Double trouble: a rare case of quadricuspid aortic valve and anomalous right coronary artery

guideline-supported stress testing in risk stratification and avoidance of unnecessary intervention [3] Fig. 1.A 44-year-old male with high functional capacity presented with mid-sternal discomfort.Coronary CT angiography (CCTA) revealed an anomalous right coronary artery (RCA) from the left coronary cusp (Fig. 1, Panel A-B) and a quadricuspid aortic valve (QAV) (Fig. 1, Panel C).The RCA followed an interarterial course with a slit-like ostium (5.0 1.8 mm), acute takeoff angle, and 5.0 mm intramural segment [1].CT-derived fractional flow reserve (FFRct) was preserved (0.95) (Panel D), concordant with normal SPECT and absence of ischemia.Although FFRct is validated mainly in atherosclerosis and may not detect dynamic compression in anomalous aortic origin, concordant normal findings supported low ischemic risk.Cardiac magnetic resonance showed mild-to-moderate aortic regurgitation (regurgitant volume 19 mL, fraction 22%), without ventricular dilation (Fig. 1, Panel E-F).Associations between aortic valve dysplasia and anomalous coronary origin have been described [2], though quadricuspid morphology remains rare.This case highlights the complementary role of CCTA, FFRct, and