A 38-year-old active smoker presented with persistent and progressive angina pectoris showing exacerbation with exercise. Computed tomography angiography (CTA) revealed the presence of a rare form variant, in which the right coronary artery originates from the left cusp with a common ostium with the left anterior descending artery and with an intra-arterial, so called "malignant," course between the ascending aorta and truncus pulmonalis (Fig. 1). The patient was referred to the cardiovascular surgery department for the evaluation of a possible corrective surgery.

Figure 1 Volume rendered image of the heart demonstrating the presence of a rare form variant, in which the right coronary artery (white arrow) originates from the left cusp (yellow arrow) with a common ostium with the left anterior descending artery (green arrow) and with an intra-arterial, so called "malignant," course between the ascending aorta (red arrow) and truncus pulmonalis (blue arrow). 

The common origin of the coronary arteries by a single trunk from the left coronary sinus is extremely rare¹. In this specific incidence, it is associated with the malignant course of the right coronary artery lying between the ascending aorta and truncus pulmonalis, a condition known to increase the risk of sudden cardiac death. CTA is a reliable imaging modality for showing the course of the coronary arteries and their myocardial relationship². The need for surgery is controversial and is rather considered in case of an intra-articular malignant course.