PMC9035512_01
(A) Exercise electrocardiogram. (B) Transthoracic echocardiography. (C,D) Coronary computed tomography angiography. LCx, Left circumflex artery; LAD, Left anterior descending artery; RCA, Right coronary artery.
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F1
ECG demonstrated marginal (1 mm) horizontal ST-segment depression in leads II, III, and aVF. Exercise testing revealed reduced maximal exercise capacity (105 W; 2.5 W/kg), inadequate chronotropic response and significant (5 mm) horizontal ST-segment depression in leads II, III, aVF, and V4-V6 (Figure 1A). Upon transthoracic echocardiography (TTE), no coronary artery ostia could be displayed at the level of the aortic valve (Figure 1B). Coronary computed tomographic angiography (CTA) demonstrated an atresia of the left main coronary artery, a single ostium with high takeoff at the ascending aorta above the left sinus of Valsalva with a stenosis due to ostial kinking (Figure 1C: CTA) and an intramural course within the aortic wall (Figure 1D: 3D CTA reconstruction). A thin conus artery branched off two cm after the common trunk and a left anterior descending and a thin circumflex artery from the conus artery whereas a large right coronary artery could be displayed until the periphery (Figure 1D: 3D CTA reconstruction).