To describe a series of acute coronary syndrome (ACS) patients in whom anomalous origin of culprit coronary artery (AOCCA) was diagnosed. Percutaneous coronary interventions (PCI) in AOCCA are performed very infrequently. Methods: Electronic databases from three high-volume tertiary cardiac centers were retrospectively searched for the presence of AOCCA in ACS. Results: Different types of AOCCA in ACS were identified in 20 patients. The most frequent AOCCA was left circumflex coronary artery

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... x) originating from right coronary artery (RCA) or directly from the right coronary sinus (RCS), n = 13, followed by high/atypical RCA, n = 3, LCA originating from RCS (n = 3) with either RCA-AOCCA (n = 1) or left anterior descending coronary artery (LAD)-AOCCA (n = 1) or RCA originating from left sinus of Valsalva, (n = 1), LAD originating from RCA (n = 1). In 1 ST-elevation myocardial infarction (STEMI)-patient RCA-AOCCA cannulation was unsuccessful, in 1 non-STEMIpatient AOCCA was missed, 1 ACS-patient was treated surgically and 1 ACS-patient was treated conservatively (both patients with non-STEMI). In the remaining patients PCI was successfully performed. Conclusions: The most frequently encountered AOCCA is LCx branching-off from RCA. AOCCA may either be difficult to cannulate and PCI aborted even in STEMI, or missed, especially when the intermediate branch from LCA is mimicking proper LCx.