# The Missing Coronary: A Case Series of Inferior Wall Myocardial Infarction Due to Coronary Anomalies

## TL;DR

This paper presents three rare cases where heart attacks were caused by unusual coronary artery structures, highlighting the need for careful diagnosis and specialized treatment.

## Contribution

The paper introduces three unique clinical cases of inferior wall MI caused by rare coronary anomalies and their management strategies.

## Key findings

- A congenital absence of the left circumflex artery can lead to a 'shark fin' ECG pattern and MI.
- Split RCA anomalies may be initially misdiagnosed but can be treated with re-evaluation and alternative imaging.
- Anomalous RCA origin from the left sinus of Valsalva can be managed with modified catheter techniques during PCI.

## Abstract

Coronary artery anomalies, while often asymptomatic, can sometimes present acutely in the context of myocardial infarction (MI). This case series highlights three unique instances of inferior wall MI precipitated by rare coronary anomalies. The first case involved a 40-year-old male with a congenital absence of the left circumflex artery, presenting with a “shark fin” ECG pattern in inferior leads. Urgent coronary angiography confirmed the anomaly and primary percutaneous coronary intervention (PCI) was performed on a superdominant right coronary artery (RCA). The second case details a 52-year-old male with a split RCA, initially undiagnosed due to apparently normal angiographic findings, later revealed to have a thrombotic occlusion of the posterior division. Careful re-evaluation and imaging from alternative angles facilitated successful PCI. The third case describes a 45-year-old male with an anomalous origin of the RCA from the left sinus of Valsalva, presenting difficulties during arterial engagement in PCI. A modified Judkins left catheter technique was employed to achieve selective cannulation and stent deployment. These cases underscore the importance of early recognition, accurate diagnosis, and innovative interventional strategies in managing acute MI due to congenital coronary anomalies.