[Interarterial anomalous right coronary artery in a competitive athlete: case report]

Anomalous origin of the right coronary artery from the left sinus of Valsalva with an interarterial course is a congenital coronary anomaly associated with myocardial ischemia and sudden cardiac death, particularly in athletes exposed to intense hemodynamic stress. In this setting, risk is dynamic and results from the interaction between anatomical features and exercise. We report the case of a 37-year-old competitive endurance athlete in whom anomalous origin of the right coronary artery from the left sinus of Valsalva with an interarterial course and an intramural segment was identified during pre-participation screening. Coronary computed tomography angiography demonstrated high-risk anatomical features, while stress cardiac magnetic resonance revealed inducible ischemia in the inferolateral myocardial territory. Invasive evaluation with intravascular ultrasound confirmed dynamic luminal compression of the intramural segment. The presence of objective ischemia represented the key determinant for clinical decision-making, leading to surgical correction with the unroofing technique. At 6-month follow-up, absence of residual ischemia allowed gradual return to competitive sports according to COCIS recommendations. This case highlights the central role of multimodality imaging in integrating anatomical and functional information, guiding risk stratification and management decisions in athletes with coronary anomalies.