a 44-year - old man , who had a medical history of panic disorder , visited another hospital due to dyspnea on mild exertion .
a coronary angiography showed a single coronary artery originating from the right coronary ostium . a single coronary artery bifurcated into the right coronary artery and left main coronary artery .
the left main coronary artery coursed between the main pulmonary artery and aorta before bifurcating into the left descending artery and circumflex artery .
we thought that panic symptoms or dyspnea on exertion might be a sign of myocardial ischemia due to compression of the left main coronary artery by the pulmonary artery and aorta .
we decided that surgical treatment was the best option due to the high risk of sudden death associated with a coronary anomaly . under general anesthesia
we dissected the left main coronary artery between the aorta and the main pulmonary artery on the beating heart .
the proximal left main coronary artery was bifurcated from a single coronary artery that originated from the right coronary sinus . under cardiopulmonary bypass ,
only one coronary ostium was observed in the right coronary sinus , and a single coronary artery originated from the ostium .
a 5-mm arteriotomy was made to the left main coronary artery at the site in which the left coronary ostium should have been located .
neo - ostium formation was performed with a 5-mm puncher in the left coronary sinus .
anastomosis between the neo - ostium and the left main coronary arteriotomy site was performed using a 7 - 0 prolene continuous running suture ( fig .
the aortic cross clamping time was 88 minutes , and total cardiopulmonary bypass time was 117 minutes .
follow - up computed tomographic angiography before discharge showed good patency of the neo - ostium in the left coronary sinus without stenosis at the anastomosis site ( fig .
the patient remained asymptomatic without any complications or events for 15 months after the surgery .
angelini reviewed 1,950 coronary angiographies and reported that the incidence of right coronary artery originating from the left coronary sinus was 0.92% and vice versa was 0.15% , with a total incidence of 1.07% .
patients are usually asymptomatic . however , it may cause angina , syncope , and even life - threatening complications such as myocardial infarction or ventricular fibrillation .
thus , we must consider surgical treatment or intervention if signs of myocardial ischemia are present .
several surgical techniques can be utilized to treat coronary anomalies , such as coronary reimplantation to the original sinus , coronary artery bypass graft ( cabg ) , pulmonary artery translocation , unroofing , and neo - ostium formation . in this case , the left main coronary artery was bifurcated from a single coronary artery originating in the right coronary sinus .
furthermore , the left main coronary artery passed between the pulmonary artery and aorta to reach the left heart .
cabg , coronary reimplantation , unroofing or neo - ostium formation could therefore have been considered as viable surgical options .
coronary reimplantation is one of the most physiologically beneficial repairs , but is technically difficult , and stenosis may occur at the site of anastomosis .
cabg is technically feasible , but the arterial conduit has a competitive flow problem if no stenotic lesions are present on the natural coronary artery .
also , a vein conduit may be problematic if the patient is young because of long - term patency .
however , extended unroofing may cause valve insufficiency if the anomalous coronary artery is located under the valve commissure .
unroofing was not proper for our case because a separated left main coronary artery originated from a single coronary artery , not the right coronary sinus .
neo - ostium formation in the left coronary sinus without unroofing was considered to be a proper surgical treatment in this case .
successful surgical treatment of anomalous of coronary anomaly depends on expertise in anatomic and hemodynamic pathophysiology , in addition to the selection of the appropriate surgical treatment option .
we report that this case was successfully treated with neo - ostium formation in anomalous origin of the left coronary artery from the right coronary system .
 anomalous origin of a coronary aortic artery is a rare cardiac anomaly . although it can cause angina , syncope , and palpitations , most patients are asymptomatic . 
 this anomaly requires surgical treatment or intervention because it is associated with sudden death . 
 several surgical techniques , such as coronary reimplantation , coronary artery bypass grafting ( cabg ) , unroofing , and neo - ostium formation , have been proposed as treatments . 
 we report a case surgically treated with neo - ostium formation in anomalous origin of the left coronary artery from the right coronary sinus . 
CASE REPORT
DISCUSSION