Anomalous right coronary artery (ARCA) with interarterial course
Atypical chest pain and normal stress test.
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An anomalous origin of the left coronary artery (LMS), which is located posteriorly on the ascending aorta right above the left sinus of Valsalva (first image). The aorta seems to be "twisted" clockwise with 90 degrees. Distally the LMS can be seen to be bifurcating into the LAD (located medially) and the circumflex artery (Cx).
There is also an anomalous origin of the right coronary artery (RCA) which is located anteriorly on the ascending aorta above the left sinus of Valsalva (second image) and has an inter-arterial course between the ascending aorta and pulmonary trunk. This is a potentially life-threatening anomaly.
This patient has an anomalous right coronary artery (ARCA) originating from the anterior side of the ascending aorta and coursing between the pulmonary trunk and ascending aorta (= inter-arterial course).
An ARCA with an inter-arterial course has a severe prognosis and is therefore referred to as malignant.
Symptomatology is thought to be caused by the rising pressure within both the aorta and pulmonary artery during exercise, thereby compressing the anomalous coronary artery by a scissor-like mechanism.