Coronary artery anomalies are often incidental findings. Most anomalies are benign, but some can cause sudden death. It is important to identify them especially before invasive procedures and cardiac surgery. The echocardiogram, as in this case report, provides a high diagnostic accuracy. We describe three typical echocardiographic signs that we find when the circumflex artery originates from the right coronary cusp and has a retroaortic course.
A 42-year-old man presented to the emergency department with oppressive chest pain at rest lasting 1 h. In his medical history, the patient reported the following cardiovascular risk factors: smoking, family history of coronary heart disease, hypertension, type 2 diabetes mellitus for 10 years and hypercholesterolemia. Electrocardiogram showed sinus rhythm at 70 bpm without signs of myocardial ischemia. Troponin, D-dimer, C-reactive protein were normal in consecutive blood samples. The echocardiogram documented a left ventricle with normal size and wall thickness, preserved systolic function and absence of significant valvular disease and pericardial effusion. Apical 4-chamber view showed a tubular structure on the atrial side of the mitral valve (Figure 1A, RAC sign). The same structure was identified in parasternal short-axis view just below the noncoronary aortic cusp (Figure 1B, crossed aorta). The tubular shape suggested a vascular structure in an anomalous position. In the parasternal long-axis view, a transverse section of this vessel was visible near aortic valve (Figure 1C, bleb sign). Patient underwent coronary angiography due to persistence of symptoms. Angiography did not reveal significant coronary stenoses, but documented anomalies in the origin and course of the coronary arteries. The circumflex artery shared its origin from the right coronary cusp with the right coronary artery and had a retroaortic course while the only anterior descending artery originated from the left coronary cusp. Anomalies of origin and/or course of the coronary arteries can be detected in 1.3% of the population undergoing coronary angiography. On echocardiogram “RAC sign”, “crossed aorta” and “bleb sign” are often misdiagnosed as artefacts, calcifications or catheter. In case of suspected coronary anomalies, CT is the reference diagnostic test. The abnormal origin and course found in our patient are considered benign and not associated with an increased risk of sudden death and myocardial ischemia.
