Case Presentation. A 50-year-old Caucasian male with a history significant for hypertension was admitted to the hospital with exertional chest pain. Laboratory findings showed the first set of troponin was 2.15 and the second set of troponin was 8.84 without ST-segment elevation. He underwent cardiac catheterization which showed an anomalous coronary origin of the left anterior descending artery and left circumflex artery from the right coronary cusp (Figure 1). In addition, all 3 coronary arteries arose from right coronary cusp (Figure 2). Acute myocardial infarction was most likely secondary to occlusion of the posterior lateral branch, which was successfully treated with a bare-metal stent (Figure 3). The left main artery is absent. All 4 vessels (right coronary, left anterior descending, left circumflex and atrioventricular nodal branch arteries) take off from the right coronary cusp, making a quadrifurcation on computerized tomographic angiography (Figure 4). The patient is at high risk for sudden cardiac death, as the left anterior descending artery crosses between the great vessels. He was subsequently evaluated by cardiothoracic surgery for bypass.

Discussion. Coronary artery anomalies are uncommon findings, but of significant clinical importance in some individuals, as they are associated with increased risk for and potentially lethal cardiac events.² Recognition of these anomalies is fundamental in patients undergoing diagnostic or interventional coronary angiography.³ Most patients presenting with coronary anomalies are asymptomatic, but the risk of myocardial ischemia and sudden death requires treatment of those patients. In our patient, the absence of the left main artery and quadrifurcation requiring intervention was challenging. To our knowledge, the findings in our case have not been previously reported as a single entity.