Case Report Journal of Integrative Cardiology J Integr Cardiol, 2016, doi: 10.15761/JIC.1000158 Volume 2(2): 275-278 ISSN: 2058-3702 Rare unexpected anatomy of the coronary artery: combination of two coronary anomalies case report Ayman Shaalan 1,3 *, Eman E. El Wakeel 2,4 , Mohamed A Alassal 3,5 and Hany H. Ebaid 6 1 Dallah Hospital, cardiac center, Riyadh, Saudi Arabia 2 Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia 3 Cardiothoracic Surgery Department, Benha University, Egypt 4 Anatomy and Embryology Department, Benha University, Egypt 5 King Salman Heart Center, King Fahd Medical City, Riyadh, Saudi Arabia 6 Cardiology Department, Benha University, Egypt Introduction Te coronary arteries and their branches perfuse the heart, which originate from the sinuses of Valsalva. Generally, the right coronary artery originates from the right anterior sinus of Valsalva, passing through the coronary groove, and emerging between the pulmonary artery trunk and right atrium. In turn, the lef coronary artery originates in the lef anterior sinus of Valsalva, behind the pulmonary artery, passing through the coronary groove, and emerging between the pulmonary trunk and lef atrium [1]. Coronary artery anomalies result from disturbances which may occur to the fetus in the third week of development [2]. Tese disturbances may lead to anatomical variations which may afect the origin, trajectory, and termination of these arteries, or alterations in their intrinsic anatomy [3]. Anomalous origin of either the lef main coronary artery (LMCA) or right coronary artery (RCA) from the aorta and their course between the aorta and pulmonary trunk is rare with prevalence about 5% and mostly considered as a fatal coronary artery anomaly [4]. Tere are fve coronary trajectories originating in contralateral aortic sinuses that can be classifed as: intraseptal (supracristal), retrocardiac, pre-aortic (between the aorta and the pulmonary artery), retroaortic, and pre-pulmonary (pre-cardiac) [3]. Coronary anomalies are classifed into four groups: 1) anomalies of coronary origin and trajectory (absence of lef main coronary artery, anomalous location of coronary ostium inside or outside the appropriate sinus of Valsalva, anomalous location of the coronary ostium in inappropriate sinus of Valsalva, and single coronary artery); 2) intrinsic abnormalities of coronary anatomy (atresia or stenosis of the coronary ostia, coronary aneurysm, coronary hypoplasia, and myocardial bridge); 3) anomalies of terminal coronary circulation (fstulas to cardiac chambers, inferior vena cava, or pulmonary arteries and veins); and 4) anomalous anastomotic vessels (Figures 1 and 2) [3]. Coronary artery diseases either atherosclerotic vessels or congenitally malformed vessels have serious sequlae if not diagnosed and managed properly .Congenital coronary abnormalities are the second leading cause of SCD (Sudden cardiac death) in the young [5]. Te degree of symptoms is variable according to the nature of anomaly. Tose with the highest risk include individuals with an anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) with this risk higher in athletes than non-athletic persons [6]. Tere is little documentation of history and long-term follow-up of patients with coronary artery anomalies. Some anomalies are only anatomic variants without clinical manifestations discovered accidentally or post mortem. Others can Correspondence to: Dr. Ayman Shaalan MD, Dallah Hospital, cardiac center, Riyadh, Saudi Arabia, Tel: +966-5-09460403, E-mail: shalaanayman@yahoo.com Key words: unexpected anatomy, coronary artery, anomalies, case report Received: February 22, 2016; Accepted: March 26, 2016; Published: March 31, 2016 Abstract Background: Anomalous origin of either the left main coronary artery (LMCA) or right coronary artery (RCA) from the aorta and their course between the aorta and pulmonary trunk is rare with prevalence about 5% and mostly considered as a fatal coronary artery anomaly. Case Summary: We reported two cases which represented one type of abnormal developmental disorder afecting coronary anatomy, with combined two rare malformations afecting coronary circulation in adult age. Also clarifed how new technology through cardiac MRI and CT coronary angiography gave us excellent gross anatomical details to complete the diagnosis and management. Conclusion: Our documented rare cases showed a combination of two coronary anomalies, frstly abnormal origin of LAD and LCX from right coronary sinus and simultaneously the abnormal malignant course of LAD between ascending aorta and pulmonary trunk. Anomalous origins of the left coronary artery is a rare case that carry a higher risk of sudden cardiac death,so need meticulous care and mangment.