All three coronary arteries and a separate conus branch arising from the right sinus of Valsalva in an octogenarian with an acute myocardial infarction: a case report.

Background: Coronary artery anomalies are encountered in less than 1% of the population and are usually found incidentally. Some vessel courses are linked to myocardial ischaemia and sudden cardiac death while successful PCI in ACS scenarios poses a clinical challenge. Case summary: An 83-year-old woman with hypertension and dyslipidaemia presented with an ACS. The ECG showed atrial fibrillation while echocardiography revealed ischaemic cardiomyopathy with mildly reduced ejection fraction. Diagnostic coronary angiography showed a four separate ostia arising from the right sinus of Valsalva: RCA, LAD, LCX, and an independent conus branch. Transient occlusion of the conal branch by the diagnostic catheter triggered VF promptly terminated with DC cardioversion. On Day 4, PCI Discussion: This constellation, a separate ostia of four coronary arteries arising from the right coronary sinus, is exceedingly rare. The case underscores several practical points. Anomalous coronaries are susceptible to atherosclerosis and should be revascularized according to clinical context and not anomaly