SESSION TITLE: Etiologies of Cardiovascular Disease Case Report PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/19/2022 12:45 pm - 01:45 pmINTRODUCTION: We present a case involving atypical coronary anatomy, specifically the right coronary artery originating from the ascending aorta. We focus on the rarity of this anomaly and the clinical implications in the management of coronary ischemia.CASE PRESENTATION: A 59-year-old Hispanic male with past medical history of atrial flutter status post ablation, mitral valve regurgitation status post annuloplasty, hypertension, hyperlipidemia, and transient ischemic attack presented to the emergency room with chest pain after riding his bicycle. He described the pain as a left-sided pressure that had initially alleviated with rest. He then returned home but had intermittent recurrence of his pain with associated diaphoresis and palpitations.On physical exam, the patient was in no apparent distress. Cardiac exam was unremarkable. Cardiac biomarkers were significantly elevated, consistent with ischemia. Electrocardiogram had revealed normal sinus rhythm with a right bundle branch block. Cardiac CT revealed aberrant origin of the right coronary artery (RCA), 1.1 cm above the sinotubular junction, then coursing between the aorta and pulmonary artery before moving laterally. The patient underwent cardiac catheterization which revealed total occlusion of the mid-RCA, resulting in successful percutaneous coronary intervention and drug-eluting stent placement. He was then discharged home the following day with no apparent complications.DISCUSSION: The incidence of coronary artery anomalies is approximately 1.3%. Of these anomalies, 87% are of origin and distribution of the arteries. The incidence of anomalous origin of the RCA is 0.25%. Origin of the RCA from the ascending aorta is an even rarer subtype, with an incidence of 0.006%. While this is often an incidental finding, it can predispose patients to ischemia through various mechanisms, such as compression or stretching of the RCA between the pulmonary artery and the aorta. These can then predispose the patients to a litany of sequelae, such as sudden cardiac death, arrhythmias, and thrombus formation. Thrombus can form due to repeated transient episodes of ischemia leading to small focal areas of necrosis and subsequent fibrosis. These patients require lifelong cardiology follow-up, consisting of annual electrocardiograms and routine echocardiograms. Management is directed by symptoms. If ischemia is induced with exercise stress testing, these patients have two surgical approaches: unroofing and reimplantation of the coronary artery, or bypass.CONCLUSIONS: There is no definitive consensus for the management of these patients long-term, and prospective studies are needed to develop care guidelines. We also raise the possibility of the anatomy having a direct effect, with chronic turbulence and micro-trauma to the areas of anomaly, another prospect to be considered.Reference #1: Zeina, A & Blinder, J & Sharif, Dawod & Rosenschein, Uri & Barmeir, E. (2008). Congenital coronary artery anomalies in adults: non-invasive assessment with multidetector CT. The British journal of radiology. 82. 254-61. 10.1259/bjr/80369775.Reference #2: 1906-1991 Netter, and Carlos A. G. Machado. Netter’s Clinical Anatomy. 4th edition. Philadelphia, PA: Elsevier, 2019.Reference #3: Charitos, Efstratios I, and Hans-Hinrich Sievers. "Anatomy of the aortic root: implications for valve-sparing surgery.” Annals of cardiothoracic surgery vol. 2,1 (2013): 53-6. doi:10.3978/j.issn.2225-319X.2012.11.18DISCLOSURES: No relevant relationships by Alejandro DominguezNo relevant relationships by Michael GirardNo relevant relationships by Shannon MohabirNo relevant relationships by Alexander Tarr SESSION TITLE: Etiologies of Cardiovascular Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: We present a case involving atypical coronary anatomy, specifically the right coronary artery originating from the ascending aorta. We focus on the rarity of this anomaly and the clinical implications in the management of coronary ischemia. CASE PRESENTATION: A 59-year-old Hispanic male with past medical history of atrial flutter status post ablation, mitral valve regurgitation status post annuloplasty, hypertension, hyperlipidemia, and transient ischemic attack presented to the emergency room with chest pain after riding his bicycle. He described the pain as a left-sided pressure that had initially alleviated with rest. He then returned home but had intermittent recurrence of his pain with associated diaphoresis and palpitations. On physical exam, the patient was in no apparent distress. Cardiac exam was unremarkable. Cardiac biomarkers were significantly elevated, consistent with ischemia. Electrocardiogram had revealed normal sinus rhythm with a right bundle branch block. Cardiac CT revealed aberrant origin of the right coronary artery (RCA), 1.1 cm above the sinotubular junction, then coursing between the aorta and pulmonary artery before moving laterally. The patient underwent cardiac catheterization which revealed total occlusion of the mid-RCA, resulting in successful percutaneous coronary intervention and drug-eluting stent placement. He was then discharged home the following day with no apparent complications. DISCUSSION: The incidence of coronary artery anomalies is approximately 1.3%. Of these anomalies, 87% are of origin and distribution of the arteries. The incidence of anomalous origin of the RCA is 0.25%. Origin of the RCA from the ascending aorta is an even rarer subtype, with an incidence of 0.006%. While this is often an incidental finding, it can predispose patients to ischemia through various mechanisms, such as compression or stretching of the RCA between the pulmonary artery and the aorta. These can then predispose the patients to a litany of sequelae, such as sudden cardiac death, arrhythmias, and thrombus formation. Thrombus can form due to repeated transient episodes of ischemia leading to small focal areas of necrosis and subsequent fibrosis. These patients require lifelong cardiology follow-up, consisting of annual electrocardiograms and routine echocardiograms. Management is directed by symptoms. If ischemia is induced with exercise stress testing, these patients have two surgical approaches: unroofing and reimplantation of the coronary artery, or bypass. CONCLUSIONS: There is no definitive consensus for the management of these patients long-term, and prospective studies are needed to develop care guidelines. We also raise the possibility of the anatomy having a direct effect, with chronic turbulence and micro-trauma to the areas of anomaly, another prospect to be considered. Reference #1: Zeina, A & Blinder, J & Sharif, Dawod & Rosenschein, Uri & Barmeir, E. (2008). Congenital coronary artery anomalies in adults: non-invasive assessment with multidetector CT. The British journal of radiology. 82. 254-61. 10.1259/bjr/80369775. Reference #2: 1906-1991 Netter, and Carlos A. G. Machado. Netter’s Clinical Anatomy. 4th edition. Philadelphia, PA: Elsevier, 2019. Reference #3: Charitos, Efstratios I, and Hans-Hinrich Sievers. "Anatomy of the aortic root: implications for valve-sparing surgery.” Annals of cardiothoracic surgery vol. 2,1 (2013): 53-6. doi:10.3978/j.issn.2225-319X.2012.11.18 DISCLOSURES: No relevant relationships by Alejandro Dominguez No relevant relationships by Michael Girard No relevant relationships by Shannon Mohabir No relevant relationships by Alexander Tarr