A 65-year-old women presented with acute congestive cardiac failure. The chest radiograph showed cardiomegaly with pulmonary congestion, and depression of the ST-T segments was noted in leads I, aVL, II, III, aVF, and V4 through V6 on her electrocardiogram. Echocardiography showed diffuse left ventricular hypokinesis and abnormally dilated coronary arteries. Coronary angiography (Fig. 1 a and b) revealed a markedly dilated left coronary artery, with extensive collateral circulation filling the pulmonary trunk (Asterisk) retrogradely through the right coronary artery. A computed tomographic scan confirmed anomalous origin of the right coronary artery from the pulmonary trunk (Fig. 2). There were no obstructive atherosclerotic plaques or thrombus, in the abnormal vessels. Reimplantation of the artery into the ascending aorta was performed, but 4 days after operation, the vessel perforated spontaneously, and was ligated as a surgical emergency. During 2 years of follow-up, the patient has been free of cardiac events, despite having the heart nourished through a solitary remaining coronary artery.
Figure 1
Figure 2
Anomalous origin of the right coronary artery from the pulmonary trunk is rare. Although usually asymptomatic until adulthood, adverse outcomes, along with myocardial ischaemia resulting from coronary arterial steal, have been reported.Reference Williams, Gersony and Hellenbrand1 Creation of a dual coronary arterial system, by translocation of the anomalous artery to the ascending aorta, is generally accepted as optimal management in infancy and childhood. As demonstrated in our patient, however, a fragile vessel that has been at low pulmonary arterial pressures for 6 decades may be unable to withstand systemic blood pressure after reimplantation. In such cases, elimination of the coronary arterial steal by simple ligation may be sufficient to relieve symptoms without risk of coronary arterial rupture.
