Abstract
BACKGROUND: Coronary artery origin anomalies, though often incidentally detected, can lead to sudden death. Comprehensive perioperative management is essential. We report a case of an anomalous right coronary artery (RCA) arising from the left main coronary artery (LMCA) and coursing between the aorta and pulmonary artery, discovered after myocardial infarction, in which intraoperative management ensured successful coronary reconstruction. CASE PRESENTATION: A 49-year-old woman presented with chest pain and ST segment elevation. Coronary angiography revealed an anomalous RCA demonstrating compressive ischemia by the aorta and pulmonary artery. Preoperatively, blood pressure was stabilized with an isosorbide dinitrate patch. Under cardiopulmonary bypass, the RCA was transected and reanastomosed to its physiological aortic position. Intraoperatively, nicorandil was administered to suppress vascular smooth muscle contraction, while five-lead ECG, transesophageal echocardiography, and operative ultrasound monitoring enabled early detection of ischemia and prevented hypertension. Postoperative ventricular premature contractions resolved by the next day, with uneventful recovery. CONCLUSIONS: Targeted pharmacologic blood pressure control and multimodal monitoring are vital for safe perioperative outcomes in anomalous coronary artery origin cases.