Weightlifting unmasks high-risk coronary anomaly.

Abstract

A 31-year-old athletic patient with a history of competitive weightlifting presented to our emergency department with intermittent chest pain and transient ST-elevations. Echocardiogram showed left ventricular hypertrophy and septal/apical hypokinesis. Coronary angiography revealed a left anterior descending (LAD) originating from the right coronary artery ostium (Panel A, Supplementary material online, Videos S1 and S2) with a significant compression of the proximal LAD (*). To evaluate the precise anatomy, we performed coronary computed tomography angiography [3D reconstruction: Panel B, multiplanar reconstruction: Panel C (Ao, aorta; LCX, left circumflex artery)]. This revealed an extremely rare case of an intramyocardial course of the LAD, deviating through the intraventricular septum. After reevaluation of initial echocardiography images, the LAD was detected in parasternal long (Panel D) and short-axis views (Panel E). We hypothesize that upon regular weightlifting training, left ventricular mass reached a critical level, causing the compression of the intramyocardial part of the LAD. The patient was discussed within our heartteam and referred for successful single graft off-pump heart surgery. Coronary anomalies are rare. They are classified according to the size/number of vessels, origin, and course. Critical anatomical features should be evaluated: (i) arteries originating from false ostia, (ii) narrowing of the ostium, (iii) take-off angle, (iv) inter-arterial course (between pulmonary artery and aorta), (v) intramural course, and (vi) length of stenoses/compression. Revascularization is recommended in case of an anomalous left main with inter-arterial course or with signs of ischaemia.