A Case of Anomalous Origin of the Right Coronary Artery from the Left Sinus of Valsalva with a Malignant Course

Congenital heart disease in adults, including congenital anomalies of the coronary arteries, can be asymptomatic and diagnosed incidentally, but they can also be a cause of sudden cardiac death. The recent guidelines on the management of adults with congenital heart disease from the American Heart Association (AHA) and the American College of Cardiologists (ACC) identify that an anomalous coronary artery origin can lead to myocardial ischemia, arrhythmias, or sudden cardiac death. When the course of the coronary artery runs between the aorta and pulmonary trunk, it is described as having a "malignant course." Emergency surgical correction is required to restore the normal anatomy of the aberrant coronary artery. This report is of a 57-year-old man with a history of hypertension who had a normal electrocardiogram (ECG). A nuclear exercise stress test showed a resting and exercise ejection fraction (EF) of 56% with transient ischemic dilatation (TID) of the left ventricle. Coronary artery computed tomography angiography (CTA) identified an anomalous right coronary artery (AORCA) originating from the left sinus of Valsalva and coursing between the aorta and pulmonary trunk. TID on nuclear imaging is usually associated with left ventricular hypertrophy, microvascular disease, or multivessel macrovascular disease and has not been previously described in AORCA.