In adulthood, congenital coronary artery anomalies represent more often as an incidental finding rather than the cause of clinical complaints. However, in some cases, congenital coronary anomalies may cause atypical chest pains, anginal pain, arrhythmias, sudden death or heart failure, even in adulthood. But the majority of patients don’t have a characteristic presentation and remain asymptomatic for a large portion of their lives. Normal coronary artery origins can be visualized in adults by transesophageal echocardiography (Figures 18.1 and 18.2). Coronary artery anomaly is defined as origin of a coronary artery from an ectopic position in the aorta.