The Single Cusp of Life: A Case Report

Background: Anomalous coronary artery (CAA) is a rare condition occurring in less than 1% of individuals. The most common form consists of the left circumflex artery (LCx) arising from the right coronary sinus. These vascular anomalies have been associated with an increased risk of sudden cardiac death. We present a rare case of an anomalous coronary artery in a patient with all three coronary arteries arising from a shared ostium. Case presentation: A 67-year-old transgender Caucasian male with medical history of dyslipidemia and hypertension presented for ischemic workup due to occasional chest pain prior to undergoing male to female gender reassignment surgery. A Regadenosan stress test with SPECT myocardial perfusion imaging revealed moderate sized, moderate intensity perfusion defect reversible in inferolateral wall and fixed in inferior wall. Coronary angiography revealed anomalous origin of the coronary arteries, with all three major coronary arteries arising from a shared, single, ostium originating from the right coronary cusp. Coronary computed tomographic angiography (CCTA) showed a “malignant course” of LAD running between the pulmonary artery and aorta. A conservative management was pursued in view of mild symptoms with close follow ups. Conclusion: It is important to evaluate all coronary artery anomalies (CAA) for a “malignant” course due to its associated risk for various cardiac events including sudden cardiac death. Surgical management is indicated in high-risk patients with malignant courses. However, asymptomatic patients and those with mild symptoms with or without malignant course can be followed closely.