Percutaneous treatment of an anomalous left main arising from the opposite sinus with subpulmonic course.

Anomalous origin of a coronary artery from the opposite sinus of Valsalva (ACAOS) is a rare malformation traditionally considered "malignant" in cases of interarterial course. Recently, a protective effect of the low interarterial subtype (between the aorta and the right ventricle outflow tract) has been described. We present an IVUS-guided percutaneous intervention in a patient with anomalous origin of the left coronary artery from the right coronary sinus presenting with anterior ischemia. In patients with ACAOS, the integration of complementary image techniques is recommended, defining the anomalous course of the vessel and providing an accurate assessment of the individual risk for each patient. The use of IVUS may be advisable, emerging as a really useful tool to complete the study and guide the treatment.