Anomalies of the coronary arteries, either congenital or acquired, can be characterized as abnormalities of the standard anatomy of two patent and separately arising right and left arterial blood vessels. The coronaries are the first branches of the ascending aorta, arise from their respective sinuses of Valsalva, and gradually branch distally to the myocardium. Anomalies can be characterized as a lack of origin, abnormal origin, anomalous course, lack of patency, abnormal connections, and/or abnormal drainage of the coronary vessels. Interruptions or lack of flow can cause significant morbidity and mortality due to ischemia, infarction, and fistulous connections, which can lead to cardiac failure. Operative intervention for congenital coronary artery anomalies is highly dependent on the specific lesion. The technique required to resolve the problem is generally grounded in coronary under-perfusion.