Assessment of AAOCA is enhanced when the precise anatomy and physiological impact of the coronary artery anomaly are understood. As described in Table 34, the specific anomalous or- igin, anatomy of the orifice and proximal vessel and presence of ischemia may all influence the clinical course and thus the management options. Understanding these issues as precisely as pos- sible will better inform clinical decisions. Figure 5. Anomalous aortic origin of the coronary artery. *Surgical intervention to involve unroofing or coronary revascularization for patients with concomitant fixed obstruction. CLINICAL STATEMENTS AND GUIDELINES 4.4.7.2. Anomalous Aortic Origin of Coronary Artery Recommendations for Anomalous Aortic Origin of Coronary Artery Referenced studies that support recommendations are summarized in Online Data Supplement 51. COR LOE Recommendations Therapeutic I B-NR Surgery is recommended for AAOCA from the left sinus or AAOCA from the right sinus for symptoms or diagnostic evidence consistent with coronary ischemia attributable to the anomalous coronary IIa C-LD Surgery is reasonable for anomalous aortic origin of the left coronary artery from the right sinus in the absence of symptoms or IIa C-EO Surgery for AAOCA is reasonable in the setting of ventricular arrhythmias. IIb B-NR Surgery or continued observation may be reasonable for asymptomatic patients with an anomalous left coronary artery arising from the right sinus or right coronary artery arising from the left sinus without ischemia or anatomic or physiological evaluation suggesting potential for compromise of coronary perfusion (eg, intramural course, fish-mouth-shaped orifice, acute Recommendation-Specific Supportive Text 1. In patients with symptoms related to AAOCA, re- pair of the anomaly should alleviate symptoms. In autopsy and surgical series, cardiac symptoms are more common in patients with a left coronary ar- tery arising from the right coronary cusp. 