Syncope - Basketball

HISTORY: A 12-year-old female basketball player had a witnessed syncopal event while playing in a basketball game for her school. A bystander felt for her pulse for 15 seconds without finding one and started CPR. An AED was placed, but no analysis was performed as patient was undergoing CPR and then had return of spontaneous circulation within 60 seconds. On EMS arrival, patient had returned to consciousness and an ECG was performed significant for ST elevation in all leads. She was taken to an outside ER where a repeat ECG was normal and initial troponin levels were normal, but repeat at 6 hours were elevated resulting in transfer to a CVICU at a local children’s hospital. There, patient continued to have elevated troponin level. PHYSICAL EXAMINATION: Examination in the ER demonstrated no cardiac abnormality with normal rate and rhythm, normal pulses, and normal heart sounds without murmur. There was no reproducible tenderness of the chest. She had an otherwise normal exam. DIFFERENTIAL DIAGNOSIS:1. Arrhythmia 2. Hypertrophic Obstructive Cardiomyopathy 3. Anomalous coronary artery TEST AND RESULTS: EKG - Diffuse ST ElevationTroponin HS: Initial 11, repeat 2200 ECHO: Left main coronary artery arises from the right coronary cusp between the origin of the right coronary artery and the commissure. The left main coronary artery then courses between the aorta and pulmonary artery. The rest of the intracardiac anatomy was normal with normal biventricular function. CT: Anomalous origin of the left main coronary artery from the right coronary sinus. The left main and the right coronary artery have separate ostia. The left main coronary artery takes off at an acute angle with an interarterial and intramural course for a length of approximately 11 mm where it takes on an elliptical shape with 50% reduction in cross-sectional area. FINAL WORKING DIAGNOSIS: Anomalous origin of left coronary artery from right coronary aortic sinus TREATMENT AND OUTCOMES: 1. Telemetry and trending of troponin values 2. Surgical unroofing of the left coronary artery 3. Exercise restriction until stress test performed 5. Indefinite aspirin therapy