Trans-septal course of anomalous left main coronary artery originating from single right coronary ostium presenting with atrial fibrillation in a severely obese patient: a case report

BACKGROUND: To present a case of anomalous origin of the left coronary artery evaluated with invasive coronary angiography (ICA) and ECG-gated coronary computed tomography (CCT). CASE PRESENTATION: A patient (55 years old, male) with a past medical history of respiratory failure and atrial fibrillation underwent ICA to rule out coronary artery disease. Subsequently, the patient underwent ECG-gated CCT to evaluate a suspected anomalous aortic origin of the left coronary artery, since the interventional cardiologist was not able to properly identify the left coronary artery and its distal branches. CCT showed left coronary artery originating from the right coronary Valsalva sinus, coursing within the interventricular septum and emerging at the middle segment of the interventricular sulcus, where the left anterior descending and circumflex arteries originated. CONCLUSION: The case we presented highlights the value of ECG-gated CCT in the evaluation of coronary anomaly anatomy and thus risk stratification derived by proper coronary anatomy assessment. Although ICA was not helpful in the diagnosis, it also has a pivotal role regarding the therapeutic management of this condition.