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A “new” coronary anomaly: origin of the right coronary artery below the aortic valve
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A 53 year old man presented with recurrent left thoracic pain suggesting coronary artery disease. Resting and exercise ECG showed no signs of ischaemia. Transthoracic echocardiography revealed all chambers to be of normal size and a normal left ventricular function. During coronary angiography, the ostium of the right coronary artery could not be found despite the use of various catheters. Injection of contrast medium into the left coronary artery showed a severely dilated proximal left anterior descending artery (LAD) (top right) with a huge tortuous collateral vessel to the right coronary artery (RCA) (bottom right). A retrograde flow was seen in the RCA. The LAD and the RCA distally to the collateral vessel were of normal diameter and there was no evidence of coronary artery disease.

Transoesophageal echocardiography confirmed the anomalous origin of the RCA from the left ventricular outflow tract (LVOT) below the aortic valve (AV) and the ascending aorta (AO) (below left). Colour Doppler flow studies revealed diastolic retrograde flow in the RCA into the LVOT (below right). The patient did not receive any specific cardiac medication or coronary intervention.