Anterior descending branch arising from the pulmonary artery: a rare congenital malformation (QF_FR_082)

Description of Clinical Presentation: The patient had previously experienced a myocardial infarction as indicated by an electrocardiogram during a health check-up in 2018, but was asymptomatic and did not seek medical intervention. In 2021, he began to experience exertional chest discomfort and mild back pain, typical symptoms of coronary heart disease, prompting him to seek medical attention at our hospital.

Diagnostic Techniques and Their Most Important Findings: Coronary CTA demonstrated an anomalous origin of the left anterior descending artery from the pulmonary artery root, accompanied by vessel enlargement and tortuosity.  The circumflex artery originated from the right coronary sinus and traversed through the interventricular groove, also exhibiting vessel enlargement.  A localized calcified plaque was observed near the distal segment.  The right coronary artery exhibited dominant blood supply, with enlarged and tortuous main trunk and branches.  The heart showed diffuse enlargement, thickened ventricular wall, and widened pulmonary trunk.  Owing to clear indications of myocardial ischemia, the decision was made that the large pulmonary blood flow was impacting myocardial perfusion.  Consequently, corrective measures were taken including closure of abnormal coronary artery origin, ligation of coronary artery-pulmonary artery fistula, and performance of end-to-side anastomosis between the left internal mammary artery and tortuous vessel bundle in the anterior descending branch during coronary artery bypass grafting under cardiopulmonary bypass.  One month post-operation, there were no further episodes of chest pain reported by the patient;  magnetic resonance imaging indicated thinning of left ventricular apical region myocardium with reduced movement, increased T1mapping in anterior wall and anterior interventricular septum along with delayed enhancement seen in endocardial layer suggesting myocardial infarction;  3-year follow-up after operation showed patent bridge vessel on coronary CTA scan as well as gradual return to normal range for pulmonary trunk diameter.

Learning Points from this Case: Through reviewing this case's diagnosis and treatment process, we have summarized imaging manifestations and classification of anomalous origin of the coronary arteries while analyzing its clinical significance in hopes of raising awareness among patients and clinicians about these malformations for early diagnosis and intervention.