PMC7536332_01
Echocardiography of patient 1: Coronary flow pattern arising from the right-facing sinus and continuing between aorta and pulmonary artery (PA) suggesting an interarterial/intramural course of the left coronary artery.
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F1
Left- and right heart dimensions and functions were normal (Figure 1).
Ultra-low dose coronary computed tomography angiography (CCTA) of patient 1: anomalous aortic origin of the left coronary artery (LCA). LCA arising from the right-facing sinus with acute take-off angle, slit-like ostium and interarterial/intramural course between aorta and pulmonary artery (PA). Normal branching in left anterior descending (LAD) and circumflex artery.
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F2
An ultra-low dose coronary computed tomography angiography (CCTA) with 0.38 mSv and 60 ml contrast agent was performed and proved the suspicion of an anomalous aortic origin of the coronary artery (AAOCA) with the left coronary artery arising from the right-facing sinus with an acute take-off angle, a slit-like ostium and an interarterial and intramural course between the aorta and pulmonary artery (Figure 2).
Surgical unroofing of the left coronary artery (LCA): Identification of the slit-like ostium of the LCA in the right- facing sinus and its intramural course toward the left-facing sinus (A). Unroofing of the LCA with a longitudinal incision into the intima from its ostium up to its off-spring from the aortic root (B). By this, enlarging the ostium and eliminating the dynamic obstruction of the proximal main stem of the LCA (C).
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F3
Five days after diagnosis, the patient underwent surgical correction (Figure 3).
PMC7536332_02
Echocardiography of patient 2: Origin of the right coronary artery (RCA) from the left-facing sinus with an interarterial and intramural course between the aorta and the pulmonary artery (PA). Normal origin of the left coronary artery from the left-facing sinus.
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F4
In the echocardiography, a coronary artery anomaly of the right coronary artery was suspected (Figure 4).
Ultra-low dose coronary computed tomography angiography (CCTA) of patient 2: AAOCA with an origin of the RCA from the left-facing sinus with an interarterial and intramural course between the aorta and the pulmonary artery and a right coronary dominance. PA, pulmonary artery.
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F5
Cardiac Magnetic Resonance (CMR), where a heartrate of 170 bpm was reached, the patient was symptomatic but no wall motion abnormalities were detected with the submaximal hear rate of 83% of the predicted maximum. CCTA confirmed an AAOCA with an origin of the RCA from the left-facing sinus with an interarterial and intramural course between the aorta and the pulmonary artery and a right coronary dominance (Figure 5).
PMC7536332_03
Coronary computed tomography angiography of patient 3: AAOCA with an anomalous origin of the left coronary artery arising from the non-facing sinus without an interarterial course, but with a short intramural course. ECMO, Extracorporeal membrane oxygenation; PA, pulmonary artery.
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F6
An invasive coronary angiography and an additional CCTA under ECMO showed an AAOCA with an anomalous origin of the left coronary artery arising from the non-facing sinus and the suspicion of a short intramural course of the LCA which may have resulted in coronary ischemia (Figure 6).