Extract

A 61-year-old male complained palpitations. Baseline ECG (PanelA), 24-h ECG monitoring and echocardiography were unremarkable. Exercise stress test showed mild ventricular repolarization abnormalities at peak (PanelB) without symptoms. Coronary CT showed a left main (LM) atresia (PanelC, arrow). Left anterior descending (LAD) and circumflex artery (Cx) received collateral perfusion from the right coronary (RCA). Feeding vessel of proximal LAD, diagonal branches, and Cx was the postero-lateral from RCA, while mid-distal LAD feeding vessels were the infundibular artery, the acute marginal branch, and the posterior descending (PanelsC–E). RCA had abnormalities but not stenosis, LAD was small, with a myocardial bridge in the mid-segment (PanelH, arrow), Cx was normal. Transoesophageal echocardiography demonstrated the absence of the LM (PanelF, arrow) and a prominent RCA (PanelG, arrow) too. CT-SPECT documented mild perfusion abnormalities under stress in the basal inferior and inferior septum segment (Panels H and I, green). The patient is now under antiplatelet, statin and B-blocker therapy. He will be reassessed in 6 months time with stress echocardiography.

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