A 57-year-old male patient who weighed 114 kg, with a height of 5’6” (170 cm) and body surface area (BSA) of 2.19 m2 presented with chest pain, shortness of breath, and was categorized to be under New York Heart Association (NYHA) class Ⅲ. The patient was referred to our institution for the evaluation of AS. On admission, the blood pressure of the patient was 152/85 mmHg and the heart rate was 71 bpm with a regular rhythm. Transthoracic echocardiography revealed a stenotic bicuspid aortic valve with a calculated valve area of 1.09 m2 and a mean gradient of 50 mmHg. The left ventricular ejection fraction was 54% without local asynergy. Coronary angiography exhibited a right coronary artery arising from the left coronary sinus with no significant stenosis. Cardiac computed tomography (CCT) revealed that the aortic valve annulus, sinus of Valsalva, and sinotubular junction (STJ) were 24, 31, and 29 mm, respectively. The anomalous aortic origin of the right coronary artery (AAORCA) originated from the left coronary sinus at a takeoff angle of 19°, which is a known risk factor for myocardial ischaemia (Fig. 1). Although the patient experienced chest pain during the adenosine triphosphate injection, single-photon emission computed tomography (SPECT) revealed no ischaemic lesions (Fig. 2). As the possibility of ischaemic complications was low, we performed AVR without revascularization. The patient underwent a median sternotomy. The bicuspid aortic valve was classified as Sievers type 1a characterized by a fusion of the right and left coronary cusps with an asymmetric commissural orientation and the right coronary artery originating from the left coronary ostium. Subsequently, the annular stitches were placed in a non-everting mattress fashion with pledgets after the excision of the leaflets and annular debridement of the calcium. Based on patient preferences, we used a biological prosthesis. A 23-mm prosthetic sizer passed through the annulus, however, mild resistance was noted. Therefore, we enlarged the aortic annulus using a Y-incision for AVR as a less than 23-mm prosthetic valve was not sufficient for the BSA, and an oversized prosthetic valve could potentially compress the right coronary artery. After root enlargement using a rectangular Hemashield Dacron patch (Boston Scientific Corp, Natick, Mass, USA), we placed a 25-mm Inspiris Resillia biologic prosthesis (Edwards Lifesciences, Irvine, California, USA) (Fig. 3). The postoperative aortic valve gradient was 6 mmHg and the take-off angle of the right coronary artery increased from 19° to 28° without dynamic compression of the interarterial segment (Fig. 4). The patient was discharged without complications. During the 6-month follow-up, the weight of the patient decreased from 114 to 95 kg with a BSA of 2.06 and NYHA class I.