DOI: https://doi.org/10.36347/sjmcr.2026.v14i01.007

Pages: 30-37

Background: Anomalous right coronary artery [RCA] arising from the left coronary cusp [LCC] with an interarterial course is a rare but clinically significant congenital coronary anomaly. This anatomical variation, often termed a "malignant" RCA, is associated with an increased risk of myocardial ischemia, arrhythmias, and sudden cardiac death, primarily due to dynamic compression between the aorta and pulmonary artery. Surgical intervention is generally recommended for symptomatic patients or those with high-risk anatomical features, even in the absence of significant coronary artery stenosis. Case Presentation: We present the case of a 38-year-old male with underlying diabetes mellitus, hypertension, and dyslipidemia who experienced recurrent episodes of angina, palpitations, and syncopal attacks. His past medical history included a motor vehicle accident [MVA] in 2014, resulting in multiple fractures managed with internal fixation. Initial cardiovascular evaluation revealed Canadian Cardiovascular Society [CCS] class I angina and New York Heart Association [NYHA] class II symptoms. Electrocardiography [ECG] showed sinus rhythm, while stress myocardial perfusion imaging demonstrated a mild perfusion defect in the inferior wall, correlating with the RCA territory. Coronary computed tomography angiography [CTCA] revealed an anomalous RCA originating from the LCC with an interarterial course between the aorta and pulmonary artery. Despite the absence of significant obstructive coronary artery disease, the high-risk anatomy of the RCA and the patient’s recurrent symptoms warranted surgical intervention. Following a multidisciplinary discussion, the patient underwent surgical translocation of the anomalous RCA via median sternotomy. Cardiopulmonary bypass [CPB] was established, and the RCA was carefully dissected, ligated at its anomalous origin, and reimplanted onto the anterior surface of the ascending aorta. Intraoperative transesophageal echocardiography confirmed s