Malignant Interarterial Right Coronary Artery in 3 Adult Patients

Anomalous coronary artery from the opposite sinus is a rare congenital anomaly with potentially fatal outcomes. Anomalous right coronary artery (ARCA) with a malignant interarterial course is strongly linked to sudden cardiac death Beyond description of anatomy, optimal management requires careful diagnostic evaluation and individualized decision-making.

We present 3 cases of ARCA with malignant interarterial course: 1) an 80-year-old man with severe aortic stenosis, 2) a 61-year-old woman with exertional angina and interarterial narrowing, and 3) a 25-year-old asymptomatic woman with ventricular ectopy and significant proximal narrowing. Each case highlights unique diagnostic challenges and therapeutic considerations.

Coronary computed tomography angiography is the gold standard for defining anatomy, whereas functional testing, cardiac magnetic resonance, and invasive imaging refine risk stratification. Management ranges from surveillance with lifestyle modification in low-risk, asymptomatic patients to surgical correction (unroofing, reimplantation, or coronary artery bypass grafting) in young or high-risk individuals. We summarize these principles in a practical flowchart to guide clinicians.

Early recognition, structured diagnostic work-up, and risk-based individualized management are essential to prevent adverse outcomes in ARCA. This case series provides both illustrative clinical examples and an evidence-based framework for evaluation and management.