Anomalous Aortic Origin of the Right Coronary Artery Between the Right and Left Coronary Sinuses: A Case Report

Anomalous aortic origin of the right coronary artery (R-ACAOS) is a rare congenital anomaly associated with an increased risk of myocardial ischemia and, in some cases, sudden cardiac death, particularly when the anomalous artery follows an interarterial course between the aorta and the pulmonary artery. This report presents the case of a 71-year-old man with nocturnal palpitations and atypical chest discomfort as the main symptoms, without syncope. Holter monitoring revealed first- and second-degree atrioventricular (AV) block. Coronary computed tomography angiography (CCTA) identified R-ACAOS with a short interarterial trajectory between the aorta and pulmonary arteries, with no significant ostial narrowing or other high-risk anatomical features. Cardiac magnetic resonance (CMR) demonstrated inferior wall ischemia. The patient was referred to the cardiothoracic surgery department, where surgical unroofing was planned to eliminate potential dynamic compression and achieve complete symptom resolution. This case underscores the importance of prompt recognition of R-ACAOS, even in elderly patients, and highlights the crucial role of coordinated care between primary and specialized services. Comprehensive anatomical evaluation using CCTA or cardiac MRI is essential to assess risk and guide appropriate management. Surgical unroofing remains a reliable and effective intervention for symptomatic patients with interarterial R-ACAOS; thus, it was selected as the optimal therapeutic approach.