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Nocturnal angina occurred in a 43-year-old man. Biplane left-ventricular angiography demonstrated normal left ventricular function (ejection fraction of 75%) with mild apical hypokinesia. The right coronary artery had a normal origin, was dominant and its lumen smooth. The left coronary artery also originated from the right coronary cusp, the left main stem coursing between the pulmonary artery and aorta within the aortic wall. It had a long, 40% stenosis. During atrial stimulation (130 beats/min) angiography demonstrated a 60% increase in luminal narrowing. Because of the symptoms caused by the stenosis in the anomalous coronary artery a mammary artery implant into the anterior interventricular branch and a vein graft to the circumflex artery were performed. The patient has since been free of symptoms. In relatively young persons the presence of coronary artery anomalies should be considered in the differential diagnosis even of atypical chest pain; indications for cardiac catheterization with angiography should be broad.

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