The prevalence of isolated right coronary artery (RCA) absence ranges from 0.014% to 0.066% in the general population, but its combination with an absent left main (dual ostium left anterior descending [LAD] and super-dominant left circumflex [LCx]) has not been previously described. We report the case of a rare coronary artery anomaly: an absent RCA with LAD and LCx coronary arteries arising separately from the left coronary sinus. A 53-year-old male with recent COVID-19 infection was referred to our service for coronary computed tomography angiography (CCTA) due to the recent onset of atypical chest pain. The RCA was absent, with no vessel leaving the right or non-coronary sinus. The LAD and LCx emerged from the left coronary sinus, with a “double-barrel” appearance. The LAD was unremarkable, with small, non-stenosed calcified plaque. The LCx had a 3 mm diameter, arching downward in the left atrioventricular groove, passing through the crux cordis, continuing into the right atrioventricular groove, and ending as a left acute artery and sinonodal artery. No significant stenosis was found on any of the vessels, ruling out atherosclerotic coronary disease.
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