The most life- threatening variants involve anomalous origin of the left main coronary artery from the right sinus of Valsalva or of the right coronary artery from the left sinus of Valsalva, after which the anomalous artery travels to its normal area of perfusion between the ascending aorta and the main pulmonary artery. In a review of consecutive echocardiograms in 2388 asymp- tomatic children and young adolescents, the incidence of anomalous coronary arteries arising from the opposite sinus of Valsalva was 0.17%.1183 Anomalous coronary arteries (particularly those traversing between the aorta and the main pulmonary artery) are associated with exercise-related sudden death in young ( 35 years of age) athletes.1184 1190 A consecutive series of 27 young athletes with sudden death who were found to have such anomalous coronary arteries at autopsy had inducible myocardial ischemia and complained of cardiac symptoms before their demise.1179 Isolated case reports of other coronary arterial anomalies in subjects with syncope or sudden death emphasize the need for careful anatomic and functional evaluation of all individuals with anomalous coronary arteries.1191 1194 The method of revascu- larization employed in adults with anomalous coronary arter- ies has been 1) CABG or, more recently, 2) PCI with stenting.1195 When CABG is employed, consideration should be given to the presence of competitive flow in the native coronary circulation.1196 In children and some adults, an unroofing procedure or coronary arterial reimplantation may provide the best long term results.1197,1198 The risk associated with these coronary anomalies if they are left untreated and the existing operative experience make corrective surgery reasonable in these individuals.1180 6.5. Patients With Chronic Obstructive Pulmonary Disease/Respiratory Insufficiency: Recommendations Class IIa 1. 