CTICasesAnomalous Left Coronary Artery from the Opposite Sinus (ACAOS) with Intramural Course
Imaging findings
Coronary CT angiography shows an anomalous left main coronary artery originating from the right coronary sinus and taking an interarterial course between the aorta and pulmonary artery. There is severe narrowing of the proximal segment of the vessel, which is surrounded by soft tissue rather than epicardial fat, confirming an intramural course. Cardiac MRI demonstrates extensive delayed gadolinium enhancement in the left anterior descending and circumflex coronary artery territories, consistent with a large myocardial infarction.
Key takeaways
Anomalous origin of the left coronary artery from the right sinus of Valsalva with an interarterial and intramural course is a high-risk congenital anomaly that can cause sudden cardiac death or myocardial infarction, particularly in young patients during exertion. CT is highly effective for identifying the key high-risk features, such as proximal slit-like ostial narrowing and the absence of surrounding fat indicating an intramural segment, while MRI can characterize downstream myocardial viability and the extent of infarction.
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