One Root to Rule Them All; A Curious Case of All Coronaries Arising From a Common Root in a High Risk NSTEMI

Abstract

Background: Anomalous and aberrant origin of coronary arteries are amongst the most common congenital coronary anomalies, with a reported prevalence of 0.1-1%. Anomalous origin of Left coronary artery is associated with a higher risk of sudden cardiac death, especially if the origin is intraarterial. Anomalous coronaries can pose a particularly difficult challenge, if encountered in the ACS setting Case: Here we present a rather curious case of a 69 years of age lady with premorbid of Diabetes, Hypertension and Hypothyroidism who presented with NSTEMI and a GRACE score of 148, with ongoing angina CCS class IV. Her Hs Troponins were 2500 pg/ml and Echocardiogram revealed an EF of 45 percent with Inferior wall hypokinesis. After informed consent, the patient was taken to the cardiac Cath lab for coronary angiogram as part of early invasive strategy. After securing the Right radial access, coronary angiogram was proceeded, which surprisingly revealed a common origin of all three major epicardial coronaries from the right coronary sinus. To add to the challenge and uniqueness of this rather curious case the angiogram revealed three vessel coronary artery disease, harbouring critical disease in osteoproximal, mid and distal course of dominant RCA, diffuse critical disease in proximal and mid LAD and critical disease in proximal Lcx. PCI to RCA with 2xDES was proceeded in the index procedure, followed by staged PCI to LAD with 1x DES, 2 weeks later, thereby allowing medical optimization of her comorbid as well as mitigating the risk of Contrast Induced Nephropathy and renal impairment Conclusion: The patient remained stable post procedure and has been in regular cardiology follow up ever since. This case emphasizes the need of familiarity with anomalous coronaries, and how to proceed with PCI, especially in ACS setting.