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A 63 year old woman presented with atypical chest pain. A 12 lead ECG showed complete left bundle brunch block; the echocardiogram was not diagnostic. At coronary angiography the left coronary ostium was not observed. Aortography showed the left anterior descending (LAD) artery and the circumflex (CX) artery each originating from a separate ostium in the right aortic sinus. The right coronary artery (RCA) had a normal independent origin. The three vessels were then selectively engaged (the LAD with an internal mammary catheter, the CX with a multipurpose catheter, the RCA with a right Judkins catheter), resulting in the patient being free from atherosclerotic disease. Subsequent stress myocardial perfusion imaging was negative for inducible ischaemia. The patient had an uneventful two year follow up.
The independent origin of both the LAD and CX from two separate ostia in the right aortic sinus is an exceedingly rare anomaly. The hazard of this coronary anomaly depends on the LAD course. An LAD course between the aorta and the pulmonary artery is potentially responsible for myocardial ischaemia and sudden death, while an LAD course anterior to the right ventricle (like the present case), or behind the aorta, is at low risk of adverse events. In this regard, the scintigraphic findings obtained in our patient confirmed the benign prognosis associated with an anterior free wall course of the LAD.