PMC8004557_01
Still frame image of the RCA in the right anterior oblique (RAO) projection. The RCA is seen arising from the left coronary cusp prior to taking a usual course through the atrioventricular groove.
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fig1
Coronary angiography showed mild nonobstructive coronary artery disease and an anomalous right coronary artery (ARCA) arising from the left coronary cusp (Figure 1 and Video 1).
(a, b) Short-axis and four-chamber myocardial delayed enhancement imaging performed 10 minutes following injection of gadolinium contrast demonstrated no evidence of late gadolinium enhancement.
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fig2
Cardiac magnetic resonance imaging (CMR) was obtained given suspicion for myocarditis as a cause of dilated cardiomyopathy which corroborated severe left ventricular dysfunction with ejection fraction of 16% (Video 2), but no myocardial edema on T2-weighted images or late gadolinium enhancement (LGE) (Figures 2(a) and 2(b)).
Axial CMR images corroborating the anomalous RCA (arrow) arising from the left coronary cusp and appearing to take an intra-arterial course.
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fig3
Axial scout images again demonstrated an ARCA arising from the left coronary cusp, but now clearly appearing to take an intra-arterial course between the aorta and the main pulmonary artery (Figure 3).
(a-d) Axial CCTA images demonstrating the anomalous RCA arising from the left coronary cusp and taking an intra-arterial course. The extent of the proximal and mid-vessel is better delineated than in CMR (a). The slit-like configuration of the ostial RCA, as well as the acute angulation of its takeoff, is seen in this en-face coronal view (b). Cross sections of the RCA are shown, demonstrating the intramural portion (c) and just distally (d).
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Cardiac computed tomographic angiography (CCTA) was obtained to better delineate its course, confirming a slit-like proximal orifice arising at an acute angle and an intramural and intra-arterial course between the great vessels (Figures 4(a)-4(d)).
(a, b) The patient achieved 11 METS on a modified Bruce protocol but developed symptomatic chest discomfort and inferior lead ST-segment depressions at peak exercise persisting 1 minute into recovery. SPECT images demonstrated a reversible inferior wall perfusion deficit.
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fig5
Exercise single-photon emission computed tomography (SPECT) demonstrated a mild-to-moderate-sized reversible defect in the inferolateral wall referable to the territory supplied by the ARCA (Figures 5(a) and 5(b)).