Bland-White-Garland syndrome and atrial septal defect - rare association and diagnostic challenge

Anomalous Left Coronary Artery From the Pulmonary Artery With Ventricular Septal Defect and Double Aortic Arch: A Unique Case Report

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is an uncommon life-threatening congenital heart defect that occurs mostly as an isolated lesion. It is very rarely associated with other cardiac abnormalities. In this report, we present a case of an infant who successfully underwent complete surgical repair of a rare triad of congenital heart defects, including ALCAPA, ventricular septal defect (VSD), and double aortic arch (DAA). To the best of our knowledge, this is only the second case of ALCAPA diagnosis associated with VSD and DAA that has been described in the literature.

Anomalous origin of coronary arteries from the pulmonary artery: A single-center experience

Background

The aim of the study was to evaluate the clinical and diagnostic findings, treatment, and follow-up of cases of anomalous origin of coronary arteries from the pulmonary artery.

Methods

Between January 1998 and June 2021, a total of 14 patients (5 males, 9 females; median age: 15 months; range, 3 to 156 months) diagnosed with anomalous origin of coronary arteries from the pulmonary artery were retrospectively analyzed. Demographic and clinical data of the patients, electrocardiographic, echocardiographic, angiographic, surgical, and follow-up findings were evaluated.

Results

The most common symptoms were respiratory distress (n=6) and murmur (n=3). With the exception of three cases, all other patients were diagnosed by echocardiography in the first examination. Severe mitral valve insufficiency was detected in four patients and four other patients had moderate mitral insufficiency on echocardiography. Ejection fraction values ranged between 38 and 79%. Eleven patients underwent direct implantation of the coronary artery into the aorta, and three underwent a Takeuchi procedure. Mortality occurred in only one case. After surgery, mitral insufficiency and ejection fraction values improved. Median follow-up was 62 (range, 5 to 170) months and all patients were asymptomatic, except one who required redo surgery.

Conclusion

Anomalous origin of the coronary arteries from the pulmonary artery is an uncommon congenital anomaly. Echocardiography is the main diagnostic tool. If all echocardiographic findings of the coronary anomaly are not investigated thoroughly, the diagnosis may be overlooked.

Diagnosis and treatment of abnormal left coronary artery originating from the pulmonary artery: A single-center experience

OBJECTIVE

We aimed to review symptoms, findings, surgical treatment options, short- and mid-term outcomes, and reoperation rate of patients diagnosed with of left coronary artery from the pulmonary artery (ALCAPA) of an anomalous origin in our institution.

METHODS

From May 2000 to March 2018, 33 patients who had left coronary artery originating from the pulmonary artery were retrospectively examined. The clinical features of patients, diagnostic tools and their efficacy, outcomes of surgical repair, and problems during follow-up were evaluated.

RESULTS

Thirty-three patients (22 females, 11 males) were included in the study. At the time of surgery, the median age and weight of patients were 6 months (minimum/maximum, 1-166 months) and 6.5 kg (minimum/maximum, 3-38.5 kg), respectively. The mean follow-up was 5±3.5 years (range, 1-16 years). Dyspnea, tachypnea, diaphoresis, prolonged feeding time, and developmental delay were common presenting signs and symptoms. It was determined that all the patients who were diagnosed at another center reached our center for surgical treatment within 1 month. Twenty-three (69.7%) patients had pathologic Q wave with anterior and/or anterolateral myocardial infarction signs on an electrocardiogram (ECG), whereas 22 (66.6%) patients had ST-T segment changes. Twenty-one (63.6%) patients had cardiomegaly on the telecardiogram. A reimplantation surgery was performed to 22 patients and 10 patients underwent the Takeuchi procedure. In addition to ALCAPA repair, 5 patients needed mitral valve plasty. Atrial septal defect (ASD) and ventricular septal defect (VSD) were closed in one patient, and Tetralogy of Fallot was totally corrected in another. At discharge, there was a significant improvement in left ventricular (LV) systolic functions. At the last visit, all patients had normal LV systolic functions except four who had mild dysfunction. The mean follow-up of the four patients was 2.8 years. In the early postoperative period, complications were seen in 10 patients. Five patients died in the early postoperative period, while one patient died 9 months after the ALCAPA surgery because of low cardiac output syndrome that developed after mitral repair.

CONCLUSION

Patients with ALCAPA commonly present with congestive heart failure symptoms. When the diagnosis is confirmed in these patients, surgical treatment should not be delayed. The availability of surgical center and surgery outcomes for ALCAPA diagnosed patients are comparable with other countries, but the delay in the diagnosis of disease is still a problem in our country.

ALCAPA Syndrome and Atrial Septal Defect In a 68-Year-Old Woman: An Extremely Rare Congenital Association

Anomalous left coronary artery arising from the pulmonary artery (ALCAPA) has been generally reported as an isolated lesion that is also called Bland-White-Garland syndrome. Herein we report a case of ALCAPA syndrome with an atrial septal defect in a 68-year-old woman. She had been asymptomatic until the age of 68. Echocardiographic examination revealed atrial septal defect, and coronary angiography showed that the left main coronary artery originated from the pulmonary artery and intensive collateral connections between the right and left coronary artery. In this case, it would appear that ALCAPA is associated with atrial septal defect.

Usefulness of multidetector-row computed tomography in diagnosis of anomalous origin of left coronary artery arising from the pulmonary artery

Anomalous origin of the left coronary artery arising from the pulmonary artery (ALCAPA) is a rare congenital heart defect that affects approximately 1 in 300,000 live births and accounts for 0.5% of all congenital heart disease. Without surgical intervention, most patients with this anomaly die in infancy. The diagnosis of ALCAPA syndrome is sometimes difficult, especially in children, because it often presents with atypical symptoms and signs. Echocardiography can yield some findings that are highly indicative of this syndrome. Cardiac catheterization usually establishes the diagnosis, but it is invasive and painful. Multidetector-row computed tomography (MDCT) is a valuable alternative tool to confirm the diagnosis of ALCAPA syndrome. In this report, we describe a 24-year-old woman with a dilated right coronary artery detected by transthoracic echocardiography, showing an interventricular abnormal flow over the diastolic phase of the cardiac cycle and the left main coronary artery not merging with the ascending aorta. The diagnosis of ALCAPA syndrome was confirmed by MDCT.

A hazardous finding of a rare anomalous left main coronary artery in a patient with a secundum atrial septal defect

A 23-year-old male referred for evaluation of a “choking” sensation with exertion and a murmur. A transthoracic echocardiogram demonstrated right atrial and ventricular dilatation, right ventricular volume overload, and a large secundum atrial septal defect (ASD) with left to right shunt and a calculated pulmonary-to-systemic blood flow ratio (Qp/Qs) estimated at 2.3 to 1. Cardiac catheterization also demonstrated evidence of the ASD with Qp/Qs of 4.6 to 1 with a significant step-up in oxygen saturation at the right atrial level. Additionally, an anomalous left main coronary artery (ALMCA) origin from the anterior right coronary cusp was suspected. Using 64-slice multidetector computed tomography coronary angiography (CCTA) the left main coronary artery was seen to arise from the right coronary cusp then traverse between the pulmonary trunk and the proximal ascending aorta before bifurcating into the left anterior descending and circumflex arteries that followed their normal courses distally. Based on the high risk nature of associated sudden death from an anomalous left main coronary artery (ALMCA) coursing between the aorta and the pulmonary trunk, the patient underwent surgical re-implantation of the ALMCA to the left coronary cusp and repair of the ASD. This case highlights a rare finding of a hazardous ALMCA in a patient with a secundum ASD and the utility of CCTA in evaluating the course of coronary anomalies along with other cardiac pathology.