An asymptomatic obese 60-year-old man with an increased cardiovascular risk profile (arterial hypertension and hypercholesterolemia) was checked prior to hip surgery. Resting ECG was normal. Exercise test was not possible. A dipyridamole myocardial perfusion scintigraphy showed inferolateral ischemia and a preserved left ventricular (LV) function. Coronary angiography demonstrated moderate atherosclerosis in the proximal segment of the right coronary artery (RCA) and a moderate stenosis in the distal segment of the posterolateral branch (Fig. A). The left anterior descending artery (LAD) and diagonal branches were visualized simultaneously. No additional coronary ostium could be found. The contrast enhanced cardiac CT was performed and it confirmed the absence of a left coronary ostium and a single RCA with two large right ventricular (RV) branches continuing to the left coronary artery (LCA). The first RV branch continued to the diagonal branch. The second RV branch continued to the LAD. Interestingly, in the anterior interventricular sulcus, the LAD had a bidirectional course proximally and distally, with proximally the emergence of an hypoplastic left circumflex artery (LCX) (Fig. B, C). None of the branches were running between the pulmonary artery and the ascending aorta, corresponding with a R-II A classification according to Lipton/ Yamanaka.