp. The left main appears long, traveling to the left side from an atypical origin as mentioned before running in a malignant course between the ascending aortic root and the right ventricular outflow tract (pulmonary artery).

Dominance: RCA.

LMS: Abnormal origin following malignant course as mentioned before, but patent.

LAD: There is evidence of wall calcification in its proximal portion but otherwise patent.

D1: Patent.

D2: Patent.

LCx: Patent.

OM: Patent.

RCA: There is evidence of minimal wall irregularity and ectasia in its proximal portion with a small spot of calcification but not resulting in significant stenosis.

PDA and PLB: Patent.

Case Discussion

ECG stress test showed changes compatible with angina. He is a smoker for 20 years but is free from chronic medical diseases. Coronary CTA was requested by the cardiologist and revealed a congenital malignant course of the left main coronary artery running between the ascending aortic root and the right ventricular outflow tract.

It is considered malignant course of the coronary artery, when it is coursing between two pulsating objects like in this case the aortic root and the pulmonary artery which can cause severe compression during excertion and might lead to sudden cardiac death. 

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