Virginia Research Day 2021

Anomalous Left Main Coronary Artery with Concomitant Atherosclerotic Disease Managed by Angioplasty

Tyler Avery MS3; Dr. Christopher Bunn DO.; Augusta Health Cardiology; Fishersville, Virginia

Case Presentation

Cardiac Cath

Conclusions

52-year-old male with a history of obesity, hypertension, GERD, and hyperlipidemia presented to the ED with chest pain. The chest pain was progressive over the last year , occurred with exertion and at rest, and radiated into the left arm. EKG demonstrated NSR without ischemic ST - T wave abnormalities and cardiac biomarkers were negative. Patient's Heart score was determined to be 3 subsequently the patient was discharged with cardiology follow up. Exercise nuclear stress test was performed after an equivocal plain exercise stress test which demonstrated reversible inferior and inferolateral defects consistent with ischemia (fig 1). Cardiac catheterization revealed anomalous left coronary artery arising from the right sinus of Valsalva (fig. 2) and an 80% lesion of the right coronary artery (fig. 3). Since the area of ischemia corresponded to the RCA lesion and not the LAD or Circumflex territory interventional cardiology proceeded with stenting (fig. 4). Had the stress test shown reversible ischemia in the anterior territory consistent with possible compression of the coronary anatomy by the pulmonary artery, then stenting would have been delayed as surgery would have been the definitive treatment for the patient's ischemia. Coronary CT angiography revealed the left main artery anterior to the pulmonary artery and low risk for compressive ischemia. These findings are consistent with the nuclear stress test which did not demonstrate ischemia in the anterior wall.

References Finocchiaro, G., Behr, E. R., & Tanzarella, G. (2019). Anomalous Coronary Artery Origin and Sudden Cardiac Death: Clinical and Pathological Insights From a National Pathology Registry. JAAC: Clinical Electrophysiology, 5(4), 516 – 522. Narayanan, M. A., Dezorzi, C., Akinapelli, A., Haddad, T. M., Smer, A., Baskaran, J., & Biddle, W. P. (2015). Malignant Course of Anomalous Left Coronary Artery Causing Sudden Cardiac Arrest: A Case Report and Review of the Literature. Case Reports in Cardiology, 2015, 1 – 4. Khalighi, K., Sharma, M., Toor, A., Toor, R. S., & Costacurta, G. (2018). Anomalous Left Main Coronary Artery Arising from the Right Sinus of Valsalva in a Young Man Presenting with Recurrent Syncope and Myocardial Infarction. Case Reports in Cardiology, 2018, 1 – 4. Marler, A. T., Malik, J. A., & Slim, A. M. (2013). Anomalous Left Main Coronary Artery: Case Series of Different Courses and Literature Review. Case Reports in Vascular Medicine, 2013, 1 – 5. Krasniqi, X.; Citaku, H. (2018). Anomalous Origin of Coronary Arteries. IntechOpen, 1 – 12. We present a case of anomalous coronary artery in an older male combined with significant atherosclerotic disease of the RCA. Interventions for anomalous Coronary vessels normally include CABG or unroofing surgeries (Narayanam et. Al., 2015). As a result of our patient presenting with unstable angina and a nuclear stress test demonstrating ischemia only in the territory of the myocardium supplied by the RCA and not in a territory consistent with a compressive surgical anomaly angioplasty was performed. Angioplasty would have been contraindicated if there was a question of possible surgical intervention secondary to the need of dual antiplatelet therapy. This case was unique in that the anomalous vessel ran anterior to the pulmonary artery and was not a significant contributor to the ischemic changes that were identified on the nuclear stress test. Coronary artery anomalies most often present as a compressive syndrome that is high-risk for ischemic chest pain or sudden cardiac death in a patients early 20’s. (Finocchiaro et al., 2019). The combination of the discovery of the anomalous vessels being the left main and ischemic changes being primarily localized to the region of the RCA, it could be concluded that the vessel was not intraarterial, the ischemia was not due to an acute-angle takeoff, myocardial bridging, or slit ostium all of which would have presented with more regional abnormalities which would have been expected in a patient with an aberrant LMCA (Krasnigi et al., 2018). With this being established in the setting of a male patient in his early 50’s with significant risk factors of atherosclerosis the cardiology team made the decision to intervene on the lesion with angioplasty using a 3.5mm x 20mm Synergy DES resulting in no surgical complications and complete resolution of anginal symptoms. Anomalous coronary arteries are rare are found in less than 1% of the population with even fewer 0.047% arising from the right sinus of Valsalva (Khalighi et al., 2018). It is important however to keep in mind that symptoms often present in a patient in their early 20’s in the setting of collegiate sports or basic training where cardiac METs are often heightened repetitively for an extended period (Marler et al., 2013). Thus, anomalous vessels should be considered on the differential of a young adult presenting with anginal symptoms to avoid SCD secondary to a compressive syndrome due to an intraarterial course of an anomalous coronary vessel.

Fig. 2- Demonstrates anomalous LCA, LAD, and LCX

Nuclear Stress Test

Fig. 3 80% lesion of RCA pre-intervention

Fig. 4 RCA lesion post intervention (3.5mm X 20mm Synergy DES)

Fig 1a and 1b demonstrate ischemia in the inferior and inferolateral wall corresponding to an RCA lesion.

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