Aberrant origin of the left coronary artery from the right-facing sinus of Valsalva with intramural course: preoperative and postoperative imaging

A 15-year-old boy experienced sudden shortness of breath during physical activity (European soccer game). On admission to hospital, he presented with pulmonary oedema, monomorphic premature ventricular contractions and signs of an anterolateral myocardial infarction on the electrocardiogram. Troponin I was elevated to 56.5 ng/l. Treatment with lidocaine, furosemide and isosorbide dinitrate led to rapid resolution of symptoms. Transthoracic echocardiography showed an aberrant origin of the left anterior descending (LAD) coronary artery from the right-facing sinus of Valsalva (panel A). This finding was confirmed by a gadolinum-enhanced magnetic resonance imaging study (panel B). A myocardial technetium scan showed a small perfusion defect near the apex of the left ventricle. The LAD coursed intramurally between the two major arteries. Surgical treatment consisted of unroofing of the LAD to the left sinus of Valsalva. An electrophysiological study was performed 2 weeks after the operation to exclude inducible life-threatening ventricular tachycardia. Postoperative magnetic resonance imaging showed an unobstructed origin of the LAD from the left facing sinus from Valsalva (panel C). In summary, transthoracic echocardiography can accurately depict this rare anomaly and hence is the ideal screening tool. In patients with symptoms treatment is warranted.

Transthoracic echocardiogram of a 15-year-old boy with aberrant origin of the left coronary artery with intramural course.

Gadolinum-enhanced magnetic resonance image depiction of the anomaly previous to surgery. The left anterior descending coronary artery has an abnormal intramural course between the aorta and pulmonary artery.

After surgical unroofing, the left anterior descending coronary artery originates without potential obstruction from the left facing sinus of Valsalva.