Anomalous aortic origin of coronary arteries from the opposite sinus (AAOCA) is a rare finding which, when discovered, raises questions regarding its approach and management. Modern imaging techniques can help us to identify certain anatomical features of the anomalous coronary arteries to further classify them as benign or malignant anomalies. We present a case of a 64-year-old male who had an incidental finding of AAOCA with the left anterior descending artery arising from the right coronary cusp from an ostium anterior to the one that gave rise to both the left circumflex artery and right coronary artery (RCA). The patient was managed with a percutaneous coronary intervention for an obstructive disease of the RCA and was discharged with regular follow-ups.

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Introduction: Anomalous origin of coronary arteries has a prevalence of 1% in the population and is independently associated with a risk of sudden cardiac death. While an anomalous coronary artery arising from the opposite sinus is rare, all three coronary arteries arising from separate ostia in a single cusp is an extremely rare phenomenon. Case: A 48-year-old male with history of hypertension presented with fevers, cough and shortness of breath of 3 days duration. CXR demonstrated multi-lobar pneumonia and serology returned positive for Influenza A. Treatment was initiated with oseltamivir, vancomycin and piperacillin-tazobactam. Subcutaneous heparin was initiated for VTE prophylaxis. On day 3, the patient developed acute hypoxic respiratory failure from flash pulmonary edema necessitating intubation and mechanical ventilation. ECG revealed ST segment elevation in leads II, III, aVF, V5 and V6 (Fig. 1A). He was taken for urgent cardiac catheterization. Coronary angiography revealed anomalous origins of the left circumflex (LCX) and left anterior descending (LAD) arteries arising from the right coronary cusp (RCC) (Fig. 1B & 1C). 99% thrombotic occlusion of the distal right coronary artery was identified as the culprit lesion (Fig 1D). Percutaneous coronary intervention with a 4 x 30 mm drug-eluting stent was performed. Discussion: Absence of the left coronary artery originating from the left coronary sinus should raise suspicion for a coronary anomaly. While an anomalous LCX artery originating from the RCC is seen in 0.7% individuals, the LAD artery arises from the RCC is seen in 0.15% of people. All three coronary arteries arising from the RCC is extremely rare. An abnormal take-off angle, compression between the aorta and the pulmonary trunk, slit-like ostia, coronary hypoplasia and accelerated atherosclerosis are responsible for the increased risk of coronary events in this population.