Case Session
SCMR 22nd Annual Scientific Sessions
Asmaa Elsayed Ahmed, MD, MSc
Instructor/Fellow
University of Alabama at Birmingham
Nadine Choueiter, MD
Director of Pediatric cardiac non invasive imaging
Albert Einstein College of Medicine/Children's Hospital at Montefiore
Linda Broyde Haramati, MD
Professor of Radiology and Medicine, Albert Einstein College of Medicine
Director of Cardiothoracic Imaging; Director of Cardiothoracic Imaging Fellowship Program, Montefiore Medical Center
Description of Clinical Presentation:
This is a 29 year old male patient, with no significant past medical history, presented to the
emergency department with chest pain and left upper extremity numbness. The pain woke him up
from sleep and was associated with shortness of breath. His ECG and troponins were normal. He
was discharged home to return to the emergency department 2 days later with a similar pain while
at the bank. The pain radiated to the left arm and was associated with diaphoresis and dizziness.
He works at a maintenance plant and plays soccer. He has no history of smoking, alcohol,
or illicit drug use. His troponin level was elevated (0.73 ng/ml) and his ECG showed Q waves
in the inferior limb leads (Fig.1 - a).
Diagnostic Techniques and Their Most Important Findings:
Echocardiography showed preserved ejection fraction with no regional wall motion
abnormalities. Cardiac catheterization showed no coronary artery stenosis but filling of the right
coronary artery (RCA) from the left main coronary artery (LMCA) (Fig.1-b&c). Cardiac CT
confirmed anomalous origin of RCA from left sinus of valsalva (AORCA) with a slit like
orifice (Fig. 1-d&e). CMR showed preserved biventricular systolic function and
decreased perfusion at the basal inferior wall on rest perfusion imaging (fig.2). T2-STIR
short axis images showed bright signal of myocardial edema at the basal inferior and mid
inferolateral walls, with corresponding areas of enhancement at the late gadolinium
enhancement images corresponding to a dominant RCA territory (Fig.3). Patient
underwent successful unroofing of the RCA.
Learning Points from this Case:
In young adults not otherwise suspected to be at risk for coronary atherosclerosis
presenting with ischemic chest pain the imager should be highly suspicious for
anomalous origin of the coronary arteries from the opposite sinus of valsalva. AORCA is
more common than anomalous origin of the left main coronary artery from the right sinus
of valsalva . Myocardial ischemia and sudden death can be associated with both types of
anomalies. However AORCA is considered more benign and surgical management
remains controversial. Multimodality imaging is helpful in the diagnosis and
management of AORCA. CMR as a non-invasive imaging modality helped in the
management by identifying the perfusion defects and myocardial injury in a dominant
RCA distribution ascertaining the need for surgical correction.