Why the study?
Anomalous origin of the LMCA from the right coronary cusp is a rare congenital anomaly with diverse clinical presentations and significant implications for patient management.
Anomalous origin of the LMCA from the right coronary cusp requires careful anatomical characterization, often with CTA, to guide management based on whether the course is benign or malignant.
Hypothesis-generating for course-based management of anomalous LMCA; prospective studies needed before practice change.
Background Anomalous origin of the left main coronary artery (LMCA) from the right coronary cusp is a rare congenital anomaly with diverse clinical presentations and significant implications for patient management. Case summary This case series presents three unique cases of anomalous LMCA origin from the right coronary cusp, each with distinct clinical manifestations and management strategies. Case 1 involved an 82-year-old male presenting with heart failure symptoms, where coronary angiography revealed an anomalous LMCA with a retro-aortic course (benign), managed conservatively. Case 2 describes a 71-year-old female presenting with non-ST-segment elevation myocardial infarction (NSTEMI) due to a culprit right coronary artery (RCA) lesion, with the LMCA taking a pre-pulmonic course (benign), successfully treated with percutaneous coronary intervention (PCI) of the RCA. Case 3 details a 76-year-old male evaluated for exertional fatigue and abnormal stress test, found to have an anomalous LMCA with a malignant interarterial course, for which surgical revascularization was recommended, though the patient opted for conservative management. Discussion The series underscores the importance of recognizing LMCA anomalies and tailoring management strategies based on anatomical course and clinical presentation. Coronary computed tomography angiography (CTA) plays a pivotal role in delineating coronary anatomy and guiding management. Benign courses are managed conservatively, while malignant interarterial courses necessitate surgical consideration due to the increased risk of sudden cardiac death. Conclusion Anomalous origin of the LMCA from the right coronary cusp presents diagnostic and therapeutic challenges, requiring a multidisciplinary approach for optimal management. Early identification and accurate characterization of the coronary course are critical for guiding intervention and improving outcomes.
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Ghumman et al. (2025) studied this question.
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