Myocardial infarction with anomalous coronary anatomy

Congenital coronary anomalies are rare but present a diagnostic challenge as detailed study of the coronary anatomy is required for their detection and accurate characterization. The authors present the case of a 71-year-old man with a previous history of angina, who had undergone cardiac catheterization several years ago, which was described as normal. He was admitted to our center with an acute myocardial infarction, three years after symptom onset; cardiac catheterization was repeated and revealed a subocclusive lesion located in a circumflex artery with an anomalous origin. We highlight the diagnostic difficulties encountered in this particular case, as the culprit artery was not identified in the first coronary angiography. Closer analysis of the images and the patient's clinical course helped identify the missing vessel, a dominant circumflex artery with an anomalous origin, and the atherosclerotic lesion responsible for the events.