A 35-year-old woman was admitted with atypical chest pain. Her electrocardiogram was normal. There was no rise in serum troponin level. Echocardiogram showed a structurally normal heart with preserved left ventricular systolic function. Her serum cholesterol was very high (total cholesterol of 7.7 mmol/L with LDL of 5.3 mmol/L) but there was no other conventional risk factor for coronary artery disease. In view of ongoing chest pain and high cholesterol, a coronary angiogram was done to rule out coronary artery disease (Figures 1 and 2; Supplementary material online, Videos S1 and S2). Answer: 3. Anomalous origin of left coronary artery from right sinus of Valsalva with retro-aortic course. Explanation Origin of the left main coronary artery (LMCA) from the right sinus of Valsalva is a rare congenital anomaly with an estimated incidence of 0.04%. It has been associated with sudden cardiac death in young persons. Identification of the course of the LMCA after its origin is important to stratify the risk of sudden death. A computed tomography coronary angiogram (CTCA) will identify the course of the LMCA after its origin but in 1985 Ishikawa et al. 1 described a method to determine the course of the LMCA by conventional invasive Figure 2 Left anterior oblique view. Figure 1 Right anterior oblique view.
European Heart Journal. Acute Cardiovascular Care, Volume 11, Issue 5, May 2022, Pages e2–e3, https://doi.org/10.1093/ehjacc/zuac030