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A 62 year old gentleman presented with a history of recurrent central chest pains radiating to the left arm and jaw lasting up to 15-20 minutes and relieved with GTN. He had numerous admissions to hospital over a period of three years with negative Troponins and normal ECGs. There were several cardiovascular risk factors including obesity, diabetes, hypertension and dyslipidaemia. He also had a family history of ischaemic heart disease, with his mother and brother having heart attacks in their 60s. He was referred for outpatient investigations on multiple occasions but did not attend. This lead to a delay in a formal diagnosis until we eventually convinced him to undergo invasive diagnostic coronary angiography in June 2018. Prior to this, an Echocardiogram was done and showed reasonably preserved cardiac systolic function. Coronary angiography demonstrated unique anatomical distribution of the three main coronary vessels, with an anomalous origin of the left main system (LMS) and left sided arteries arising from the right coronary cusp. The right coronary artery stemmed from its natural position and was the dominant vessel. Hence, all the coronary arteries arose from the same cusp. The LMS was anomalous and hypoplastic; an exceedingly rare occurrence of less than 0.03%. These unusual findings were then confirmed on CT Coronary Angiogram. Although a surgical opinion was sought, the decision was a non-operative approach in view of no significant obstructive lesions and given the technical difficulties of undertaking coronary bypass. Viability imaging and ischaemia testing were then pursued with nuclear modalities. Ultimately, it was proven that the lesions did not show any significant reversible ischaemia and so a continued aggressive secondary prevention strategy was adopted. The patient is stable and doing well on optimal medical therapy. Abstract P1496 Figure. LMS Arising From Right Coronary Cusp

P1496 Congenital anomalous origin of the left coronary system