Tehran University of Medical Sciences The Research in Heart Yield and Translational Medicine (RHYTHM) 3115-7270 17 2 2022 04 30 71 74 Muhammad Mansoor National Institute of Cardiovascular Disorders, Karachi, Pakistan. Waqar Khan National Institute of Cardiovascular Disorders, Karachi, Pakistan. Fakhar Abbas Mayo Hospital, King Edward Medical University, Lahore, Pakistan. Usha Kumari Dow University of Health Sciences, Karachi, Pakistan. 2022 01 23 2022 04 16 Congenital anomalous coronary arteries (CACAs) comprise an important variant of the coronary vasculature. They are benign in the vast majority of cases, whereas a small minority may be affected by serious consequences such as myocardial infarction, arrhythmia, cardiac arrest, and even death. We herein describe a 62-year-old man with sudden and severe substernal chest pain; Q waves in electrocardiographic leads II, III, and aVF; and positive serum troponin I enzyme. Left heart cardiac catheterization revealed triple coronary vessel disease with a 60% to 70% occlusion in the left main coronary artery (LMCA). The left anterior descending (LAD) and the left circumflex artery arose from the ostium of the right coronary artery. Additionally, a rudimentary type IV dual LAD originated from the LMCA. A coronary artery bypass graft surgery was performed using a left internal mammary artery graft for the LAD and a saphenous vein graft for the diagonal branches (I & II) of the LAD and the posterior descending artery. The patient was discharged after an uneventful 1-week hospital course. https://jthc.tums.ac.ir/index.php/jthc/article/view/1598 https://jthc.tums.ac.ir/index.php/jthc/article/download/1598/1008