Assessment and treatment of dynamic obstruction in anomalous right coronary artery using dynamic diastolic pressure gradient change during dobutamine challenge with rapid atrial pacing

In anomalous right coronary artery (RCA), extravascular coronary compression results in dynamic obstruction which can cause effort angina as well as syncope. Measurement of dynamic intracoronary pressure gradient (ΔP) change across the lesion using dobutamine challenge with rapid atrial pacing (RAP) can be used for assessment of dynamic obstruction in anomalous coronary artery. We report a case of anomalous origin of RCA which dynamic diastolic pressure gradient (ΔP) was measured using this method. During dobutamine challenge with RAP, diastolic ΔP significantly increased from 6 mm Hg at baseline to 13 mm Hg, and when diastolic ΔP reached to 13 mm Hg, T wave inversion was observed, the chest pain was developed. After intracoronary stenting, diastolic ΔP decreased to 2 mm Hg, chest pain was relieved, and T wave inversion was disappeared. The patient was asymptomatic at two months' follow-up.