In autopsy and surgical series, cardiac symptoms are more common in patients with a left coronary ar- tery arising from the right coronary cusp. In au- topsy studies of patients who died because of an anomalous coronary artery, fibrosis is a common finding, suggesting that ischemia preceded the ter- minal event. However, there are patients in whom a SCD event occurred despite normal stress ECG, and consequently absence of ischemia is not reas- suring. Autopsy series show that many patients whose death is attributed to anomalous coronary arteries are young, thus management of patients should take age into account, with heightened concern about the risk of sudden death in younger 2. Anomalous left coronary from the right sinus is less common than anomalous right coronary from the but anomalous left coronary artery from the right is more commonly found in autopsy series of athletes and military recruits who had non- traumatic death than right coronary from the left The overrepresentation of the anomalous left coronary from the right sinus suggests a higher risk of SCD, particular at extremes of exertion and in patients <35 years of age. There are some anatomic features that are thought to be associated with increased risk of com- promise of coronary flow and/or SCD, including a fish-mouth-shaped or slit-like orifice, or intramural although the slit-like orifice is more commonly encountered in a right coronary arising from the left cusp. It is difficult to quantitate the ab- solute risk of SCD associated with anomalous aortic origin of the left coronary from the right sinus, and data demonstrating that surgery ameliorates the SCD risk have not been published. 