Presentation
Chest pain with associated lightheadedness on exertion. Positive exercise tolerance test. Her brother had an MI at the age of 50.
Patient Data
Coronary arteries:
Dominance: Right dominant. The left main coronary artery arises from the right coronary cusp with a common origin of the RCA/LCA and has an interarterial course. The SA nodal branch is probably arising from a small left circumflex.
LMS: Normal
LAD: Proximal mixed plaque, 50-70% stenosis.
CX: Small vessel, normal.
RCA: Proximal calcified plaque, less than 25% stenosis.
Cardiac findings:
Normal valves and chambers. Minor calcification of the tricuspid aortic valve is noted.
Non-cardiac findings:
Normal visualized chest.
Conclusion:
Anomalous left coronary artery with interarterial course. Non-obstructive coronary artery disease.
Case Discussion
This patient has a single coronary artery arising from the right coronary cusp, with the left coronary arteries branching from this vessel and coursing between the aorta and pulmonary artery. This is known as an interarterial course, sometimes referred to as a malignant course. This abnormality can potentially lead to life-threatening complications, such as myocardial ischemia, arrhythmias, or sudden cardiac death, particularly during exercise or periods of increased demand.
In anomalous coronary arteries with interarterial course, the morphology of the vessel also is a determinant of likely outcomes. Patients whose vessels have a particularly acute angle at the ostium or patients where the coronary artery has an intramural course (e.g. travels within the wall of the aorta) are more likely to suffer from complications.
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