ECG stress test showed changes compatible with angina. He is a smoker for 20 years but is free from chronic medical diseases. Coronary CTA was requested by the cardiologist and revealed a congenital malignant course of the left main coronary artery running between the ascending aortic root and the right ventricular outflow tract.

It is considered malignant course of the coronary artery, when it is coursing between two pulsating objects like in this case the aortic root and the pulmonary artery which can cause severe compression during excertion and might lead to sudden cardiac death.