Ectopic connection of left coronary artery from right coronary sinus, is the treatment always surgical?

Abstract

Background: Anomalous left coronary artery aortic origin from the right sinus (ALCA) is rare. Anomalous origin of coronary arteries (AOCA) is the second leading cause of cardiac death among young athletes in the US. Their management remains controversial and there are still no pre-established recommendations for risk stratification. Case presentation: A 45-year-old male with no cardiovascular risk factors, was admitted to our hospital for constrictive, intense, retrosternal chest pain during intense activities. His vital signs were normal. ECG was normal and biology revealed high troponin levels. Echocardiogram revealed a non-dilated left ventricle with a preserved left ventricle ejection fraction. Coronary artery angiography showed an abnormal left coronary artery origin from the right coronary sinus with no significant coronary stenosis and coronary computed tomography described a pre-aortic initial course of the left main artery. Stress myocardial scintigraphy did not show residual ischemia. The patient was medically treated with changes in his lifestyle and regular monitoring. A one-year follow-up showed a perfectly asymptomatic patient. Conclusion: ALCA is very rare but must be particularly considered given the higher risk of cardiac events. It is possible to use imaging techniques to better analyze the connection and the initial course. The decision to correct surgically or not to correct an ALCA remains difficult. Our cases were treated differently, with satisfactory long-term follow-up showing that the treatment should be individualized with a benefit/risk ratio assessed preferentially for each patient separately.