IJCS | Volume 31, Nº5, September / October 2018

DOI: 10.5935/2359-4802.20180057 551 CASE REPORT International Journal of Cardiovascular Sciences. 2018;31(5)551-555 Mailing Address: Raiana Maciel Miranda Avenida Romualdo Galvão, 2.464, apto 4b. Postal Code: 59056-100, Lagoa Nova, Natal, RN – Brazil. E-mail: mirandaraiana@gmail.com , raiana_maciel@hotmail.com Monomorphic Ventricular Tachycardia as the First Manifestation in a Patient with Anomalous Coronary Artery Júlio César Vieira de Sousa, 1,2,3 Raiana Maciel Miranda, 2,3 Gabriela Melchuna Madruga, 2,3,4 Domitila Costa de Farias, 2,3,5 Paula de Medeiros Nacácio e Silva, 2,3,6 Nastassja Morgana de Sousa Figueiredo 2,3 Departamento de Medicina Integrada - Universidade Federal do Rio Grande do Norte; 1 Natal, RN - Brazil Hospital Universitário Onofre Lopes; 2 Natal, RN - Brazil Universidade Federal do Rio Grande do Norte; 3 Natal, RN - Brazil Irmandade da Santa Casa de Misericórdia de São Paulo; 4 São Paulo, SP -Brazil Hospital Giselda Trigueiro; 5 Natal, RN - Brazil Hospital do Servidor Público Estadual; 6 São Paulo, SP - Brazil Manuscript received on September 15, 2017; revised manuscript on January 17, 2018; accepted on February 07, 2018. Arrhythmias, Cardiac; Tachycardia, Ventricular; Coronary Vessel Anomalies; Death. Sudden, Cardiac. Keywords Introduction Coronary artery anomalies comprise a heterogeneous group of rare congenital heart defects, being classified according to their origin, course and distal bed, with an incidence ranging between 0.3% and 1.5% in the overall population. Dodge-Khatami et al. 1 subdivided them into seven categories, according to their clinical complexity: coronary arteries originating from the pulmonary artery, coronary arteries with anomalous aortic origin, congenital atresia of the left main coronary artery, coronary arteriovenous fistulas, coronary arteries forming myocardial bridges, coronary artery aneurysms and coronary stenosis. The Texas Children’s Hospital classification uses angiotomography with virtual angioscopy and divides the classification into three topics: origin of the anomalous coronary artery, coronary artery course and ostium morphology. From the viewpoint of anatomical risk, the anomalous left coronary artery with an interarterial course, presence of intramurality and a slit-like ostium are the main predictive factors of severity. 1-3 A specific type is the anomalous origin of the left coronary artery from the right coronary sinus with an interarterial course, which is associated with hard outcomes in approximately 60% of the cases. 2 Clinically, patients may present with nonspecific symptoms, ranging from palpitations, chest pain, post-exertion syncope or remain asymptomatic throughout life, with sudden death being the first and only manifestation of this condition. 4 Most cases have been reported in young male individuals, but there is no scientific evidence yet whether the incidence is actually higher in males, or if this gender is more often diagnosed by performing more intense physical activities, therefore triggering symptoms. Themost common of these conditions is the anomalous origin of the left coronary artery from the pulmonary artery. However, we present herein a case with an anomalous origin of the left coronary artery from the right coronary sinus, with a proximal course between the aortic and the pulmonary arteries in a 31-year-old man. Case report A previously healthy 31-year-old male patient, a mason, was admitted to the Emergency Unit in October 2012, complaining of palpitations and cold sweats, with hypotension (BP = 90 x 50 mmHg), which developed into syncope at the hospital unit. He was submitted to the first electrocardiogram (Image 1A), which disclosed sustained monomorphic ventricular tachycardia (SMVT). He underwent electrical cardioversion and was transferred to intensive care unit (ICU) for clinical stabilization. Therapy with amiodarone was started in the ICU, with some episodes of slow ventricular tachycardia (VT) and periods of accelerated idioventricular rhythm (Image 1B), albeit asymptomatic. He reverted to sinus