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A 57 year old man with multiple risk factors for coronary artery disease presented with exercise related chest pain. An x ray angiogram revealed no coronary atherosclerosis but, rather, an anomalous left coronary artery course. Whether the anomalous coronary artery travelled a clinically benign course posterior to the aorta or a potentially lethal course between the aorta and pulmonary trunk, however, could not be ascertained by the two dimensional x ray angiography. Because of severe bradycardia (heart rate 47 beats per minute), causing prolonged breath-hold times, a magnetic resonance coronary angiogram was limited by extensive respiratory motion artefact and failed to clarify the route of the anomalous coronary artery. Consequently, the patient underwent coronary computed tomographic (CT) angiography. On a Siemens 16 slice CT scanner, the entire heart was scanned by using 12 × 0.75 mm collimation spiral scanning and retrospective ECG-gating technique.
The left main coronary artery had an anomalous origin from the right, anterior sinus of Valsalva originating just above the right coronary artery ostium and followed a benign, retroaortic course (black arrowhead) after which it bifurcated into the left circumflex artery and a small left anterior descending artery (lower panels A–C: Ao, aorta; GCV, great cardiac vein; LA, left atrium; LAA, left atrial appendage; LAD, left anterior descending artery; LCx, left circumflex artery; LM, left main coronary artery; LV, left ventricle; PDA, posterior descending artery; PT, pulmonary trunk; RA, right atrium; RCA, right coronary artery; RV, right ventricle; RVB, right ventricular branch). The first septal perforating artery (white arrowhead) arose just anterior to the right coronary artery ostium (upper panels A and B), consistent with the x ray angiogram. The dominant right coronary artery bifurcated into the posterior descending artery and right ventricular branch at its mid distal portion. As CT findings excluded malignant coronary anomaly, there was no need for surgical intervention.