Yonsei Med J 50(1):164 - 168, 2009 DOI 10.3349/ymj.2009.50.1.164 A Case of Acute Myocardial Infarction with the Anomalous Origin of the Right Coronary Artery from the Ascending Aorta above the Left Sinus of Valsalva and Left Coronary Artery from the Posterior Sinus of Valsalva Jung-Jin Lee,1 Dae-Hyeok Kim,1 Sung-Su Byun,2 Woong-Gil Choi,1 Chan-Woo Lee,1 Seung-Min Yi,1 Jun Kwan,1 Keum-Soo Park,1 and Woo-Hyung Lee1 Departments of 1Cardiology and 2Radiology, Inha University College of Medicine, Incheon, Korea. Coronary anomalies are rare angiographic findings. Moreover, there are few reports of cases of an anomalous origin of the right coronary artery from the left sinus of Valsalva and of the left coronary artery from the posterior sinus of Valsalva. Here, we report a case with an anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva and the left coronary artery from the posterior sinus of Valsalva. This was observed in a patient who was treated for a myocardial infarction of the inferior wall caused by a thrombus in the proximal right coronary artery. The patient was treated successfully with the implantation of a stent in the anomalous origin of the right coronary artery using a 6Fr Amplatz left 1 catheter. Key Words: Anomalous origin of coronary artery, myocardial infarction INTRODUCTION The reported incidence of coronary anomalies is approximately 1%. However, the incidence was found to be 5.6% in a recent prospective angio- graphic study of 1,950 consecutive cases.1 Among these cases, an anomalous right coronary artery (RCA) from the left sinus was found in approxi- mately 0.03 - 0.9% of patients undergoing coronary angiography.2 An anomalous origin of the RCA from the ascending aorta above the left sinus is Received May 8, 2007 Accepted August 9, 2007 Reprint address: requests to Dr. Dae-Hyeok Kim, Department of Cardiology, Inha University College of Medicine, 7-206 3-ga, Sinheung-dong, Jung-gu, Incheon 400-711, Korea. Tel: 82-32-890- 2440, Fax: 82-32-890-2447, E-mail: kdhmd@korea.com Yonsei Med J Vol. 50, No. 1, 2009 associated with angina pectoris, acute myocardial infarction or sudden cardiac arrest when it courses between the aorta and the pulmonary trunk. A case of an anomalous origin of the left coronary artery (LCA) from the posterior sinus is extremely rare. We present a case of a RCA, in which an anom- alous right coronary artery arises from the as- cending aorta above the left sinus of Valsalva and courses between the aorta and pulmonary trunk. Additionally, this individual had an acute myocardial infarction of the inferior wall and an anomalous origin of the LCA from the posterior sinus of Valsalva. CASE REPORT A 54-year-old man arrived at the emergency room in an inebriated state complaining of left shoulder pain accompanied by headache. His risk factors included smoking one-half of a pack of cigarettes per day over a 20-year period and a 10- year history of hypertension. Physical examination revealed a blood pressure of 70/40 mmHg and a pulse rate of 40 beats per minute. His limbs were cold and clammy. There were no abnormal cardiac or respiratory sounds. Electrocardiography revealed Q waves and 2-mm to 3-mm elevations of the ST segment in II, III and aVF and 3:1 AV block (Fig. 1), indicating an acute myocardial infarction involving the inferior wall. An echocardiogram revealed akinesia of the inferior wall and a mildly