Physiologic Unmasking of an Anomalous Right Coronary Artery in a Competitive Lacrosse Athlete

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Anomalous origin of the right coronary artery (ARCA) (n=1). Intervention: Surgical unroofing and neo-ostium creation. Primary outcome: Symptom resolution and CPET performance.

Marius I. Chukwurah; Oluwakorede Akele; Ranvir Raman Bhatia; Paishiun N. Hsieh; Aubrey J. Grant; J. Sawalla Guseh

doi:10.1016/j.jaccas.2026.109246

July 1, 2026JACC Case ReportsOpen Access

Physiologic Unmasking of an Anomalous Right Coronary Artery in a Competitive Lacrosse Athlete

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Key result

Surgical unroofing normalizes CPET kinetics and resolves symptoms in anomalous right coronary artery.

n=1

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Graphical abstract published by JACC Case Reports — Graphical abstract · Published by JACC Case Reports · CC BY-NC-ND

Why the study?

ARCA with an interarterial and intramural course is linked to exertional ischemia and sudden cardiac death in athletes, but routine stress testing may fail to detect physiologic limitation in well-conditioned individuals.

Key Points

To describe the diagnostic utility of cardiopulmonary exercise testing in detecting exertional ischemia in a competitive athlete with an anomalous right coronary artery despite normal conventional testing.
Evaluated an 18-year-old male high school lacrosse player presenting with a 1-year history of exertional dyspnea that did not improve with a bronchodilator trial.
Performed cardiac diagnostics including transthoracic echocardiography, coronary computed tomography angiography, resting cardiac magnetic resonance, nuclear exercise stress testing, and pre- and postoperative cardiopulmonary exercise testing.
Preoperative nuclear exercise testing was negative for ischemia with an exercise capacity of 20.3 metabolic equivalents at 96% of predicted maximum heart rate, whereas cardiopulmonary exercise testing revealed a premature plateau in oxygen consumption and oxygen pulse.
Coronary computed tomography angiography confirmed an anomalous right coronary artery arising from the sinotubular junction above the right-left commissure with an interarterial and intramural course.
At 8-week postoperative follow-up, repeat cardiopulmonary exercise testing demonstrated a peak oxygen consumption of 48.4 mL/kg/min (119% predicted) and normal curve augmentation without ischemia or premature plateau.

Study Design

Type

Case Report (n=1)

Structured PICO

P

Population

An 18-year-old male competitive lacrosse player with an anomalous right coronary artery and exertional dyspnea who underwent surgical correction and was followed for 8 weeks.

I

Intervention

Surgical management via mini-sternotomy with unroofing and neo-ostium creation

O

Outcome

Symptom resolution and normalization of VO2 and O2 pulse kinetics on cardiopulmonary exercise testing (CPET)surrogate

Cardiopulmonary exercise testing can reveal subtle physiologic ischemia in athletes with interarterial ARCA even when traditional noninvasive tests appear normal, guiding successful surgical intervention.

Limitations

Single case report limits generalizability.
Reliability of O2 pulse as a surrogate for stroke volume is highly debated in the athletic population.
Distinguishing physiologic from pathologic plateaus in VO2 and O2 pulse remains an area requiring further investigation.
The reliability of O2 pulse as a surrogate for stroke volume is highly debated in the athletic population
The use of the O2 pulse plateau in diagnosing myocardial ischemia has not been validated in athletes
Distinguishing physiologic from pathologic plateaus remains an area requiring further investigation

Implication

May guide CPET use in ARCA athletes with normal routine tests; leaves open broader efficacy and prospective validation.

Abstract

BACKGROUND: Anomalous origin of the right coronary artery (ARCA) with an interarterial and intramural course is a rare congenital anomaly associated with exertional ischemia and sudden cardiac death in athletes. Routine stress testing may fail to detect physiologic limitation, especially in well-conditioned individuals. CASE SUMMARY: pulse with complete symptom resolution. DISCUSSION: This case highlights the diagnostic limitations of routine testing and the utility of advanced physiologic assessment. TAKE-HOME MESSAGES: Cardiopulmonary exercise testing can reveal subtle physiologic ischemia in athletes with interarterial ARCA even when all other noninvasive tests appear normal. Combining anatomic imaging with multidisciplinary physiologic assessment is critical for guiding management and safe return-to-play in athletes with coronary anomalies.

Discussion

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Cite This Study

Chukwurah et al. (2026) conducted a case report in Anomalous origin of the right coronary artery (ARCA) (n=1). Surgical unroofing and neo-ostium creation was evaluated on Symptom resolution and CPET performance. Surgical unroofing and neo-ostium creation resulted in complete symptom resolution and normalization of VO2 and O2 pulse kinetics on cardiopulmonary exercise testing in an athlete with ARCA.

synapsesocial.com/papers/6a5b38f68167787360d24dd7 https://doi.org/10.1016/j.jaccas.2026.109246

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Physiologic Unmasking of an Anomalous Right Coronary Artery in a Competitive Lacrosse Athlete

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Physiologic Unmasking of an Anomalous Right Coronary Artery in a Competitive Lacrosse Athlete

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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