A 58-year-old man presented with complaints of retrosternal chest pain and diaphoresis. Electrocardiogram revealed ST depressions in leads V2–V5. Two-dimensional echocardiography revealed an ejection fraction of 45% with moderate mitral regurgitation. Troponin-I levels were 24.1 ng/mL (normal 0–0.4 ng/mL). A diagnosis of non-ST-elevation myocardial infarction was made. Coronary angiography revealed triple vessel coronary artery disease along with a unique coronary artery anomaly (see Video 1). The left anterior descending (LAD) had an anomalous high origin above the aortic sinus. Right coronary artery (RCA) originated from the left coronary sinus (LCS), close to the LAD ostium. The left circumflex (LCx) arose as a proximal branch of the anomalous RCA. Multidetector computed tomography (MDCT) was done. The examination was carried out by a 128-slice computed tomography with 0.8 mm acquiring thickness and 0.35 s rotation time. 100 mL of non-ionic contrast was injected at 5 mL/s. In view of atrial fibrillation, image quality was reduced. However, MDCT further confirmed the anomalous origin of RCA from LCS, close to the origin of LAD (Figures 1 and 2). The RCA had a slit-like orifice. It followed an inter-arterial course between the great vessels and continued in the right atrioventricular groove (Figure 2). The LCx arose as a proximal branch of this anomalous RCA. It followed a retro-aortic course coursing behind the aortic annulus, into the left atrioventricular groove, such that the RCA and LCx formed a girdle around the aorta (Figures 1 and 2; Supplementary material online, Figure S1). The patient underwent coronary artery bypass grafting with saphenous venous graft to LAD and RCA. He later underwent percutaneous intervention to native LCx.
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