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Cardiac arrest as the first manifestation of single coronary artery – potential role of FFRCT for detecting critical flow reduction. A case reportKeywords: cardiac arrest, ventricular fibrillation, coronary artery anomaly, single coronary artery, fractional flow reserve - computed tomographyBackground. Undiagnosed coronary artery anomaly (CAA) is the second most common cause of SCD in young competitive athletes and myocardial ischemia is considered the primary cause of underlying malignant arrhythmias. Cardiac computed tomography (CCT) has become increasingly important not only for detecting coronary artery disease (CAD) but also for the diagnosis of coronary anomalies. However, the prognostic impact of CAA is highly individual and difficult to predict. In this case, FFRCT was performed as a novel means of evaluating the hemodynamic significance of abnormal coronary circulation due to CAA in a male victim of aborted sudden arrhythmic death.Case summary: A 31-year-old male was admitted to the hospital after an aborted cardiac arrest. Ventricular fibrillation (VF) occurred in resting conditions which was diagnosed on-site and terminated with a single DC shock. Emergency coronary angiography revealed complete right coronary atresia. Thereafter, the patient was referred to our center without neurological sequelae for further management. Echocardiogram and cardiac MRI were normal. An implantable cardioverter-defibrillator (ICD) for secondary prevention was implanted. Subsequently, the patient underwent complementary investigations to detect myocardial ischemia during rest and exercise – treadmill stress test and single-photon emission computerized tomography (SPECT) were all within normal limits. In order to assess the hemodynamic impact of the right coronary atresia, CCT with FFRCT calculation (HeartFlow Inc., Redwood City, California, USA) was applied and demonstrated significant flow reduction in the mid to distal segments of the LAD and CX arteriesConclusion: This case report demonstrates the potential of CCT and FFRCT to detect a potentially malignant reduction of coronary flow in distal segments of otherwise normal left coronary tree in the presence or right coronary artery atresia.Introduction: Coronary artery anomalies (CAAs) are a group of congenital conditions characterized by abnormal origin, course, or termination of any of the 3 main epicardial coronary arteries [1]. The increasing use of invasive and non-invasive cardiovascular imaging detected a 7.9% prevalence of CAAs[2]. CAAs are extremely variable necessitating a highly individualized therapeutic approach. [3, 4].However, clinical correlates and prognostic implications of CAAs remain poorly understood [1, 3, 4]. According to current knowledge, isolated congenital coronary atresia should be considered potentially fatal, increasing the risk of neonatal death and later in the life of heart failure or malignant arrhythmias [5, 6]. Angina, dyspnoea, and chest discomfort may represent the first clinical manifestations. Most importantly, however, CAA-related cardiac arrest may occur in up to 50% of previously asymptomatic patients [7, 8].Case presentation: A 31-year-old male was admitted to the hospital after out-of-hospital cardiac arrest followed by 10 minutes of cardiopulmonary resuscitation performed by the patient´s wife who is a non-healthcare professional. ECG at the arrival of the ambulance confirmed VF and one successful DC shock was delivered on-site. The patient was free of cardiovascular risk factors. An urgent coronary angiogram ruled out acute coronary syndrome (ACS) and coronary artery disease was detected, however, right coronary atresia was confirmed. Further cardiac investigations including echocardiography, CMRI, and CCTA were performed to confirm the diagnosis and to rule out other possible causes of VF.