This was a middle aged concert pianist who complained of dizzyness and palpitations during stressful performances. His electrophysiology suggested sick-sinus syndrome, with periods of atrial standstill. He had nothing to suggest ischaemic heart disease, but I was asked to study his coronaries in case of non-atheromatous disease.
As you see, he had no right coronary artery, the left circumflex continuing past the crux to pass up the right atrioventricular groove to supply the right sided structures. It is a little easier to see on the full angio, but there was no doubt that the last branch of the circumflex was the sinu-atrial nodal vessel (arrow).
It is tempting to wonder if the pulse wave in the SA nodal vessel was dampened by being at the end of a much longer vessel than its usual origin. Could this have interfered with nodal function? Or was it just a coincidence? Though I have seen this anomaly a handful of times since, none has had this sort of history. Does anyone out there know the answer? The patient was given a pacemaker and did well