The Egyptian Cardiothoracic Surgeon Corresponding author: Abdullah Alshehri Al-shehri99@live.com Original Article Right internal mammary artery for the management of anomalous right coronary artery from the left sinus of Valsalva; a case report Abdullah Alshehri, Khaled Alotaibi, Mortadha Alawami, Claudio Pragliola Prince Sultan Cardiac Center, Saudi Arabia Introduction Anomalous right coronary artery [ARCA] from the left sinus of Valsalva is a rare congenital anomaly. The prevalence of coronary artery anomalies among adult patients who undergo coronary angiography was estimated to be 0.9% [1]. The prevalence of ARCA from the left sinus ranged from 0.02 to 0.2% [1] and it accounts for 8% of all coronary anomalies [1]. Many coronary artery anomalies are asymptomatic and discovered accidentally during coronary angiography. However, ARCA from the left sinus with an inter-arterial course is a relatively dangerous lesion. Patients with this anomaly could present with myocardial ischemia or sudden cardiac death [1]. The optimal surgical treatment of symptomatic patients with ARCA from the left sinus is controversial. Therefore, we present a case of ARCA from the left sinus of Valsalva who was managed with coronary artery bypass grafting [CABG] using the right internal mammary artery concomitant with ligation of the proximal right coronary artery. Case description We present a case of a 56-year-old male patient who presented to our center with typical chest pain radiating to the left arm and related to physical activity. The pain started four years ago with increasing frequency, and the patient was completely asymptomatic before this. The patient underwent a stress ECG with negative results. The patient had no other symptoms, and the clinical examination was unremarkable. Echocardiography revealed normal cardiac functions and valves with no regional wall motion abnormalities. CT coronary angiography showed the anomalous origin of RCA from the left aortic sinus with an inter-arterial course between the aorta and right ventricular outflow tract. The anomalous artery had a separate slit-like orifice that originated with an acute angle. [Figure 1] Coronary angiography showed no other associated coronary lesions. Myocardial perfusion studies revealed reversible perfusion defects in the inferior wall. Vol. 4, No. 6, 97 - 99 Abstract Background: Anomalous origin of the right coronary artery from the left sinus of Valsalva (ARCA) is a rare anomaly. Surgery is recommended in symptomatic patients, while the optimal surgical approach is controversial. Case presentation: We present a case of an ARCA in a 56-year-old male who was managed with coronary artery bypass grafting using the right internal mammary artery and ligation of the proximal right coronary artery. The patient remained asymptomatic after 1 year of follow-up. Conclusions: ARCA can be managed using the right internal mammary artery with ligation of the proximal right coronary artery to prevent the competitive flow. KEYWORDS Anomalous right coronary artery; Right internal mammary artery; Coronary artery anomaly Article History Submitted: 17 Aug 2022 Revised: 27 Aug 2022 Accepted: 2 Sep 2022 Published: 1 Nov 2022