Coronary Artery Anomaly and Myocardial Infarction 165 Fig. 1. Electrocardiography shows Q waves and 2-to 3-mm elevations of the ST segment in II, III and aVF and 3 : 1 AV block. A B Fig. 2. Multidetector computed tomography (MDCT) showed a high take-off of the LCA and RCA. (A) The LCA originated from above the posterior sinus of Valsalva (arrow). (B) The RCA originated from above the left sinus of Valsalva (arrow) and it coursed between the ascending aorta and the pulmonary trunk. Ao, ascending aorta; P, pulmonary artery; LCA, left coronary artery; RCA, right coronary artery. depressed left ventricular ejection fraction of 47%. His cardiac enzyme levels, such as creatine kinase- MB and cardiac troponin-I, were elevated to 60.1 ng/mL and 27 ng/mL, respectively. Blood urea nitrogen and serum creatinine also were elevated to 34 mg/dL and 2.6 mg/dL, respectively. He was implanted with a transvenous temporary pacemaker and an emergency direct coronary an- giography was performed. However, in the first trial the LCA could not be selectively cannulated with Judkins left (JL) or Amplantz left (AL) catheter and the RCA could not be selectively cannulated with Judkins right (JR) catheter, Amplantz right (AR) catheter, or the AL catheter. Nonselective coronary angiography was performed by ascending aortography, and this revealed TIMI III distal flow of the RCA. Also, the LCA and RCA were sus- pected to originate from the left sinus of the Valsalva. During angiography, the patient's chest pain subsided spontaneously, his vital signs were stabilized, and he recovered from the 3 : 1 AV block and returned to sinus rhythm. Due to transient acute renal failure, the initial serum creatinine level was too high to use a radiocontrast for taking multi-detector computerized tomography (MDCT). Therefore we waited and serially monitored the Yonsei Med J Vol. 50, No. 1, 2009