case_images: PMC9222707_01
case_images: The electrocardiogram global ST segment depression of leads II, III, aVF and V3-V6 was more than 0.05 mV, and abnormal Q waves were observed.
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case_images: F1
case_images: II, III, aVF, and V3-V6 of more than 0.05 mV and abnormal Q waves (Figure 1), which revealed myocardial ischemia. In addition, the serum level of cardiac troponin I (cTnI) was greater than the upper threshold (>50.00 mug/L, n.v. <0.06 mug/L) and significantly elevated B-type natriuretic peptide (BNP) at 1157.14 pg/mL (n.v. <100 pg/mL).
case_images: The echocardiographic presentation. (A) Left ventricular ejection fraction (LVEF) decreased dramatically to 23%. (B) The right coronary artery presented clearly with normal formation and lumen diameter. (C) The origin and course of the left coronary artery seemed to be normal, with a related narrowed lumen diameter. (D) Doppler demonstrated a non-continuous blood flow in the left coronary artery. RCA, right coronary artery; LCA, left coronary artery.
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case_images: F2
case_images: However, his left ventricular ejection fraction (LVEF) decreased dramatically to 23% (Figure 2A). In these images, the right coronary artery clearly presented with normal formation and lumen diameter (Figure 2B). The origin and course of the left coronary artery seemed to be normal, presenting a slightly narrowed lumen diameter (Figure 2C). However, Doppler demonstrated non-continuous blood flow in the left coronary artery (Figure 2D), which indicated dysfunction of the left coronary artery.
case_images: Cardiac CTA and MRI imaging. (A) Left coronary artery originated from an abnormal location at the superior and posterior sites in the left coronary sinus. (B-D) LAD and LCX demonstrated severe dysplasia under several sections of CTA. (E) Cardiac MRI demonstrated significant myocardial ischemia and fibrosis in the left ventricular wall before surgical correction. (F) Cardiac MRI image after surgical correction revealed a normal perfusion. LCA, left coronary artery; LAD, left anterior descending; LCX, left circumflex.
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case_images: F3
case_images: TNF-alpha) and autoimmune antibodies, which excluded a diagnosis of vasculitis. CTA was performed to determine the overall shape of the left coronary artery. The results of CTA from diverse sections of the heart revealed that the left coronary artery originated from an abnormal location at the superior and posterior sites in the left coronary sinus (Figure 3A). Importantly, the CTA images presented dysplasia of the left coronary artery (Figures 3B-D). Furthermore, cardiac MRI demonstrated significant myocardial ischemia and fibrosis in the left ventricular wall (Figure 3E). Cardiac MRI post-surgery presented a normal myocardial perfusion (Figure 3F).
case_images: Coronary angiography images. (A) Angiography at the root of the aorta. The right coronary artery could be perfused with contrast agent, but the left coronary artery was missing. (B) Selective right coronary artery angiography demonstrated a dilated right coronary artery. (C) Delay radiological exposure revealed that the left ventricle could be supplied by the right coronary artery, which was considered the right coronary artery-dependent left coronary artery circulation. (D) The angiography failed to illustrate the left coronary artery in the left coronary sinus. (E) A strange curve-like migration of the origin of the left coronary artery by angiography at a superior location. (F) Then, the left coronary artery could be perfused at an extremely low volume. (G) Anatomic aspect of the axial section of aortic and pulmonary valves and left coronary artery arising from the non-coronary sinus of Valsalva with an intramural segment course. RCA, right coronary artery; LCA, left coronary artery; R, right coronary sinus; L, left coronary sinus; N, non-coronary sinus; P, pulmonary artery.
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case_images: F4
case_images: Angiography at the root of the aorta showed that the right coronary artery could be perfused with contrast agent, but the left coronary artery was missing (Figure 4A). Selective right coronary artery angiography demonstrated a dilated right coronary artery (Figure 4B). Delay radiological exposure revealed that the left ventricle could be supplied by the right coronary artery, which was considered right coronary artery-dependent left coronary artery circulation (Figure 4C). Compared to the CTA images, angiography illustrated the left coronary artery originated from the non-coronary sinus (Figure 4D). However, a strange curve, such as migration of the origin of the left coronary artery, was observed by angiography at a superior location (Figure 4E). Then, the left coronary artery could be perfused as an extremely low volume (Figure 4F). The intramural wall segment finally exited from the margin of the left-right-coronary sinus, generated a sharp angle and coursed between the aorta and the pulmonary artery with general severe stenosis, resulting in severe coronary artery dysplasia (Figure 4G).