Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is an uncommon congenital anomaly. We report a rare association of ALCAPA with tetralogy of Fallots (TOF). The physiology, clinical presentation and specific echocardiographic clues that suggest diagnosis in these circumstances can be different from a patient having isolated ALCAPA. In such clinical scenario, the anesthesiologist should able to recognize the echocardiographic features of the coexistence of ALCAPA and be aware of the potential pitfalls.