A Malignant Course of Anomalous Right Coronary Artery Arising From Left Coronary Cusp Presenting With Exertional Syncope

Anomalous origin of the right coronary artery from the left sinus of Valsalva is a rare congenital disease. It is mostly benign, with malignant variants reported in a few instances. One such "malignant course" is its course between the main pulmonary artery and the aortic root. It is relatively uncommon but may present with angina or sudden cardiac death (SCD) in the absence of significant atherosclerosis, especially in young patients. Therefore, diagnosis becomes pivotal. Here, we report a case of a female in her late 70s with a history of vertigo who presented to the hospital with exertional syncope without prodromal symptoms. Further workup demonstrated high-sensitivity troponin that peaked at 3300 ng/dl. She was evaluated by cardiology for NSTEMI (non-ST segment elevation myocardial infarction) and underwent a coronary angiogram that identified non-obstructive coronary artery disease but an anomalous origin of the right coronary artery arising from the left coronary cusp. She underwent a CT (computed tomography) chest angiogram, which demonstrated an interarterial course between the aorta and pulmonary artery with multiple areas of significant stenosis. After extensive discussion, she decided to be treated conservatively due to its benign condition and late presentation. Identification of this anomalous course becomes pivotal as surgical correction can improve patient outcomes. Definitive therapy is surgery with unroofing of intramural segments, stenting, or surgical intervention with bypass grafting, reimplantation of the anomalous artery, or osteoplasty. However, in older patients, conservative management with exercise limitations is an acceptable option.