Case report
A 30-years old man was presented with exertional chest pain repeatedly, without hypertension and dyslipidemia. On physical examination, his blood pressure was 105/55mmHg, heart rate is 70 bpm, cardiac murmur was not obvious. Electrocardiogram showed the sign of ischemia in inferior wall and previous infarction in interventricular septum. Hypersensitive troponin I level was 37.5 ng/L, the blood NT-ProBNP level was 376.0 pg/ml, the inflammatory markers were normal. Transthoracic echocardiography(TTE) found an enlarged mass (5.1×4.3cm) close to right coronary artery opening, with thrombus contained probably and no flow signal inside, compressing the anterior part of tricuspid annular and right ventricle without abnormal hemodynamics (Figure 1A and B). Besides of that, the decreased motion of middle segment anterior septal wall was detected by TTE. Coronary angiography showed that there were multiple aneurysms in proximal and middle part of right coronary artery (RCA), but distal part of RCA can’t be displayed (Figure 2A). The left anterior descending (LAD) and left circumflex artery (LCX) were occluded in proximal part, and collateral circulation was developed around (Figure 2B). To clearly displaying the distal part of RCA, CCTA was performed and found a string of aneurysms distributed in distal part of RCA (Figure 3A). Unexpectedly, CCTA found the origin of left coronary artery was abnormal, which arising from left side of sinotubular junction and part of left main coronary arteries distributing between the ascending aorta and the main pulmonary artery (Figure 3B). CMR found some of aneurysms had thrombose inside (Figure 3C), and distinctly displayed the course of left main coronary arteries distributing between two arteries (Figure 3D). Taken imaging characteristics of coronary artery into consideration, the diagnosis mostly be suspected as multiple giant right coronary artery aneurysms with thrombus combined with anomalous aortic origin of left coronary artery. Finally, coronary artery bypass graft surgery was performed, and intraoperative finding demonstrated the suspected diagnosis. In the intraoperative view, there were two giant coronary artery aneurysms with thrombus adjacent to each other in proximal and mid part of right coronary artery (Figure 4).