Coronary artery anomalies: A case of the "malignant" left coronary artery and its surgical management.

Background: Any variance of the normal coronary vasculature is regarded as a coronary artery anomaly (CAA). An atypical left coronary artery arising from the right aortic sinus of Valsalva has been identified as the rarest CAA and the second leading cause of sudden cardiac death (SCD) in young people. Prompt identification of the anomalous vessel is essential to mitigate early mortality risk. Case summary: A 33-year-old male, ex-smoker presented with exertional breathlessness and retrosternal chest tightness for the past 1 year. Past history also revealed a significant decline in his exercise tolerance. His initial work-up, which included a resting electrocardiogram and echocardiogram were within normal limits. His exercise tolerance test however, was discontinued early due to the onset of symptoms, and his exercise stress echocardiogram proved positive for angina at a low workload. The cardiac computed tomography angiography revealed a common origin for the left and right coronary systems from the right ostium, with the left main stem following an inter-arterial course and showing mild, diffuse narrowing. The patient was green-lit for coronary artery bypass grafting (CABG). Post recovery and almost 2 years on, he has remained symptom-free and has regained his physical activity. Conclusion: This case underlines the need for prompt identification and subsequent management of anomalous coronary arteries, given their association with SCD. Timely surgical intervention such as CABG can greatly mitigate the risk of grievous complications. The patient's complication-free postop recovery and resumption of physical activity, assures the reader that it is a viable and durable option with long-term quality of life improvement.