All three coronary arteries and a separate conus branch arising from the right sinus of Valsalva in an octogenarian with an acute myocardial infarction: a case report.

BACKGROUND: Coronary artery anomalies are encountered in less than 1% of the population and are usually found incidentally. Some vessel courses are linked to myocardial ischaemia and sudden cardiac death while successful PCI in ACS scenarios poses a clinical challenge.

CASE SUMMARY: An 83-year-old woman with hypertension and dyslipidaemia presented with an ACS. The ECG showed atrial fibrillation while echocardiography revealed ischaemic cardiomyopathy with mildly reduced ejection fraction. Diagnostic coronary angiography showed a four separate ostia arising from the right sinus of Valsalva: RCA, LAD, LCX, and an independent conus branch. Transient occlusion of the conal branch by the diagnostic catheter triggered VF promptly terminated with DC cardioversion. On Day 4, PCI via right transulnar access was performed as we treated a first diagonal branch with DCB and mid-RCA stenosis with two DES. CTCA at follow-up confirmed an anterior (pre-pulmonic) course of the LAD, a retroaortic course of the LCX, and a dominant RCA. LAAT was detected and oral anticoagulation was initiated. The patient was discharged in stable condition on GDMT.

DISCUSSION: This constellation, a separate ostia of four coronary arteries arising from the right coronary sinus, is exceedingly rare. The case underscores several practical points. Anomalous coronaries are susceptible to atherosclerosis and should be revascularized according to clinical context and not anomaly per se. Furthermore, meticulous catheter manipulation should be performed in order to avoid transient ostial compromise of small branches, such as in our case. Finally, CTCA complements invasive angiography by clarifying spatial relationships essential for risk stratification.