Physiologic Unmasking of an Anomalous Right Coronary Artery in a Competitive Lacrosse Athlete

Anomalous origin of the right coronary artery (ARCA) with an interarterial and intramural course is a rare congenital anomaly associated with exertional ischemia and sudden cardiac death in athletes. Routine stress testing may fail to detect physiologic limitation, especially in well-conditioned individuals.

An 18-year-old competitive lacrosse player presented with progressive exertional dyspnea despite a normal electrocardiogram, cardiac magnetic resonance, and nuclear stress testing. Baseline transthoracic echocardiogram raised concern for an ARCA. Coronary computed tomography angiography confirmed this by revealing an interarterial and intramural course and mild ostial narrowing. Cardiopulmonary exercise testing showed supranormal aerobic capacity but demonstrated a premature plateau in Vo₂ and O₂ pulse suggestive of subtle ischemia. He underwent surgical unroofing with neo-ostium creation. Recovery was uncomplicated, and follow-up testing demonstrated normal augmentation in Vo₂ and O₂ pulse with complete symptom resolution.

This case highlights the diagnostic limitations of routine testing and the utility of advanced physiologic assessment.

Cardiopulmonary exercise testing can reveal subtle physiologic ischemia in athletes with interarterial ARCA even when all other noninvasive tests appear normal. Combining anatomic imaging with multidisciplinary physiologic assessment is critical for guiding management and safe return-to-play in athletes with coronary anomalies.