Title : Anomalous left main coronary artery from the right coronary cusp with intraconal course and ostial stenosis in an elderly patient: A case report
Abstract:
Background: Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital anomaly associated with myocardial ischemia and sudden cardiac death. The risk is particularly significant when the left main coronary artery (LMCA) arises from the right coronary sinus and follows an inter-arterial or intramural course. While AAOCA is frequently reported in younger patients and athletes, cases presenting in elderly individuals are uncommon. Surgical correction, most commonly via coronary unroofing, has demonstrated favorable outcomes in appropriately selected patients.
Case Presentation: We report the case of a 74-year-old male with hypertension, type 2 diabetes mellitus, and new-onset atrial fibrillation who presented with fatigue and was transferred for cardiac surgical evaluation following a non-ST elevation myocardial infarction. Diagnostic workup revealed atrial fibrillation with rapid ventricular response on electrocardiogram and mildly reduced left ventricular function on transthoracic echocardiography. Left heart catheterization demonstrated an anomalous LMCA arising from the right coronary cusp with approximately 90% ostial stenosis. Cardiac computed tomography angiography confirmed the anomalous origin with an inter-arterial course and an intraconal segment extending into the right ventricular outflow tract (RVOT) region before emerging onto the epicardium.
The patient underwent surgical repair via median sternotomy and cardiopulmonary bypass. After aortic transection and inspection of the coronary ostium, the narrowed LMCA origin was opened and augmented with autologous pericardial patch osteoplasty. Due to the artery’s intraconal course within the RVOT, a transconal approach with supra-coronary myotomy was performed to free the vessel from surrounding muscle. The resulting RVOT defect was reconstructed using bovine pericardium. To eliminate potential compression from the pulmonary artery, the main pulmonary artery was transected and translocated, with reconstruction performed using patch augmentation.
Outcome: The patient was successfully weaned from cardiopulmonary bypass in sinus rhythm with minimal inotropic support. Postoperative recovery was uneventful. He was extubated the same day, mobilized with physical therapy, and discharged home on dual antiplatelet therapy, beta-blocker, statin, and amiodarone. Follow-up imaging demonstrated no evidence of dissection or ischemic complications.
Conclusion: Anomalous LMCA arising from the right coronary cusp with an intraconal course is an uncommon and potentially high-risk anatomical variant. This case highlights that complex surgical management—including transconal unroofing, coronary osteoplasty, RVOT reconstruction, and pulmonary artery translocation—can be performed safely even in elderly patients with favorable outcomes.
