Anomalous Right Coronary Artery: Culprit or Innocent Bystander?

Anomalous aortic origin of a coronary artery is a rare congenital heart defect. The detection of anomalous coronary arteries is likely to increase with increased availability and application of cardiac computed tomography and magnetic resonance imaging. Once detected, the recommendation for surgical intervention on anomalous coronary arteries depends upon patient symptoms, the presence or absence of inducible ischemia on stress imaging, and high-risk anatomic features. A 77-year-old man with a history of hypertension, hyperlipidemia, chronic kidney disease Stage III, and moderate aortic stenosis presented with a non-ST-elevation myocardial infarction and was found to have an anomalous aortic origin of the right coronary artery on cross-sectional imaging. His aortic stenosis had also progressed from moderate to severe, and it was not clear whether his myocardial infarction could be exclusively attributed to a supply-demand disparity within the context of profound aortic stenosis or if his aberrant coronary anatomy could be implicated as the culprit for his presentation. A multidisciplinary heart team decided to proceed with a transcatheter aortic valve replacement and then readdress surgical intervention on his anomalous right coronary artery if his anginal symptoms persisted following valve replacement.