Anomalous origin of the right coronary artery from the pulmonary artery and simultaneous coronary-bronchial artery fistula

A 63-year-old male presented to cardiology clinic with complaints of dyspnea and chest pain during exercise since 2 months. The patient's medical history and family history were unremarkable. He was an ex-smoker and has a history of 10 pack-years of smoking. His cardiac examination was normal, except for tachycardia. His extremities were free of edema. Atrial fibrillation was detected in the patient's electrocardiogram, and laboratory results showed slightly elevated troponin level (0.91 ug/L; normal range, <0.1 ug/L). Complete blood count and other laboratory test results were within normal limits. Transthoracic echocardiogram revealed depressed left ventricular function with an estimated ejection fraction of 35%, global hypokinesia in the left ventricular walls, and mild pericardial effusion. The patient underwent coronary angiography with a preliminary diagnosis of non-ST segment elevation myocardial infarction. The left main coronary artery and its branches were found to be normal. However, the right coronary artery (RCA) ostium was unidentifiable, and there appeared to be collaterals with retrograde filling of the RCA (Fig. 1). The patient underwent coronary computed tomography angiography (CTA) for further investigation with suspicion of anomalous origin of the RCA. Coronary CTA demonstrated an anomalous RCA from the pulmonary artery (ARCAPA) (Fig. 2)