Ischaemic Injury Associated with Anomalous Origin of the Left Coronary Artery
Robin Nijveldt1, *, Aernout M Beek1, Paul G Melman2, Albert C van Rossum1
1VU University Medical Center, Amsterdam, The Netherlands, 2St. Elisabeth Hospital, Tilburg, The Netherlands, *De Boelelaan1117, 1081 HV Amsterdam, P.O. Box 7075, 1007 MB Amsterdam, The Netherlands.
A 19-year-old woman presented with stress-induced chest pain and dizziness. Physical examination was unremarkable. The electrocardiogram showed transient ST-depression with subsequent elevation in troponin T. The patient had a history of poor exercise capacity associated with syncope, which had been attributed to hyperventilation. Echocardiography suspected an anomalous origin of the left main coronary artery (LMCA), which could not be selectively engaged at catheterisation.
MR coronary angiography images revealed the anomalous LMCA, originating from the right coronary cusp, with a proximal course between the aortic root and main pulmonary artery (Panel A). In addition, delayed contrast enhanced imaging 15 minutes after Gd-DTPA injection showed several regions of sub-endocardial hyper-enhancement in the anterior wall of the left ventricle, suggestive of micro-infarction (Panel C & D). In conclusion, this patient suffered from recurrent ischemia due to the acute angle of the anomalous origin and compression of the inter-arterial segment of the LMCA during exercise. The patient underwent surgical angioplasty of the LMCA, with side-to-side positioning of the LMCA to the aortic wall. A year after surgery the patient has experienced no functional limitation, including sports participation. MR coronary angiography demonstrated the origin and course of the LMCA after operative correction (Panel B).
Figure legend
Panel A. Transverse image, showing the origin of the LMCA and its proximal course (black arrows). Ao: ascending aorta, PA: pulmonary artery.
Panel B. Transverse oblique image after surgical correction, showing the origin and proximal course of the LMCA (black arrows). Ao: asending aorta, PA: pulmonary artery.
Panel C. Delayed contrast enhanced image. Two chamber view of the left ventricle (LV), with hyper-enhanced regions (white arrows).
Panel D. Delayed contrast enhanced image. Short axis view of the left ventricle (LV), with a hyper-enhanced region (white arrow).