Introduction: The abnormal origin of the coronary ar-teries represents a rare condition and has an important clinical impact due to the interference with the normal function of the coronary arteries which consists in pro-viding adequate blood flow to the myocardium. We present one of the rarest coronary arteries anomalies (CAAs) described as an anormal origin of left circum-flex artery (LCX) and left anterior descending artery (LAD) from the right coronary sinus. The particularity of this case relies in the fact that the patient had no pre-vious medical history.

Methods: An 85 year-old female without previous me-dical history was admitted in our cardiology depart-ment for intense constrictive thoracic pain with recent onset and sweating. The objective exam revealed fine bilateral crackles, tachycardia (85 beats/minute) and no cardiac murmurs. There was no pulse deficiency or difference regarding the blood pressure on both arms (150/90 mmHg on the left hand and 145/90 mmHg on the right hand).

Results: T he electrocardiography illustrated ST seg-ment elevation in DII, DIII and avF. Right and posteri-or leads were also recorded but there were no ischemic changes. High sensitivity troponin was elevated (1900 ng/L) and the D-dimers were in normal ranges (3.47 ug/ml).The primary percutaneous coronary interventi-on was done next and the result was amazing. The pa-tient had coronary malformation with common origin of the three coronary arteries from separate ostium in the right Valsalva sinus. Also the examination revealed multivessel coronary disease with significant stenosis of right, left and circumflex and a 99% stenosis on the second segment of right coronary artery. According to the specific features of the coronary arteries and the guidelines, the case had indication of surgical myo-cardial revascularization so we transferred the case to a center specialized in cardiovascular surgery. CABG was performed and the outcome was favorable.

Conclusions: Coronary artery anomalies are usually associated with congenital heart disease so the isolated CAAs are found in exceptional conditions. The com-mon origin of left coronary artery and RCA from right coronary sinus is one of the rarest anomalies with an incidence of 0.15%. There are only a few cases descri-bed in the literature with this uncommon condition. The LAD arising from the right coronary sinus is a hi-gher risk lesion and should be repaired in all patients.