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came with complaints of chest pain that starting with exertion and ending with rest. Physical examination revealed a 1/6 systolic murmur. The electrocardiogram showed no signs of ischemia. The transthoracic echocardiogram at admission revealed no significant finding except that minimal mitral valve regurgitation. Treadmill showed significant horizontal ST-segment depression in D11-D111-aVF and V4–V5-V6 with accompanied by chest pain. Cardiac catheterization showed a fistuluzation from circumflex coronary artery to pulmonary artery (Figure 1, 2). Origin of the circumflex artery from the pulmonary artery has been proved by multislice computed tomography (Figure 3). Myocardial perfusion scintigraphy were performed to evaluate myocardial ischemia and ischemia was identified at the perfusion area of the circumflex coronary artery. As a result of this, the patient was advised surgery