ABC | Volume 112, Nº1, January 2019

Case Report Silva-Estrada et al Anomalous left coronary and myocardial infarction Arq Bras Cardiol. 2019; 112(1):110-112 Figure 1 – CT angiography shows anomalous origin of the left coronary artery arising at the right sinus of Valsalva from a separate ostium. Figure 2 – Three-dimensional reconstruction shows high-risk coronary anatomy: acute take-off angle, no intramural interarterial segment, long stenotic-hypoplastic segment (11 mm). RC: right coronary artery; LC: left coronary artery. a differential diagnosis in every previously healthy young patient with acute onset chest pain and evidence of acute myocardial ischemia. Transthoracic echocardiography can be the ideal diagnostic test in low-income settings; however, it must be noted that its accuracy is limited 6 and a specific evaluation may obtain better results in the diagnosis. The detailed description of the anomaly should always be sought considering that there are three anatomical features that have been linked to a worse prognosis: intramural course, slit-like coronary ostium, and acute take-off angle of the anomalous coronary. 7 In this case, apart from an acute take-off angle, a stenotic and hypoplastic course added to the disease burden. Given the aggravating coronary features encountered in this patient, aborted cardiac arrest or even sudden cardiac death could have been an expected outcome. Furthermore, the surgical approach could not tackle the coronary anomaly. Regardless of these apparently adverse factors, the patient fully recovered and reports asymptomatic with no evidence of cardiac lesion at more than one year follow up, which gives light to the fact that there must be other factors, such as vasoreactive ability and early collateral circulation, that can influence the course of this disease. Corrective surgery, such as coronary translocation, must be offered to symptomatic patients with this coronary anomaly and high-risk features. 7 Although the safety of corrective surgery has been demonstrated, 8,9 its efficacy in the prevention of sudden cardiac death in the long term remains to be proven with further prospective studies. Besides, whenever we encounter aggravating features that make corrective surgery a difficult approach, coronary artery bypass grafting poses an alternative without undermining patient’s short- and long-termprognosis. Comparing these surgical approaches in cohort studies should be advocated. The poorly understood physiopathology and natural history of this coronary anomaly hinder the development of risk stratification strategies and causes controversies in management algorithms. The presence of knowledge gaps regarding true worldwide prevalence, specific mechanisms of myocardial ischemia and optimal surgical options call for ongoing research to improve evidence-based decision making. Author contributions Acquisition of data: Silva-Estrada JA, Domínguez-Camacho A; writing of the manuscript: Silva-Estrada JA, Reyes-de-la- Cruz L, Reyna-Figueroa J; critical revision of the manuscript for 111