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A 15-year-old boy with anomalous origin of the left coronary artery arising from the right coronary sinus with an interarterial course between aorta and pulmonary artery (Panels A and B, green arrowheads) was admitted for cardiac arrest during physical activity. He underwent cardiopulmonary resuscitation, and because of no immediate return of spontaneous circulation was put on ExtraCorporeal Membrane Oxygenation (ECMO) in an early stage. Transoesophageal echocardiography (TOE, Panel E) and computed tomography (CT, Panels A–C) were performed, and the patient underwent surgical intervention of left main transposition to the left coronary sinus, being then discharged after 57 days in intensive care unit (ICU) with a good recovery.

Since he had experienced exercise-induced syncope, he had been evaluated 2 years before with a transthoracic echocardiography (TTE, Panel D), which had shown an apparent ‘normal’ origin of the left coronary artery (Panel D, arrow); an analogue image was seen in the intra-hospital TOE in an off-axis 0-degree aortic valve view (Panel E, arrow). The comparison with multislice CT showed that what was seen during echocardiography was actually the bifurcation of the left main running distally from its interarterial course (Panel C, arrow) leading to a pitfall in the correct diagnosis of anomalous coronary artery. At the CT evaluation, left main takes off with a 35° acute angle, has a 12 mm interarterial course and an oval stenosis with 40% proximal narrowing (Panels A–C).

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