Virginia Via Research Day Book 2026

Medical Resident Research Case Reports

06 SNAP, CRACKLE, POPS

Justin Salak, DO; Julia Stelter, DO; Priscilla Tu, DO Corresponding author: jpsalak@carilionclinic.org

Virginia Tech Carilion Clinic, Roanoke, Virginia

mitral regurgitation, and mild to moderate pulmonic regurgitation. Electrocardiogram revealed normal sinus rhythm at a rate of 62 beats-per-minute with evidence of a first-degree AV block. Exercise stress echocardiogram was negative for any acute ischemic changes. However, due to his persistent concerns of intermittent back discomfort and pre-existing medical history placing him at high-risk for coronary artery disease, a left-heart catheterization was scheduled. Left heart catheterization revealed a congenital abnormality absence of the left main coronary artery with the left descending and circumflex vessels arising from the right coronary artery without obvious obstructive coronary artery disease. He was referred for a cardiac CT angiogram to better visualize the course of the great vessels. Comments: Coronary artery anomalies (CAAs) are detected in less than 1% of the population (1). They range in presentation from asymptomatic, incidental findings to chest pain, dyspnea, arrhythmias, or even sudden cardiac death (2). CAAs are the second most common cause of sudden cardiac death, after hypertrophic cardiomyopathy (1,2,3). While the majority of CAAs do not cause any clinical symptomatology, some variants impede blood flow and lead to cardiac dysfunctions including congestive

heart failure, ventricular aneurysms, and myocardial infarctions (2). 1. Agarwal, Prachi & Dennie, Carole & Pena, Elena & Nguyen, Elsie & LaBounty, Troy & Yang, Bo & Patel, Smita. (2017). Anomalous Coronary Arteries That Need Intervention: Review of Pre- and Postoperative Imaging Appearances. Radiographics : a review publication of the Radiological Society of North America, Inc. 37. 160124. 10.1148/rg.2017160124. 2. Villa AD, Sammut E, Nair A, Rajani R, Bonamini R, Chiribiri A. Coronary artery anomalies overview: The normal and the abnormal. World J Radiol. 2016 Jun 28;8(6):537-55. doi: 10.4329/wjr.v8.i6.537. PMID: 27358682; PMCID: PMC4919754. 3. Alam MM, Tasha T, Ghosh AS, Nasrin F. Coronary Artery Anomalies: A Short Case Series and Current Review. Cureus. 2023 May 8;15(5):e38732. doi: 10.7759/cureus.38732. PMID: 37292534; PMCID: PMC10247158. Diagnosis: Congenital anomalous coronary arteries as evidenced by findings on left heart catheterization.

Context: A 65 year-old male was found to have anomalous coronary arteries on a left heart catheterization with findings of absence of the left main coronary artery while the left descending and circumflex artery both originate from the right coronary artery. Coronary artery anomalies are the second-most common cause of sudden cardiac death. Report of Case: A 65 year-old male with a past medical history of hypertension, hyperlipidemia, non-rheumatic aortic valve insufficiency, mitral valve regurgitation, nonrheumatic pulmonary valve insufficiency, elevated coronary artery calcium score, and malignant neoplasm of the urinary bladder initially presented to the cardiology clinic as a referral from primary care for complaints of intermittent right posterior interscapular back discomfort with concerns of an anginal equivalent to his back pain. The patient had been worked up by his primary care provider with a coronary artery calcium score which resulted at 2,642 (90th percentile) Agatston units. He had also undergone a trans-thoracic echocardiogram which revealed an ejection fraction of 60%, mildly dilated left ventricle with normal function, mild left ventricular hypertrophy, mildly dilated left atrium, trileaflet aortic valve, mild aortic regurgitation, mildly dilated aortic root, mildly enlarged ascending aorta, mild

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137 2026 Research Recognition Day