Presentation
Chest pain. History of COPD, current smoker. Increasingly short of breath.
Patient Data
Coronary arteries:
Right dominant coronary system.
Anomalous left coronary artery arising from the right coronary cusp, passing between the aorta and pulmonary artery with a short intramural course. SA nodal branch arises from the left circumflex.
LMS: Mild calcified plaque distally, less than 25% stenosis.
LAD: Mild calcified plaque in the proximal vessel, less than 25% stenosis. Mild mixed plaque in the mid vessel, <50% stenosis. Otherwise normal vessel.
LCX: Minor calcified plaque in the proximal vessel, less than 10% stenosis. Mild calcified plaque in OM3, less than 25% stenosis. Otherwise normal.
RCA: Large plaque with high-risk plaque features in the proximal vessel (positive remodeling, low attenuation plaque, napkin ring sign), 50-70% stenosis. Otherwise normal.
Cardiac findings:
Mild aortic valve and mitral valve calcification. Otherwise normal cardiac valves and chambers.
Mildly enlarged ascending aorta - up to 45 mm. The sinus of Valsalva measures 41 mm in diameter.
Conclusion:
Anomalous origin of the left coronary artery with the inter-arterial course.
Nonobstructive coronary artery disease with high-risk plaque in the proximal right coronary artery.
Case Discussion
This patient's left coronary artery arises from the right coronary cusp and courses 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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