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Second AD

74-year-old with history of aortic valve repair at an outside hospital.

First figure represents volume-rendered image of the heart with the right coronary artery demonstrated.

Myocardial bridging of the right coronary artery

Malignant course of the right coronary artery

Answer: Malignant course of the right coronary artery.


This case demonstrates a malignant course of the right coronary artery. Best seen on the volume-rendered image, the right coronary artery courses between the aorta and the main pulmonary artery, an interarterial course often referred to as a malignant course. A congenital anomalous origin of the right coronary artery is seen, arising from the left cusp of the aortic valve adjacent to the left main artery.

Anomalous courses of the coronary arteries are thought to be present in 0.3%–1.6% of the population and are usually discovered incidentally. Anomalous courses of the coronary arteries are the second most common cause of sudden cardiac death in young healthy individuals, second only to hypertrophic cardiomyopathy. A malignant course is defined as passage of the coronary artery between the aorta and the pulmonary artery.

An anomalous left coronary artery with a malignant course has a much higher risk of sudden death than an anomalous right coronary artery with a malignant course. As patients age, their risk of sudden death with these anomalies decreases significantly and surgical management is rarely warranted. In young patients with malignant right coronary artery courses, proper management is not fully defined and the decision to perform surgery is multifactorial. Young patients with malignant left coronary artery courses usually undergo surgical correction.


Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, del Nido P, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. 

PeÃ±alver JM, Mosca RS, Weitz D, Phoon CK. Anomalous aortic origin of coronary arteries from the opposite sinus: a critical appraisal of risk. 

Image IQ: 74-year-old, History of Aortic Valve Repair

Duke Duncan, MD