Multimodality Imaging of Anomalous Left Main Coronary Artery From the Right Sinus of Valsalva

Anomalous left main coronary artery (LMCA) arising from the right sinus of Valsalva is an uncommon congenital anomaly that may predispose to myocardial ischemia, heart failure, or sudden cardiac death.

A 53-year-old woman presented with non-ST-segment elevation myocardial infarction. Coronary angiography identified an anomalous LMCA arising from the right coronary sinus. Computed tomography angiography confirmed a shared ostium with the right coronary artery and interarterial course. Stress positron emission tomography revealed reversible ischemia in the left anterior descending and circumflex territories, prompting surgical reimplantation of the LMCA. Postoperatively, the patient developed cardiogenic shock due to dynamic coronary compression, requiring percutaneous revascularization and mechanical circulatory support. The patient eventually underwent successful orthotopic heart transplantation.

This case highlights the role of multimodality imaging in risk stratification and management of anomalous LMCA and emphasizes the potential for postoperative ischemic complications despite anatomical correction.

Multimodality imaging, including computed tomography and combined positron emission tomography/computed tomography, plays a pivotal role in identifying high-risk features and guiding management of anomalous LMCA. Even after anatomical correction, dynamic coronary compression can cause recurrent ischemia, requiring ongoing surveillance and multidisciplinary intervention.