The Left Turn from the Right Side: A Circumflex Artery Arising from the Right Sinus

Coronary artery anomalies remain uncommon yet clinically relevant findings, with anomalous origin of the left circumflex artery from the right sinus of Valsalva representing one of the more frequently encountered variants. We describe a 44-year-old woman with obesity, uncontrolled diabetes and hypertension who presented with progressive exertional dyspnea. Transthoracic echocardiography demonstrated elevated left-ventricular filling pressures and a high probability of pulmonary hypertension; right-heart catheterization confirmed moderate post-capillary pulmonary hypertension secondary to longstanding hypertension. Coronary angiography performed during the same session unexpectedly revealed a small-caliber right coronary artery and a separate circumflex artery arising from the right sinus. Subsequent coronary computed tomography angiography confirmed the anomalous origin, a posterior retro-aortic course and an inter-atrioventricular trajectory without evidence of compression or ischemia. Stress echocardiography was negative for inducible ischemia. Recognition of this anomaly is essential to avoid procedural complications during angiography, percutaneous intervention or cardiac surgery, even when the variant itself proves benign.