Challenges in primary PCI: congenital anomalous origin of the left main coronary artery from the right coronary sinus of Valsalva

Case Report
Cardiovasc Med. 2022;25:w02239

Published on 01.09.2022

A rare congenital cardiac anomaly that has been associated with myocardial ischaemia and sudden cardiac death in young patients.


Anomalous origins of the coronary arteries are a rare congenital anomaly. One of the rarest anomalies of the coronary artery origin is the left main coronary artery (LMCA) originating from the right coronary sinus (RCS) of Valsalva. Coronary artery anomalies presenting with acute coronary syndrome are also extremely uncommon and represent a technical challenge during percutaneous coronary intervention (PCI) [1]. Here, we report on a patient presenting with acute ST-segment elevation myocardial infarction (STEMI) as the first manifestation of an anomalous congenital origin of the LMCA from the RCS of Valsalva, which was successfully treated by PCI.

Case description

A 75-year-old man, an active smoker with no relevant past medical history, presented to our emergency department with a 90-minute history of de novo acute typical chest pain at rest. The physical examination did not show signs of heart failure or an abnormal heart murmur. The 12-lead ECG showed an anterolateral ­STEMI (fig. 1). Echocardiography showed a moderately impaired left ventricular ejection fraction visually estimated at 35–40% with antero-septo-apical akinesia, type I diastolic dysfunction and mild aortic regurgitation.
Figure 1:
12-lead ECG showing an anterolateral ST-segment elevation myocardial infarction.
The patient underwent urgent coronary angiography via the right radial arterial approach. The right coronary artery (RCA) angiogram showed no significant stenosis (fig. 2A). Selective engagement of the LMCA was finally achieved with the use of several different diagnostic catheters and demonstrated an anomalous origin of the LMCA from the RCS of Valsalva (fig. 2B). LMCA angiography demonstrated an acute thrombotic occlusion of the proximal left anterior descending ­artery (LAD) and severe stenoses of the ostial LAD, mid-LAD and proximal left circumflex artery (LCx) (fig. 2B). The patient underwent successful primary PCI with four zotarolimus-eluting stents, from the LMCA to proximal LAD and from the LMCA to LCX using the Culotte technique, and from the proximal LAD to mid-LAD. The LMCA ostium was engaged with a 6-French MB1 guiding catheter (Launcher, Medtronic Inc., USA) and the procedure was performed with the support of a 6-French guide extension (Telescope, Medtronic Inc., USA). The final angiogram showed no significant residual stenosis or complication (fig. 2C). The peak troponin level was 9184 ng/l. Coronary computed tomography angiography confirmed the anomalous origin of the LMCA arising from the RCS of Valsalva and a retro-aortic course of the LMCA (fig. 3). The clinical course was uneventflul and the patient was discharged at day 9.
Figure 2:
Urgent coronary angiogram. A: Right coronary ­artery in a left anterior oblique and cranial angiographic view demonstrating no significant stenosis. B: Anomalous origin of the left main coronary artery from the right coronary sinus with an acute thrombotic occlusion of the proximal left anterior descending artery (LAD, red arrow) and severe stenosis of the proximal left circumflex artery (LCx, blue arrow). C: ­Final coronary angiography after primary percutaneous coronary intervention to the proximal LAD and LCx showing no significant residual stenosis.
Figure 3:
Coronary computed tomography angiography demonstrating an anomalous origin of the left main coronary artery (blue arrows) at the level of the right coronary sinus, with two separated ostia. Red arrows show the origin of right coronary artery.
No financial support and no other potential conflict of interest relevant to this article was reported.
Telmo Silva dos Santos
Department of Cardiology
Geneva University Hospitals
Rue Gabrielle-Perret-Gentil 4
CH-1205 Geneva
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