case_images: PMC8004557_01
case_images: Still frame image of the RCA in the right anterior oblique (RAO) projection. The RCA is seen arising from the left coronary cusp prior to taking a usual course through the atrioventricular groove.
case_images: CRIC2021-6686227.001.jpg
case_images: PMC8004557_01_CRIC2021-6686227.001.jpg
case_images: fig1
case_images: Coronary angiography showed mild nonobstructive coronary artery disease and an anomalous right coronary artery (ARCA) arising from the left coronary cusp (Figure 1 and Video 1).
case_images: (a, b) Short-axis and four-chamber myocardial delayed enhancement imaging performed 10 minutes following injection of gadolinium contrast demonstrated no evidence of late gadolinium enhancement.
case_images: CRIC2021-6686227.002.jpg
case_images: PMC8004557_01_CRIC2021-6686227.002.jpg
case_images: fig2
case_images: Cardiac magnetic resonance imaging (CMR) was obtained given suspicion for myocarditis as a cause of dilated cardiomyopathy which corroborated severe left ventricular dysfunction with ejection fraction of 16% (Video 2), but no myocardial edema on T2-weighted images or late gadolinium enhancement (LGE) (Figures 2(a) and 2(b)).
case_images: Axial CMR images corroborating the anomalous RCA (arrow) arising from the left coronary cusp and appearing to take an intra-arterial course.
case_images: CRIC2021-6686227.003.jpg
case_images: PMC8004557_01_CRIC2021-6686227.003.jpg
case_images: fig3
case_images: Axial scout images again demonstrated an ARCA arising from the left coronary cusp, but now clearly appearing to take an intra-arterial course between the aorta and the main pulmonary artery (Figure 3).
case_images: (a-d) Axial CCTA images demonstrating the anomalous RCA arising from the left coronary cusp and taking an intra-arterial course. The extent of the proximal and mid-vessel is better delineated than in CMR (a). The slit-like configuration of the ostial RCA, as well as the acute angulation of its takeoff, is seen in this en-face coronal view (b). Cross sections of the RCA are shown, demonstrating the intramural portion (c) and just distally (d).
case_images: CRIC2021-6686227.004.jpg
case_images: PMC8004557_01_CRIC2021-6686227.004.jpg
case_images: fig4
case_images: Cardiac computed tomographic angiography (CCTA) was obtained to better delineate its course, confirming a slit-like proximal orifice arising at an acute angle and an intramural and intra-arterial course between the great vessels (Figures 4(a)-4(d)).
case_images: (a, b) The patient achieved 11 METS on a modified Bruce protocol but developed symptomatic chest discomfort and inferior lead ST-segment depressions at peak exercise persisting 1 minute into recovery. SPECT images demonstrated a reversible inferior wall perfusion deficit.
case_images: CRIC2021-6686227.005.jpg
case_images: PMC8004557_01_CRIC2021-6686227.005.jpg
case_images: fig5
case_images: Exercise single-photon emission computed tomography (SPECT) demonstrated a mild-to-moderate-sized reversible defect in the inferolateral wall referable to the territory supplied by the ARCA (Figures 5(a) and 5(b)).