A Case Report of Successful Treatment of a Patient with Anomalous Origin Coronary Artery Suffered from Acute Myocardial Infarction

A Case Report of Successful Treatment of a Patient with Anomalous Origin Coronary Artery Suffered from Acute Myocardial Infarction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Case Report of Successful Treatment of a Patient with Anomalous Origin Coronary Artery Suffered from Acute Myocardial Infarction Wei Huang, Zhinan Chen, Huagang Zhang, Wenbo Fu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4006028/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract A 63-year-old male patient diagnosed as “Acute myocardial infarction" while emergent Coronary angiography showed that the mid-to-distal segment of the circumflex branch was occluded. Unexpectedly, the left coronary artery was originated from the right sinus of Valsalva (ALCA-R). Successful PTCA recover blood flow of the occluded circumflex branch without MACE occurred. Anomalous origin of left coronary artery ALCA-R Acute myocardial infarction Percutaneous coronary intervention case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Anomalous aortic origin of a coronary artery (AAOCA) is a subgroup of coronary artery anomalies in adult patients, which account for the second leading cause (second to hypertrophic cardiomyopathy) of sudden cardiac death in athletes 1 . We reported a patient suffer from acute myocardial infarction with left coronary artery originating from the right coronary sinus (ALCA-R), which accounts for approximately 1–5% coronary artery anomalies 2 . The ratio of the incidence of ARCA-L to ALCA-R is approximately 6:1 3 . AAOCA can be divided into five categories: interarterial, intraseptal, prepulmonic, retroaortic, and cardiac posterior type 4 . Interarterial AAOCA has accounted for coronary blood flow obstruction, syncope, and sudden death 5 . However, the incidence of sudden death in ALCA-R is about 1.8 to 4.7 fold higher than than that in ARCA-L 6 . Endothelial cells in may be more incline to be injure and spasm due to atherosclerosis in such ALCA patients, which were both classic pathogenesis of acute coronary syndrome (ACS). We reported a case of a 63-year-old male patient with anomalous origin coronary artery suffered from acute myocardial infarction. Case presentation A 63-year-old male patient was admitted to the hospital at 23:53 on April 7th, 2022 for "Chest tightness for 17 hours". He was diagnosed with "acute non-ST-segment elevation myocardial infarction" with elevated bedside Troponin T level 378ng/L(normal range: 0 ~ 40 ng/L) and an electrocardiogram At 20:12 (as shown in Fig. 1 ). Coronary angiography showed the circumflex branch was occluded in the remoted mid-segment. The left main coronary artery was normal without stenosis. The anterior descending branch and the right coronary artery both showed slight stenosis(20%~30%) in the mid and distal segments. Exceptionally, the left coronary artery was originated from the side wall of the right coronary sinus. A PCI was performed on the circumflex branch with a 6FJR4.0 guiding catheter instead of a routine 6FJL4.0 guiding catheter which failed to reach the opening of the left coronary artery. After successful PTCA (Percutaneous Transluminal Coronary Angioplasty) the angiography showed that the circumflex branch was recanalized with TIMI grade 3 distal blood flow without stent implantation at the residual stenosis for the diameter of LCX less than 2mm. A follow-up of 24-hours dynamic electrocardiogram showed no ST-T changes (as shown in Fig. 1 ) and no malignant arrhythmias after PCI. Coronary artery computed tomography angiography (CTA) further showed that the left main coronary artery was originated from the right coronary sinus and ran through the gap between the pulmonary artery and the aorta (as shown in Fig. 4 ). Six days after percutaneous coronary intervention (PCI), no major adverse cardiovascular events (MACE) occurred during hospitalization and during the 1year follow-up period. MACE was defined as recurrent angina pectoris and myocardial infarction, malignant arrhythmias (ventricular tachycardia, ventricular fibrillation, new-onset atrial fibrillation, and second-degree or higher atrioventricular block), heart failure, sudden cardiac death. Timeline Discussion and Conclusions AMI in the patients with ALCA do not always represent typical ST segment changes in the electrocardiogram 7 . In this case, the electrocardiogram showed no ischemic changes in ST segment but angiography confirmed acute occlusion of the circumflex artery (STEMI). If ischemic chest pain symptoms persist with positive serum troponin T/I testing, emergency coronary angiography is suggested to be performed. For diagnosis of ALCA, coronary CT imaging is the gold standard which can completely show the origin of the coronary artery and its relationship with large arteries, and can also clearly display the direction, angle, and stenosis of the coronary artery. 8 For the patients with coronary arteries running between the main and pulmonary arteries, it is necessary to the coronary artery and prediction of MACE 9 . In this case, CTA scan showed a gap between the aorta and pulmonary arteries, which may relieve the compress of two large vessels on the main stem of left coronary artery and protect him from angina or sudden death before. For the treatment of ALCA-R, if there are no symptoms or evidence of myocardial ischemia and no concomitant coronary stenosis, regular follow-up is recommended 10 unless ischemic symptoms occur. Interventional methods are recommended including surgical and interventional therapy 11 . Individualized selection of guide catheter is required for emergency PCI performance 12 . In this case, application of 6FJR4.0 guide catheter successfully enter the abnormal opening instead of 6FJL4.0. Surgical intervention is currently the preferred treatment option for symptomatic patients (load-induced myocardial ischemia or arrhythmia) or patients with evidence of high risk (malignant arrhythmia, myocardial infarction, sudden death) 13 .Sometimes, coronary artery bypass grafting or intracoronary stent implantation can also be chosen 14 . For asymptomatic patients or patients without evidence of load-induced myocardial ischemia or arrhythmia, there is no consensus on management strategies currently 1 . List of abbreviations AAOCA Anomalous aortic origin of a coronary artery ALCA-R Left coronary artery originating from the right coronary sinus ARCA-L Right coronary artery originating from the left coronary sinus ACS Acute coronary syndrome MACE Major adverse cardiovascular events PCI Percutaneous coronary intervention STEMI ST-elevated myocardial infarction Declarations Ethics approval and consent to participate The study has the ethics approval from the General Hospital of Central Theater Command of PLA Ethic Committee (NO. [2023] 018-01, Fig.S3). The patient has given informed consent to participate (Fig.S1). Consent for publication Informed consent was obtained from all the participants ( Fig.S2 ) Availability of data and materials Data is provided within the manuscript and supplementary information files. The data and materials are all available in the medical system in General Hospital of Central Theater Command of PLA. Competing interests We declare no competing interests of our research. Funding This work was supported in part by the National Natural Science Foundation of China (81800261). Authors' contributions Wei Huang wrote the main manuscript text, Wenbo Fu prepared figures 1-4 and supervised the disccusion part of the case report. Zhinan Chen and Huagang Zhang did the PCI and help collected the medical records of the case. References Molossi S, Martínez-Bravo LE and Mery CM. Anomalous Aortic Origin of a Coronary Artery. Methodist Debakey Cardiovasc J . 2019;15:111-121. Molossi S and Agrawal H. Clinical evaluation of anomalous aortic origin of a coronary artery (AAOCA). Congenit Heart Dis . 2017;12:607-609. Brothers JA. Introduction to anomalous aortic origin of a coronary artery. Congenit Heart Dis . 2017;12:600-602. Young ML, McLeary M and Chan KC. Acquired and congenital coronary artery abnormalities. Cardiol Young . 2017;27:S31-s35. Gaillard M, Pontailler M, Danial P, Moreau de Bellaing A, Gaudin R, du Puy-Montbrun L, Murtuza B, Haydar A, Malekzadeh-Milani S, Bonnet D, Vouhé P and Raisky O. Anomalous aortic origin of coronary arteries: an alternative to the unroofing strategy. Eur J Cardiothorac Surg . 2020;58:975-982. Gharibeh L, Rahmouni K, Hong SJ, Crean AM and Grau JB. Surgical Techniques for the Treatment of Anomalous Origin of Right Coronary Artery From the Left Sinus: A Comparative Review. J Am Heart Assoc . 2021;10:e022377. Warner ED, Gulati A, Halpern E, Fischman DL, Ruggiero NJ, Keith SW, Layser RB, McCarey M and Savage MP. Clinical Outcomes in Adult Patients With an Anomalous Right Coronary Artery from the Left Sinus of Valsalva. Am J Cardiol . 2023;204:122-129. Fan C, Zeng M, Huang T, Mei X, Jiang B, Liu J and Peng D. Clinical manifestations and computed tomography angiography features of anomalous left coronary artery from the pulmonary artery syndrome. Zhong Nan Da Xue Xue Bao Yi Xue Ban . 2023;48:1008-1016. Türkoğlu S, Ünlü S, Taçoy GA and Özdemir M. Right Coronary Artery Originating from the Left: Do Not Miss the Diagnosis! Cardiol Res Pract . 2018;2018:1210791. Doan TT, Zea-Vera R, Agrawal H, Mery CM, Masand P, Reaves-O'Neal DL, Noel CV, Qureshi AM, Sexson-Tejtel SK, Fraser CD, Jr. and Molossi S. Myocardial Ischemia in Children With Anomalous Aortic Origin of a Coronary Artery With Intraseptal Course. Circ Cardiovasc Interv . 2020;13:e008375. Aubry P, Halna du Fretay X, Boudvillain O and Degrell P. Place of Angioplasty for Coronary Artery Anomalies With Interarterial Course. Front Cardiovasc Med . 2020;7:596018. Chong SZ, Fang HY and Fang CY. Intravascular ultrasound-guided treatment for simultaneous ostial left main intramural hematoma and anomalous right aortocoronary dissection. Int J Cardiovasc Imaging . 2022;38:485-487. [Expert consensus for the interventional treatment of pediatric congenital heart disease]. Zhonghua Er Ke Za Zhi . 2015;53:17-24. Mery CM. Decision making in anomalous aortic origin of a coronary artery. Congenit Heart Dis . 2017;12:630-632. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4006028","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":283151899,"identity":"ec2c9b08-ae4a-4b51-a034-ffb66628b3ba","order_by":0,"name":"Wei Huang","email":"","orcid":"","institution":"General Hospital of Central Theater Command of PLA","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Huang","suffix":""},{"id":283151900,"identity":"12faa42b-b018-48b8-8a97-10879c25f61e","order_by":1,"name":"Zhinan Chen","email":"","orcid":"","institution":"General Hospital of Central Theater Command of PLA","correspondingAuthor":false,"prefix":"","firstName":"Zhinan","middleName":"","lastName":"Chen","suffix":""},{"id":283151901,"identity":"33bb63d7-0de4-4c1d-aa51-32e4c7ffd8f9","order_by":2,"name":"Huagang Zhang","email":"","orcid":"","institution":"General Hospital of Central Theater Command of PLA","correspondingAuthor":false,"prefix":"","firstName":"Huagang","middleName":"","lastName":"Zhang","suffix":""},{"id":283151902,"identity":"5de25d57-1eca-41cb-9a79-28ae7d22088e","order_by":3,"name":"Wenbo Fu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYBAC9gYgwdjAwMMGZB0gSgvPAYgWGX4gizQtNpIzEoh0GI9EjuHjwh02PAY3nz88XFDDIM8vRsAyoBZj45ln0ngMbucYHJ5xjMFw5mwC1tlL5G6T5m07DNLCcJiHjSHB4DYBLTwSudt/g7XcPP7gMM8/4rRsYwZpkZzBYHCYt40YLTzvP0vzAv3CzwP0C2+fBGG/8LCnJX7m3WFjz8Z+/PFnnm828vzSBLSgAwnSlI+CUTAKRsEowA4ACyw/pA38PasAAAAASUVORK5CYII=","orcid":"","institution":"General Hospital of Central Theater Command of PLA","correspondingAuthor":true,"prefix":"","firstName":"Wenbo","middleName":"","lastName":"Fu","suffix":""}],"badges":[],"createdAt":"2024-03-02 09:20:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4006028/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4006028/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53506584,"identity":"3a9cf21a-3e27-4bbf-acba-0e0190a4249c","added_by":"auto","created_at":"2024-03-26 20:27:13","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":144517,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eElectrocardiogram characteristic of the patient\u003c/strong\u003e Both the admittedelectrocardiogram (A) and a follow-up of 24- hours dynamic electrocardiogram(B) showed no ST-T changes.\u003c/p\u003e","description":"","filename":"fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4006028/v1/15f1a3aeab754888db1437b6.jpg"},{"id":53506583,"identity":"15fcd9c6-6809-44c7-b05c-e3bd61802c14","added_by":"auto","created_at":"2024-03-26 20:27:12","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":101244,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAngiography images (arrow indicates occluded circumflex artery) \u003c/strong\u003eA-D Preoperative angiographic image (arrow indicates occluded circumflex artery) E-F Post-PCI (arrow indicates reopened circumflex artery)\u003c/p\u003e","description":"","filename":"fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4006028/v1/03d7ecce700b79de0d5c4625.jpg"},{"id":53507151,"identity":"08b557f5-44b3-4c1a-911a-93f877109e83","added_by":"auto","created_at":"2024-03-26 20:35:13","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":106428,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCoronary CT angiography \u003c/strong\u003eFigures A-C showed that the left main coronary artery was originated from the right coronary sinus, while figures D-F demonstrated that the left main coronary artery passed through the gap between the pulmonary artery and the aorta. (Blue area indicated by arrow represents pulmonary artery)\u003c/p\u003e","description":"","filename":"fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4006028/v1/16ee9e7d57676cfaca8e8c27.jpg"},{"id":53506585,"identity":"36598c29-438e-407a-b253-0ee8f79ee0d5","added_by":"auto","created_at":"2024-03-26 20:27:13","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":82942,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCentral illusion of the case\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA 63-year-old male patient diagnosed as “Acute myocardial infarction\" while emergent Coronary angiography showed that the mid-to-distal segment of the circumflex branch was occluded. Unexpectedly, the left coronary artery was originated from the right sinus of Valsalva (ALCA-R). Successful PTCA recovered blood flow of the occluded circumflex branch without MACE occurred. We discussed definition, epidemiology, typing and prognosis of AAOCA.\u003c/p\u003e","description":"","filename":"fig4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4006028/v1/67b1d9a4e05b48a1f9eb55f0.jpg"},{"id":73074602,"identity":"c84b0b19-f2df-448c-9430-69d33957bd21","added_by":"auto","created_at":"2025-01-06 13:09:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":737181,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4006028/v1/b4e92eb2-ad72-49fc-9378-707a9ef6604e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Case Report of Successful Treatment of a Patient with Anomalous Origin Coronary Artery Suffered from Acute Myocardial Infarction","fulltext":[{"header":"Background","content":"\u003cp\u003eAnomalous aortic origin of a coronary artery (AAOCA) is a subgroup of coronary artery anomalies in adult patients, which account for the second leading cause (second to hypertrophic cardiomyopathy) of sudden cardiac death in athletes\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. We reported a patient suffer from acute myocardial infarction with left coronary artery originating from the right coronary sinus (ALCA-R), which accounts for approximately 1\u0026ndash;5% coronary artery anomalies\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The ratio of the incidence of ARCA-L to ALCA-R is approximately 6:1\u003csup\u003e3\u003c/sup\u003e. AAOCA can be divided into five categories: interarterial, intraseptal, prepulmonic, retroaortic, and cardiac posterior type\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Interarterial AAOCA has accounted for coronary blood flow obstruction, syncope, and sudden death \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. However, the incidence of sudden death in ALCA-R is about 1.8 to 4.7 fold higher than than that in ARCA-L \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Endothelial cells in may be more incline to be injure and spasm due to atherosclerosis in such ALCA patients, which were both classic pathogenesis of acute coronary syndrome (ACS). We reported a case of a 63-year-old male patient with anomalous origin coronary artery suffered from acute myocardial infarction.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 63-year-old male patient was admitted to the hospital at 23:53 on April 7th, 2022 for \"Chest tightness for 17 hours\". He was diagnosed with \"acute non-ST-segment elevation myocardial infarction\" with elevated bedside Troponin T level 378ng/L(normal range: 0 ~ 40 ng/L) and an electrocardiogram At 20:12 (as shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Coronary angiography showed the circumflex branch was occluded in the remoted mid-segment. The left main coronary artery was normal without stenosis. The anterior descending branch and the right coronary artery both showed slight stenosis(20%~30%) in the mid and distal segments. Exceptionally, the left coronary artery was originated from the side wall of the right coronary sinus. A PCI was performed on the circumflex branch with a 6FJR4.0 guiding catheter instead of a routine 6FJL4.0 guiding catheter which failed to reach the opening of the left coronary artery. After successful PTCA (Percutaneous Transluminal Coronary Angioplasty) the angiography showed that the circumflex branch was recanalized with TIMI grade 3 distal blood flow without stent implantation at the residual stenosis for the diameter of LCX less than 2mm.\u003c/p\u003e\n\u003cp\u003eA follow-up of 24-hours dynamic electrocardiogram showed no ST-T changes (as shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) and no malignant arrhythmias after PCI. Coronary artery computed tomography angiography (CTA) further showed that the left main coronary artery was originated from the right coronary sinus and ran through the gap between the pulmonary artery and the aorta (as shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). Six days after percutaneous coronary intervention (PCI), no major adverse cardiovascular events (MACE) occurred during hospitalization and during the 1year follow-up period. MACE was defined as recurrent angina pectoris and myocardial infarction, malignant arrhythmias (ventricular tachycardia, ventricular fibrillation, new-onset atrial fibrillation, and second-degree or higher atrioventricular block), heart failure, sudden cardiac death.\u003c/p\u003e\n\u003ch3\u003eTimeline\u003c/h3\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Discussion and Conclusions","content":"\u003cp\u003eAMI in the patients with ALCA do not always represent typical ST segment changes in the electrocardiogram\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. In this case, the electrocardiogram showed no ischemic changes in ST segment but angiography confirmed acute occlusion of the circumflex artery (STEMI). If ischemic chest pain symptoms persist with positive serum troponin T/I testing, emergency coronary angiography is suggested to be performed.\u003c/p\u003e \u003cp\u003eFor diagnosis of ALCA, coronary CT imaging is the gold standard which can completely show the origin of the coronary artery and its relationship with large arteries, and can also clearly display the direction, angle, and stenosis of the coronary artery. \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e For the patients with coronary arteries running between the main and pulmonary arteries, it is necessary to the coronary artery and prediction of MACE\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. In this case, CTA scan showed a gap between the aorta and pulmonary arteries, which may relieve the compress of two large vessels on the main stem of left coronary artery and protect him from angina or sudden death before. For the treatment of ALCA-R, if there are no symptoms or evidence of myocardial ischemia and no concomitant coronary stenosis, regular follow-up is recommended\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e unless ischemic symptoms occur. Interventional methods are recommended including surgical and interventional therapy \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Individualized selection of guide catheter is required for emergency PCI performance \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In this case, application of 6FJR4.0 guide catheter successfully enter the abnormal opening instead of 6FJL4.0. Surgical intervention is currently the preferred treatment option for symptomatic patients (load-induced myocardial ischemia or arrhythmia) or patients with evidence of high risk (malignant arrhythmia, myocardial infarction, sudden death) \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.Sometimes, coronary artery bypass grafting or intracoronary stent implantation can also be chosen \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. For asymptomatic patients or patients without evidence of load-induced myocardial ischemia or arrhythmia, there is no consensus on management strategies currently \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e"},{"header":"List of abbreviations","content":"\u003cp\u003eAAOCA Anomalous aortic origin of a coronary artery\u003c/p\u003e\n\u003cp\u003eALCA-R Left coronary artery originating from the right coronary sinus\u003c/p\u003e\n\u003cp\u003eARCA-L Right coronary artery originating from the left coronary sinus\u003c/p\u003e\n\u003cp\u003eACS Acute coronary syndrome\u003c/p\u003e\n\u003cp\u003eMACE Major adverse cardiovascular events\u003c/p\u003e\n\u003cp\u003ePCI Percutaneous coronary intervention\u003c/p\u003e\n\u003cp\u003eSTEMI ST-elevated myocardial infarction\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has the ethics approval from the General Hospital of Central Theater Command of PLA Ethic Committee (NO. [2023] 018-01, Fig.S3). The patient has given informed consent to participate (Fig.S1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all the participants \u003cstrong\u003e(\u003c/strong\u003eFig.S2\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData is provided within the manuscript and supplementary information files. The data and materials are all available in the medical system in General Hospital of Central Theater Command of PLA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe declare no competing interests of our research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported in part by the National Natural Science Foundation of China (81800261).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWei Huang wrote the main manuscript text, Wenbo Fu prepared figures 1-4 and supervised the disccusion part of the case report. Zhinan Chen and Huagang Zhang did the PCI and help collected the medical records of the case.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMolossi S, Mart\u0026iacute;nez-Bravo LE and Mery CM. Anomalous Aortic Origin of a Coronary Artery. \u003cem\u003eMethodist Debakey Cardiovasc J\u003c/em\u003e. 2019;15:111-121.\u003c/li\u003e\n\u003cli\u003eMolossi S and Agrawal H. Clinical evaluation of anomalous aortic origin of a coronary artery (AAOCA). \u003cem\u003eCongenit Heart Dis\u003c/em\u003e. 2017;12:607-609.\u003c/li\u003e\n\u003cli\u003eBrothers JA. Introduction to anomalous aortic origin of a coronary artery. \u003cem\u003eCongenit Heart Dis\u003c/em\u003e. 2017;12:600-602.\u003c/li\u003e\n\u003cli\u003eYoung ML, McLeary M and Chan KC. Acquired and congenital coronary artery abnormalities. \u003cem\u003eCardiol Young\u003c/em\u003e. 2017;27:S31-s35.\u003c/li\u003e\n\u003cli\u003eGaillard M, Pontailler M, Danial P, Moreau de Bellaing A, Gaudin R, du Puy-Montbrun L, Murtuza B, Haydar A, Malekzadeh-Milani S, Bonnet D, Vouh\u0026eacute; P and Raisky O. 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Clinical manifestations and computed tomography angiography features of anomalous left coronary artery from the pulmonary artery syndrome. \u003cem\u003eZhong Nan Da Xue Xue Bao Yi Xue Ban\u003c/em\u003e. 2023;48:1008-1016.\u003c/li\u003e\n\u003cli\u003eT\u0026uuml;rkoğlu S, \u0026Uuml;nl\u0026uuml; S, Ta\u0026ccedil;oy GA and \u0026Ouml;zdemir M. Right Coronary Artery Originating from the Left: Do Not Miss the Diagnosis! \u003cem\u003eCardiol Res Pract\u003c/em\u003e. 2018;2018:1210791.\u003c/li\u003e\n\u003cli\u003eDoan TT, Zea-Vera R, Agrawal H, Mery CM, Masand P, Reaves-O\u0026apos;Neal DL, Noel CV, Qureshi AM, Sexson-Tejtel SK, Fraser CD, Jr. and Molossi S. Myocardial Ischemia in Children With Anomalous Aortic Origin of a Coronary Artery With Intraseptal Course. \u003cem\u003eCirc Cardiovasc Interv\u003c/em\u003e. 2020;13:e008375.\u003c/li\u003e\n\u003cli\u003eAubry P, Halna du Fretay X, Boudvillain O and Degrell P. Place of Angioplasty for Coronary Artery Anomalies With Interarterial Course. \u003cem\u003eFront Cardiovasc Med\u003c/em\u003e. 2020;7:596018.\u003c/li\u003e\n\u003cli\u003eChong SZ, Fang HY and Fang CY. Intravascular ultrasound-guided treatment for simultaneous ostial left main intramural hematoma and anomalous right aortocoronary dissection. \u003cem\u003eInt J Cardiovasc Imaging\u003c/em\u003e. 2022;38:485-487.\u003c/li\u003e\n\u003cli\u003e[Expert consensus for the interventional treatment of pediatric congenital heart disease]. \u003cem\u003eZhonghua Er Ke Za Zhi\u003c/em\u003e. 2015;53:17-24.\u003c/li\u003e\n\u003cli\u003eMery CM. Decision making in anomalous aortic origin of a coronary artery. \u003cem\u003eCongenit Heart Dis\u003c/em\u003e. 2017;12:630-632.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anomalous origin of left coronary artery, ALCA-R, Acute myocardial infarction, Percutaneous coronary intervention, case report","lastPublishedDoi":"10.21203/rs.3.rs-4006028/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4006028/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eA 63-year-old male patient diagnosed as \u0026ldquo;Acute myocardial infarction\" while emergent Coronary angiography showed that the mid-to-distal segment of the circumflex branch was occluded. Unexpectedly, the left coronary artery was originated from the right sinus of Valsalva (ALCA-R). Successful PTCA recover blood flow of the occluded circumflex branch without MACE occurred.\u003c/p\u003e","manuscriptTitle":"A Case Report of Successful Treatment of a Patient with Anomalous Origin Coronary Artery Suffered from Acute Myocardial Infarction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-26 20:27:08","doi":"10.21203/rs.3.rs-4006028/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7e4b9fbe-f0bc-4053-ac70-62641b8d8a8d","owner":[],"postedDate":"March 26th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-06T13:08:57+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-26 20:27:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4006028","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4006028","identity":"rs-4006028","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}