In this case, a patient presents for pre-operative evaluation prior to a neuro-surgical spinal operation. He has a history of coronary heart disease and a known anomaly of the left coronary artery from the right coronary artery. Our patient underwent non-invasive PET perfusion imaging and coronary angiography. There was a discussion of the risk of coronary anomalies and potential strategies to mitigate that risk. Of interest, most patients with an anomalous left coronary artery have the left main arising from the right coronary cusp. In this patient, the LAD and circumflex arteries have separate ostia and separate courses – an unusual finding.