Management of a Patient With an Anomalous Coronary Artery

Video 1 and 2

A 45-year-old man presented to the emergency department for evaluation of acute onset of chest pain. He reported the acute onset of severe, retrosternal chest pain, with radiation to the left arm. The patient was dyspneic and diaphoretic during the initial episode. The symptoms resolved spontaneously after about one hour. 

In the emergency room, the initial electrocardiogram demonstrated non-specific ST segment changes, with T wave flattening in the inferior limb leads. The initial troponin T value was 0.06 ng/mL, with subsequent values of 2.0 ng/mL, then 1.6 ng/mL on serial measurements. He continued to have several mild episodes of chest pain, similar in character to the initial episode. He was started on oral aspirin, ticagrelor, and intravenous unfractionated heparin, and admitted to the cardiology service. 

The following day, the patient was referred for coronary angiography, revealing the single origin of the coronary arteries from the right coronary cusp, with the left main coronary artery coursing posterior to the aorta, as seen in the right anterior oblique (RAO) projection (Video 1). The left anterior descending (LAD) artery had a 95% discrete stenosis in the mid-vessel, with TIMI 2 distal vessel flow (Video 2). The left circumflex artery and right coronary arteries had mild, non-obstructive coronary artery disease (CAD). The serum glucose was normal, and transthoracic echocardiography revealed normal left ventricular systolic function. 

Which of the following is next most appropriate step in the management of this patient?

Show Answer