Introduction: Single coronary artery is a rare congenital malformation (incidence between 0.024% and 1%), reported at coronary angiography or at autopsy. This anomaly is characterized by a unique coronary artery originating from a single coronary sinus which, throu-gh its branches, maintains the vascularization of the entire heart. Multiple anatomical variations are described, however the clinical implications are still not completely known. Coronary anomalies are an important cause of sudden cardiac death in young athletes. Ischemic manifestations, arrhythmia, syncope, non-specific symptoms have been described in adults and in elderly patients. We wish to present the case of anomalous co-ronary artery and dilated cardiomyopathy.

Case presentation: We describe the case of a 73 year-old man, with a history of hypertension and permanent atrial fibrillation with rapid ventricular response who was admitted to the Cardiology Department with clini-cal picture of heart failure class IV of NYHA Functio-nal Classification. The patient has no history of angina, myocardial infarction, syncope or other types of cardiac decompensation, no medical family history of heart disease. The patient doesn’t present dynamic changes in cardiac enzymes serum levels, nor increased inflamma-tion markers. The electrocardiogram shows atrial fibrillation, newly diagnosed left bundle branch block and no R wave progression in V1-V4 leads. The echocardiography shows severe atrial enlargement, moderate left ventricular systolic dysfunction with a left ventricular ejection fraction of 40%. The coronarography reveals a common right trunk, divided in two arteries. The first one runs along the right coronary artery`s course, and the second artery has an anomalous path, ascendant and parallel to the pulmonary trunk, describing a loop around it. The path continues towards the left coronary sulcus, with hypoplasia of the left anterior descending artery. The coronary arteries do not present significant atherosclerotic stenoses. The computed tomography angiography confirms the single coronary trunk, with an Agatston calcium score of 306.2, with no significant stenoses.

Particularty: Single coronary artery diagnosed in the case of an elderly patient, with multiple cardiovascular risk factors, may entail difficulties in angiographic diagnosis and in the therapeutic management. In this case, the pre-pulmonic distribution of the left coronary branch is considered benign. The imagistic investigations describe coronary arteries with no significant atherosclerotic stenoses. After the management of the rapid ventricular response of the atrial fibrillation and the congestive phenomena, the patient has a favorable clinical evolution, with an improved ejection fraction and minimized congestive signs and symptoms. We consider the diagnosis of dilated cardiomyopathy of uncertain etiology, probably tachycardia-induced, in a patient diagnosed with a rare coronary artery anomaly raises multiple diagnostic hypotheses with therapeutic implications.