An anomalous left main coronary artery is a rarely seen clinical entity, particularly when it arises from the right sinus of Valsalva. This case report highlights this uncommon finding and how it affects the care of a patient with significant coronary artery disease.

Case Presentation

A 66 year-old male with a history of hypertension, hyperlipidemia, and type II diabetes presented with progressive exertional mid-epigastric and mid-chest discomfort. The patient stated that he had been feeling this “heaviness” with various activities and occasionally at rest for the past nine months. When it occurred with activity, the pain was generally relieved by rest within several minutes. His medications on presentation included insulin glargine, glyburide, metformin, simvastatin, pioglitazone, and lisinopril. Vital signs at the time of presentation included a temperature of 98.2°F, heart rate of 82 beats per minute, and blood pressure of 130/70 mmHg in both arms.

Laboratory investigation showed a total cholesterol of 178 mg/dL (normal range = 150-250), high-density lipoprotein (HDL) cholesterol of 42 mg/dL, low-density lipoprotein (LDL) cholesterol of 111 mg/dL, triglycerides of 123 mg/dL, and hemoglobin A1C of 7.9% (normal range = <5.7%). Pharmacologic nuclear stress testing revealed a severe, medium sized defect in the inferolateral wall that was predominately reversible. Thus, the patient underwent a cardiac catheterization which revealed an anomalous left main (LM) coronary artery arising from the right sinus of Valsalva separately from the origin of the right coronary artery (RCA). The distal left anterior descending artery (LAD) had a total occlusion, while the RCA had several areas of 70% stenosis. A subsequent coronary CT scan displayed an anomalous left coronary artery coursing anterior to the pulmonary artery (Figures 1, 2). The CT scan also showed moderate to high grade RCA stenosis in the mid to distal area of the vessel, as well as high-grade stenoses in the small-sized LAD and left circumflex arteries.