A rare case of malignant anomalous origin of the right coronary artery

3^rd Global Experts Meeting on Medical Case Reports

May 09-10, 2016 New Orleans, USA

Anantha Chentha and Shyamala Arani

University of Illinois at Urbana Champaign, USA

Posters & Accepted Abstracts: J Clin Case Rep

Abstract :

Case Description: A 19 year old Caucasian male with no relevant medical history presented to the emergency department (ED) complaining of a one-day history of nausea, vomiting and multiple episodes of diarrhea. He denied any chest pain and shortness of breath at this time. Examination showed sinus tachycardia at 200 beats per min and diffuse tender abdomen. Abnormal labs included leukocytosis at 17,700/uL with an absolute neutrophilic count of 16,410/uL, elevated creatinine of 1.29 mg/dl and hyperkalemia with a potassium of 5.3 mmol/L. Cardiac enzymes were normal. Triage electrocardiogram (EKG) showed ST elevation in V3, V4 and T-wave inversion in lead III and aVF. ST elevation was resolved after he was hydrated with 3 liters of 0.9% normal saline but T-wave inversions persisted. The patient was discharged with a diagnosis of viral gastroenteritis and acute kidney injury. A day later, he presented to the ED with left sided chest tightness associated with shortness of breath that is worse on standing, on exertion and gets better with lying down. He was an active individual and never had chest pain or shortness of breath on exertion. He denied smoking and use of recreational drugs. The physical examination and labs were unremarkable. EKG showed ectopic atrial rhythm with early repolarization and some inferior T-wave inversions. Cardiac computed tomography (CT) scan showed the malignant origin of the right coronary artery (RCA) which emanated from the left coronary cusp and coursed between the aorta and pulmonary artery. Discussion: Our case demonstrates that clinicians need to recognize such presentations of the anomalous coronary artery which is a lethal anomaly and may cause sudden death. AORCA is a rare congenital anomaly which was described by White and Edwards in 1948. In patients undergoing angiography the incidence of the RCA originating from the left sinus of Valsalva (LSV) is 0.03-0.17%. Though pathophysiology is unclear, the usual explanation is the mechanical compression of the RCA by the great vessels (aorta and pulmonary artery) during its course to normal position causes vascular compromise. The anomalous origin may have inter-arterial, retro-aortic, pre-pulmonic or septal (sub-pulmonic) course, the most common being inter-arterial as in our case. The incidence of sudden death with this anomaly is estimated at 25-40%. According to the American College of Cardiology and American Heart Association (ACC/AHA) guidelines for congenital heart diseases, surgical correction is a class IB indication for documented ischemia and also recommended in the absence of ischemia. These include the coronary artery bypass grafting, re-implantation of the coronary ostia and unroofing of the coronary artery.

Biography :

Email: achentha@illinois.edu