PMC10348437_01
ECG on presentation
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T-wave abnormality in lateral leads (Fig. 1). Transthoracic echocardiography revealed a dilated right coronary artery (RCA) of 8 mm with a mildly dilated left ventricle (LV) and preserved systolic function (Fig. 2A, clip 1).
(A) The parasternal long-axis view. The dilated right coronary artery (RCA) is clearly visible. (B) The parasternal short-axis view. The green arrows demonstrate the increased flow in the intraventricular collateral vessels from the RCA to the LCA. (C) The parasternal right ventricle outflow view shows the take-off of the anomalous left coronary artery (red arrow) from the pulmonary artery. (D) Retrograde blood flow to the pulmonary artery from LCA (red arrow). AO: aorta, LA: left atrium, LV: left ventricle, RV: right ventricle, PA: pulmonary artery, LCA: left coronary artery.. Clip 1: https://youtu.be/18wAsx8Ab9I. Clip 2: https://youtu.be/AfUAmPnoRCg. Clip 3: https://youtu.be/DlVfNVBOh_Y. Clip 4: https://youtu.be/uUEPZm-1xP8
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T-wave abnormality in lateral leads (Fig. 1). Transthoracic echocardiography revealed a dilated right coronary artery (RCA) of 8 mm with a mildly dilated left ventricle (LV) and preserved systolic function (Fig. 2A, clip 1). On the short axis view the colour Doppler showed a turbulent flow within the interventricular septum, which raised the possibility of intercoronary collateral between right and left coronary arteries (Fig. 2B, clip 2).
Coronary computed tomography: two-dimensional views of the proximal right coronary artery from the aorta (thick blue arrow) and anomalous left main coronary artery flowing into the pulmonary artery (thin red arrow). LM: left main coronary artery, AO: aorta, LV: left ventricle, MPA: main pulmonary artery, RCA: right coronary artery
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On the parasternal right ventricle outflow view, a take-off of anomalous left coronary artery was noted from the posteromedial aspect of the main pulmonary artery (MPA) (Fig. 3C, clip 3). The patient underwent a multislice computed tomographic angiography (CTA) (Fig. 3).
Multislice computed tomographic coronary angiography with 3-dimensional reconstruction images. (A) Cross-section volumetric rendering demonstrates a dilated right coronary artery (RCA) from the right aortic sinus and anomalous drainage of the left main coronary artery (LM) to the posteromedial aspect of the main pulmonary artery (MPA). (B) A posterior volumetric rendering shows RCA from the aorta and LM from MPA with collaterals between the left and right coronary systems. (C) An anterior volumetric rendering illustrates the origin of dilated RCA from the aorta and both branches of the left main coronary artery (LM), left descending artery (LDA) and left circumflex artery (LCx). (D) Volumetric rendering of the apex of the heart demonstrates a tortuous RCA with extensive apical collateralisation (black arrows) to the wrap-around left anterior descending artery (LAD)
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A colour Doppler showed a flow passage from the left coronary artery (LCA) into the pulmonary artery indicating a left-to-right shunt (Fig. 4D, clip 4). The CTA with three-dimensional reconstruction showed a dilated RCA that originates from the right aortic sinus and anomalous drainage of the LCA to the posteromedial aspect of the MPA (Fig. 4A). The three-dimensional reconstructed images clearly exposed the extensive intercoronary collaterals between the left and right coronary systems (Fig. 4B, C and D).