A Missed Malignant Right Coronary Artery Anomaly Detected Post-Cardiac Event in an Adult Patient

Aims: We present this case to raise awareness of this unusual presentation of a malignant anomalous right coronary artery arising from the left coronary cusp in a patient older than 50 years. We describe a useful imaging modality and discuss therapy.
Presentation of the Case: We report a case of a 63-year-old male with an interarterial coursing right coronary artery arising from the left coronary cusp with a history of a mechanical aortic valve replacement. The patient presented to our emergency department after being resuscitated from a cardiac arrest and later had a normal coronary angiogram. High suspicion of his right coronary artery angulation, he underwent a computed tomography with angiogram that revealed his anomalous course and anatomy.
Discussion: We discuss the importance of coronary artery anomaly detection in the young at risk population (athletics), pathophysiology, diagnostic modalities, and treatment recommendations. Surgical revascularization has been advocated in malignant coronary anomalies, however, the lack of large randomized clinical trials for patients older than 50-year-old left this topic controversial. Medical therapy augmented with implanted cardioverter defibrillator (ICD) was utilized in this case. Medical management could be considered in centers that don’t have surgical experience or in adult patients who are a poor surgical candidate because of other comorbidities or life expectancy.
Conclusion: Computed tomography with angiogram seems to be the best noninvasive modality to delineate coronary course and anatomy. There is a need for randomized clinical trials to determine the best management of anomalies arising from opposite sinus with an interarterial course in adults >50-year-old.