A case report of a symptomatic right anomalous coronary artery with concomitant atherosclerotic disease: the benefit of a sequential comprehensive non-invasive and invasive diagnostic approach.

Bigler, Marius Reto; Huber, Adrian Thomas; Räber, Lorenz; Gräni, Christoph (2021). A case report of a symptomatic right anomalous coronary artery with concomitant atherosclerotic disease: the benefit of a sequential comprehensive non-invasive and invasive diagnostic approach. European heart journal - case reports, 5(3), ytab081. Oxford University Press 10.1093/ehjcr/ytab081

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Background

Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital disease associated with an increased risk of myocardial ischaemia, ventricular arrhythmias, and heart failure.

Case summary

A 75-year-old Caucasian man was referred for invasive coronary angiography (ICA) due to atypical chest pain. Invasive coronary angiography demonstrated non-significant atherosclerotic disease of the left coronary artery and an anomalous origin of the right coronary artery (RCA); without selective intubation. Coronary computed tomography angiography (CCTA) revealed a right-AAOCA with interarterial and intramural course, and a soft plaque in the distal RCA. Subsequent physical-stress single-photon emissions computed tomography (SPECT) showed exercise-induced inferoapical myocardial ischaemia, giving a Class IC level of evidence for surgical correction of the AAOCA. Repeated ICA with selective R-AAOCA intubation confirmed an 80% distal atherosclerotic stenosis, which was treated with direct stenting. Subsequent invasive physiologic evaluation under maximal dobutamine-volume challenge (gradually increasing dose of dobutamine max. 40 μg/kg per body weight/min, 3000 mL ringer lactate and 1 mg atropine was given until the patient reached a maximum of 145 b.p.m.), revealed a haemodynamically non-relevant anomalous segment with a fractional flow reserve (FFR) of 0.91. A follow-up SPECT was normal, and the patient was completely symptom-free at 1 month.

Discussion

We present the sequential diagnostic approach in a symptomatic patient with a right anomalous coronary artery and concomitant atherosclerotic disease. Using this approach, the patient could be deferred from guideline recommended open-heart surgery of the AAOCA, as direct invasive dobutamine/volume FFR revealed haemodynamic non-relevance of the anomalous segment after stenting the concomitant atherosclerotic stenosis in the distal segment within the same coronary artery.

Item Type:

Journal Article (Further Contribution)

Division/Institute:

04 Faculty of Medicine > Department of Cardiovascular Disorders (DHGE) > Clinic of Cardiology
04 Faculty of Medicine > Department of Radiology, Neuroradiology and Nuclear Medicine (DRNN) > Institute of Diagnostic, Interventional and Paediatric Radiology

UniBE Contributor:

Bigler, Marius Reto; Huber, Adrian Thomas; Räber, Lorenz and Gräni, Christoph

Subjects:

600 Technology > 610 Medicine & health

ISSN:

2514-2119

Publisher:

Oxford University Press

Language:

English

Submitter:

Maria de Fatima Henriques Bernardo

Date Deposited:

28 Apr 2021 11:49

Last Modified:

02 May 2021 03:04

Publisher DOI:

10.1093/ehjcr/ytab081

PubMed ID:

33718769

Uncontrolled Keywords:

Anomalous aortic origin of a coronary artery (AAOCA) Case report Coronary computed tomography angiography Fractional flow reserve Multimodality cardiac imaging Single-photon emission computer tomography

BORIS DOI:

10.48350/154032

URI:

https://boris.unibe.ch/id/eprint/154032

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