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We present a rare case of a 67-year-old woman with exertional chest discomfort who was found on coronary computed tomography angiography (CCTA) to have two coexisting congenital cardiac anomalies; an anomalous right coronary artery (RCA) originating from the left coronary cusp (LCC) with an inter-arterial course between the aorta and pulmonary trunk, and an interventricular membranous septal aneurysm (IVMSA). Anomalous RCA with inter-arterial course is considered a malignant variant due to its association with myocardial ischemia and sudden cardiac death [1,2,6], while IVMSA, although often incidental, may be associated with conduction disturbances and thromboembolic complications [4,5,8]. The patient was discussed in a multidisciplinary team and surgical correction was offered, but she opted for conservative management and declined surgical intervention. Recognition of such dual congenital anomalies is crucial, as both may carry significant prognostic and management implications. This case underscores the essential role of CCTA in accurately delineating complex coronary and structural anomalies, guiding individualized treatment decisions, and optimizing patient counseling and follow-up [7].

Keywords: Anomalous right coronary artery; Left coronary cusp; Inter-arterial course; Interventricular membranous septal aneurysm; Coronary CT angiography