PMC6091280_01
Chest X-ray did not reveal any significant radiographic abnormalities.
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fig1
His chest X-ray did not reveal any acute cardiopulmonary process (Figure 1).
Admission EKG showed a rhythm of sinus origin at a rate of 80 BPM, with normal axis and 2-3 mm horizontal dawn sloping with ST segment depression in anterolateral leads.
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fig2
His initial electrocardiogram (EKG) revealed significant 4 mm to 5 mm ST depression in the anterolateral leads but otherwise unremarkable (Figure 2).
EKG 2 hours after admission showed a rhythm of sinus origin at a rate of 95 BPM, with normal axis and with reversal of ST-T wave changes present on admission.
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fig3
A repeat EKG done within 2 hours of the initial presentation showed reversal of ST depression (Figure 3).
Two-dimensional transthoracic echocardiogram showing normal sized cardiac chambers. Diastole phase (b) and systole phase (a).
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Immediate bedside echocardiogram showed a nondilated left ventricular cavity with normal LV wall thickness and a mildly diminished LV ejection fraction at 45-50% (Figure 4). In the emergency room, immediate treatment with 325 mg of Aspirin and therapeutic Lovenox (1 mg/kg) was given.
(a) Anomalous LMCA course (yellow arrow) between the aorta (red arrow) and the pulmonary outflow track (blue arrow) showing narrowing. (b) Oblique view demonstrating the common origin of the right (green arrow) and the left coronary arteries (yellow arrow).
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The LMCA narrowed in its midportion as it passed between these two structures (Figures 5(a) and 5(b)).
(a) demonstrates the anomalous origin of the left main coronary artery (blue arrow) along with stenosis of the left main coronary (red arrow). (b) demonstrates the course of the RCA (yellow arrows).
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fig6
These findings were confirmed by cardiac catheterization which showed an anomalous origin of the LMCA, originating from the right sinus of Valsalva (Figures 6(a) and 6(b)).