ST-segment elevation myocardial infarction in a patient with anomalous origin of left circumflex coronary artery Masahiro Yamamoto, MD, Kenichi Tsujita,

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ST-segment elevation myocardial infarction in a patient with anomalous origin of left circumflex coronary artery Masahiro Yamamoto, MD, Kenichi Tsujita, MD, PhD, Kenshi Yamanaga, MD, Naohiro Komura, MD, PhD, Kenji Sakamoto, MD, PhD, Sunao Kojima, MD, PhD, FJCC, Eiichiro Yamamoto, MD, PhD, Tomoko Tanaka, MD, PhD, Megumi Yamamuro, MD, PhD, Yasuhiro Izumiya, MD, PhD, Sunao Nakamura, MD, PhD, Koichi Kaikita, MD, PhD, FJCC, Seiji Hokimoto, MD, PhD, FJCC, Hisao Ogawa, MD, PhD, FJCC Journal of Cardiology Cases Volume 11, Issue 4, Pages 120-123 (April 2015) DOI: 10.1016/j.jccase.2015.01.002 Copyright © 2015 Japanese College of Cardiology Terms and Conditions

Fig. 1 Emergency diagnostic coronary angiography. Left coronary arteriogram showed no total occlusion in the left anterior coronary artery, and the absence of left circumflex coronary artery (LCX) in the region of the great cardiac vein (left panel). The right coronary arteriogram demonstrated, albeit faintly, that LCX arising from the right coronary sinus ran through retroaortic space (white arrowhead, right panel). Journal of Cardiology Cases 2015 11, 120-123DOI: (10.1016/j.jccase.2015.01.002) Copyright © 2015 Japanese College of Cardiology Terms and Conditions

Fig. 2 Angiographic and intravascular ultrasound images summarizing the culprit lesion morphology and interventional procedure. Selective left circumflex coronary artery (LCX) angiography (upper left panel) revealed an obstruction at an anomalous course of proximal LCX with haziness (allegedly thrombus). Pre-percutaneous coronary intervention (PCI) intravascular ultrasound (IVUS) revealed plaque rupture at the culprit lesion (lower left panel). Note plaque ulceration with a fissure at 8–11 o’clock and a communication between the cavity of the rupture and the lumen. Also, IVUS demonstrated coronary intramural mobile mass around the culprit lesion (lower middle panel). Note the protruding structure with irregular surface and heterogeneous echogenicity at 11–3 o’clock. Post-intervention angiography showed favorable dilatation of the culprit lesion with Thrombolysis In Myocardial Infarction grade 3 flow (upper right panel). Post-intervention IVUS visualized optimal stent expansion (minimum stent area: 8.4mm2) with slight tissue (thrombus) protrusion at 5–6 o’clock (lower right panel). Journal of Cardiology Cases 2015 11, 120-123DOI: (10.1016/j.jccase.2015.01.002) Copyright © 2015 Japanese College of Cardiology Terms and Conditions

Fig. 3 Post-percutaneous coronary intervention computed tomography coronary angiography showed that the culprit lesion (stented site, dashed line, right panel) was located at the retroaortic course of the left circumflex coronary artery (LCX) with anomalous origin. The right coronary artery and LCX originated from the common trunk arising from the right coronary sinus (white arrowhead, right panel). Ao, aorta; LA, left atrium; LCX, left circumflex coronary artery; RCA, right coronary artery. Journal of Cardiology Cases 2015 11, 120-123DOI: (10.1016/j.jccase.2015.01.002) Copyright © 2015 Japanese College of Cardiology Terms and Conditions