Anomalous Right Coronary Artery

Figures

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  Visual Summary. A 35-Year-Old Athlete With Exertional Angina and Chronotropic Incompetence Due to Sinoatrial Nodal Ischemia From an Anomalous Right Coronary Artery Multimodality imaging and heart team discussion guided surgical revascularization, with resolution of symptoms and improved chronotropic response post-CABG. CABG = coronary artery bypass grafting; CTCA = computed tomography coronary angiography; ECG = electrocardiogram; PMHR = predicted maximal heart rate; RCA = right coronary artery; RIMA = right internal mammary artery; RWMA = regional wall motion abnormality; SA = sinoatrial.

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  Figure 1. 12-Lead ECG on Index Presentation ECG displays sinus rhythm, with early repolarization pattern in the inferolateral leads and biphasic T waves in V1 to V3. ECG = electrocardiogram.

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  Figure 2. ECG-Gated Contrast-Enhanced Coronary CT Angiography After Administration of Sublingual Nitrates, With Heart Rate of 65 Beats/Min at Time of Acquisition (A) The nondominant RCA arises from the left coronary sinus with an acute-angled takeoff (<45°) and an intramural course of the proximal vessel as it extends anteriorly between the aorta and the pulmonary artery. Trifurcation of the left coronary artery is also noted. (B-E) Three-dimensional multiplanar reconstruction with double oblique planes perpendicular to the aortic annulus showing a cross-sectional view of the ostium of the RCA. The slit-like orifice measured 1.77 mm in width (<50% of the orifice height of 3.9 mm), elliptical luminal vessel shape (height/width ratio of >1.3). (F) Orifice takeoff in relation to the sinotubular junction. (G) Cross-sectional view of the RCA after the intramural segment. The ratio between proximal and distal vessel width was 60%. Ao = aorta; CO = coronary ostium; CT = computed tomography; DA = descending aorta; ECG = electrocardiogram; LA = left atrium; LV = left ventricle; PA = pulmonary artery; RA = right atrium; RCA = right coronary artery; RV = right ventricle; RVOT = right ventricular…

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  Figure 3. 3-Dimensional Reconstructions Demonstrating Anomalous RCA Originating From the Left Sinus of Valsalva (A) The vessel shows a likely proximal intramural course, with a sharp takeoff angle and slight change in caliber between the aorta and pulmonary artery compared with the distal vessel. (B) The vessel then continues and supplies the right ventricle and sinoatrial node. Cx = circumflex artery; LCS = left coronary sinus; LDA = left descending artery; RCA = right coronary artery; SNA = sinoatrial artery.

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  Figure 4. Coronary Angiography of Anomalous Right Coronary Artery (A) LAO cranial nonselective coronary angiogram of the anomalous RCA. The RCA has a separate ostium arising from the left coronary cusp. It is a nondominant vessel. The arrow shows the sinoatrial branch. (B) RAO cranial selective coronary angiogram of the dominant left system. LAO = left anterior oblique; RAO = right anterior oblique; RCA = right coronary artery; SNA = sinoatrial artery.