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A 77 year old man was brought to our hospital with an episode of dyspnoea on 29 December 2003, and hospitalised on the following day. The chest radiograph indicated cardiomegaly and pulmonary oedema, and the ECG showed a QS pattern and an elevated ST segment in V1–V3 and a depressed ST segment in V5 and V6. Although he was diagnosed as having congestive heart failure caused by acute myocardial infarction, we did not perform emergency cardiac catheterisation because too much time had passed from the onset of the disease. There was a mild elevation in max creatine kinase (CK) (521 iu/l) and in max CK-MB (61 iu/l). We performed diagnostic cardiac catheterisation on 26 January 2004. Left ventriculography indicated that contraction was absent in segments 2, 3, 4, and 6 and that the ejection fraction was 26%. Left coronary angiography indicated 100% stenosis in number 7, 90% in number 13, 75% in number 14, and 90% in number 15. Since there was a chronic complete occlusion in number 7, the left circumflex branch was most likely involved in the infarction. Some of the blood in the left circumflex branch and the left anterior descending branch was flowing into the pulmonary artery via the right coronary artery. We performed contrast enhancement multidetector row computed tomography (MDCT) of the chest on 27 January 2004. We obtained detailed images that clearly indicated that the right coronary artery had an anomalous origin from the pulmonary artery (panel: Ao, aorta; LAD, left anterior descending coronary artery; PA, pulmonary artery; RCA, right coronary artery). Since the left anterior descending branch was completely occluded and the left circumflex branch was severely stenotic, coronary artery bypass graft surgery (CABG) was judged to be appropriate, and the patient was transferred to the referral hospital. He underwent CABG for two branches (LITA-ltRA-PL1-PL2) and left ventriculoplasty. We gave up on bypass graft surgery for the left anterior descending branch because of the remarkable calcification and stenosis present. We decided to follow up the course of the right coronary artery disease with palliative treatment only.
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