Anomalous left coronary artery from the pulmonary artery (ALCAPA) diagnosed in adulthood: Varied clinical presentation, therapeutic approach and outcome

Anomalous Left Coronary Artery from the Pulmonary Artery: How to Diagnose and Treat

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare coronary anomaly that can present in childhood or adulthood with a multitude of symptoms depending on the age of presentation. It should be suspected in infants presenting with heart failure in the setting of left ventricular systolic dysfunction and associated mitral regurgitation from papillary muscle ischemia. Adults with ALCAPA may present with cardiac ischemic symptoms. Prompt diagnosis with echocardiography and cross-sectional chest imaging is important to guide surgical intervention and improve the patients' survival and prognosis. The goal of surgery is to establish a dual-coronary system with mid-term results revealing progressive recovery of left ventricular function and improvement in mitral regurgitation. Patients with ALCAPA should maintain life-long follow-up with a cardiologist with congenital heart disease expertise for surveillance of post-operative complications.

Acute myocardial infarction in the elderly with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA): A case report and literature review

INTRODUCTION

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary artery malformation, with a fatality rate of 90% at 1 year of age; only 10% to 15% of patients are diagnosed in adulthood. However, elderly survivors are particularly rare. Here, we report a case of elderly ALCAPA presented with acute myocardial infarction.

CASE PRESENTATION

A 64-years-old female, complained of acute precordial pain in our hospital for 2 days. She was diagnosed with an acute non-ST-segment elevation myocardial infarction. Aortic angiography revealed emptiness of the left coronary sinus, and coronary angiography showed that the tortuous right coronary artery supplied blood to the left coronary artery through collateral circulation, and the contrast medium spilled from the opening of the left coronary artery. It was suspected that the left coronary artery was opened in the pulmonary artery. This finding was subsequently confirmed by coronary artery CT. The patient refused surgery to restore double coronary circulation and was administered standardized drug treatment. There was no chest pain during the 6-month follow-up.

CONCLUSION

ALCAPA should be considered in patients with Myocardial Infarction with Non-obstructive Coronary Arteries, and surgical intervention is the first choice for such patients; However, chronic myocardial damage persists regardless of surgical treatment, prophylactic implantation of an ICD may be an important means of preventing sudden cardiac death and such patients should be followed up for a lifetime.

Anomalous coronary artery from the pulmonary artery diagnosed in adulthood: a case series on variations of coronary anatomy and the diagnostic value of cardiac magnetic resonance imaging

Background

Anomalous coronary artery from the pulmonary artery is a rare congenital disorder with high mortality rates in infancy. Adult cases can present with life-threatening arrhythmias and sudden cardiac death.

Case summary

We report three cases of adults with anomalous pulmonary origin of each of the main coronary branches. The first patient with an anomalous left coronary artery from the pulmonary artery presented with an out-of-hospital cardiac arrest. The second patient with an anomalous circumflex artery from the pulmonary artery was evaluated for a bicuspid aortic valve and a suspected coronary fistula but was otherwise asymptomatic. The third patient with an anomalous right coronary artery from the pulmonary artery presented with anginal symptoms. In all cases, the diagnosis was made by cardiac computed tomography or coronary angiography. Cardiac magnetic resonance imaging was performed in all patients to guide clinical decision making on surgical or non-invasive management. All patients underwent surgical repair. In two patients, a dual coronary artery system was restored by aortic reimplantation of the anomalous coronary artery. In one patient, aortic reimplantation was unsuccessful due to poor vessel quality and the anomalous coronary artery was ligated. Clinical follow-up during 1.8–9.7 years did not show any cardiovascular complications and all patients are currently alive and asymptomatic.

Discussion

Anomalous coronary artery from the pulmonary artery can have various clinical presentations in adulthood. Cardiac magnetic resonance imaging is a useful modality to guide selection of patients who might have symptomatic or prognostic benefit from surgical repair.

Life saved and a lesson learned-anomalous origin of the left coronary artery from pulmonary artery in pregnancy

Anomalous origin of the left coronary artery from pulmonary artery constitutes 0.5% of all CHD (Boutsikou M, Shore D, Li W, et al, Int J Cardiol 261: 49-53, 2018). Fifteen percent survive into adulthood undiagnosed and 90% present with sudden death (Yau JM, Singh R, Halpern EJ, Fischman D, Clin Cardiol 34: 204-210, 2011; Alexi-Meskishvili V, Berger F, Weng Y, Lange PE, Hetzer R, J Card Surg 10: 309-315, 1995). We describe an enigmatic case of a 29-year-old female who presented after an aborted cardiac arrest and was diagnosed with anomalous origin of the left coronary artery from pulmonary artery.

Sudden Cardiac Arrest in an Adult with Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA): Case Report

Introduction: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare coronary artery anomaly that carries 90% mortality in the first year of life when left untreated. The diagnosis of ALCAPA is rare in adulthood, and it includes a broad spectrum of clinical manifestations, including sudden cardiac death (SCD). Case report: We report a rare case of resuscitated sudden cardiac arrest in a 55-year-old female, who was diagnosed with ALCAPA and underwent successful surgical correction and implantable cardioverter defibrillator (ICD) implantation for secondary prevention. Discussion: ALCAPA diagnosis is not confined to childhood, and it represents a rare cause of life-threatening arrhythmias and SCD in the adult population. Surgical correction is recommended, regardless of age, presence of symptoms or inducible myocardial ischemia. Multimodality imaging is crucial for diagnosis, management planning and follow up. Assessment of the risk of recurrent ventricular arrhythmias, despite full revascularization, should be performed in all adults with ALCAPA. Myocardial scar detected via late gadolinium enhancement represents a potential irreversible substrate for ventricular arrhythmias, and it provides additional information to evaluate indication of an ICD for secondary prevention.

Coronary Artery Anomaly, What Radiologist Should Know?

심장 전산화단층촬영(이하 CT)은 현재 관상동맥기형을 진단하고, 평가하는 가장 정확한 진단 도구로 자리매김하였으며, 심장 CT 촬영 건수가 증가함에 따라 관상동맥기형을 종종 관찰할 수 있다. 본 종설은 관상동맥기형에서 영상의학과 의사들이 꼭 알아야 할 대표적인 기형의 CT 소견들에 대해 다루었다. 관상동맥기형의 종류를 3부분 즉, 기시부, 동맥 내, 그리고 연결 부위로 나누어 설명하였으며, 임상에서 볼 수 있는 대표적인 기형들 중심으로 다루었다. 특히 혈역학적 이상을 유발하거나, 급사의 위험이 있는 기형들의 CT상 위험한 해부학적 소견에 대해서는 자세히 기술하였다.

Total anomalous origin of the coronary arteries from the pulmonary artery: a systematic review

BACKGROUND

Although rare, coronary artery anomalies can have significant clinical implications. Total anomalous origin of the coronary arteries from the pulmonary artery (TCAPA) represents a rare subtype of coronary artery anomaly for which little is known. The aim of this review was to characterise the presentation, utilised diagnostic modalities, associated cardiac lesions, and treatment strategies in patients with TCAPA.

METHODS

A systematic review was performed for cases of TCAPA using PubMed, Embase, and Web of Science. Keywords searched included "total anomalous origin of the coronary arteries from the pulmonary artery," "single ostium anomalous coronary artery from the pulmonary artery," and "anomalous origin of both coronary arteries from the pulmonary artery."

RESULTS

Fifty-seven cases of TCAPA were identified in 50 manuscripts. Fifty-eight per cent of patients were male and the median age at presentation was 10 days (mean 1.71 ± 6.6 years, range 0 days-39 years). Most patients were symptomatic at the time of presentation; cyanosis (n = 22) and respiratory distress (n = 14) were the most common symptoms. Cases were most commonly diagnosed at autopsy (n = 26, 45.6%), but operative intervention was pursued in 22 cases (45.6%); aortic re-implantation (n = 14) and a Takeuchi-type repair (n = 7) were the most common routes of repair.

CONCLUSIONS

The clinical presentation of patients with TCAPA was found to be variable, likely related to the presence of associated cardiac lesions. TCAPA should be considered in patients with suspected anomalous origin of the left coronary artery from the pulmonary artery for the serious consequences that can occur if not promptly corrected.

Anomalous origin of left main coronary artery from pulmonary artery: Patient characteristics and imaging associations on multidetector computed tomography angiography

AIM

To evaluate the various imaging features and associations on multidetector computed tomography (CT) angiography in patients with anomalous origin of left main coronary artery (LMCA) from pulmonary artery (ALCAPA).

MATERIALS AND METHODS

We retrospectively reviewed multidetector CT angiography studies done for the evaluation of congenital heart diseases at our institution through 2014 to 2021. Cases with ALCAPA were identified and relevant history and imaging findings including the origin of coronary arteries, left ventricular (LV) morphology and functions, intercoronary collaterals, and associated abnormalities were evaluated.

RESULTS

Twelve patients (eight males, three adults, and nine children; age range: 2 months to 54 years) with ALCAPA were included. Gradually progressive dyspnea and failure to thrive (6/9; 66.67% each) were the most common symptoms among children, whereas adults were commonly asymptomatic (2/3; 66.67%). The LMCA was originating from pulmonary sinus, main, and right pulmonary artery in 6 (50%), 5 (41.66%), and 1 (8.3%) patients, respectively. In adult-type ALCAPA, right coronary artery (RCA), left anterior descending artery (LAD), and left circumflex artery (LCx) were dilated and tortuous, with the presence of well-developed intercoronary collaterals and preserved LV ejection fractions; these features were not seen in patients of infantile ALCAPA. LV dysfunction with global hypokinesia was the most common wall motion abnormality (7/12; 58.33%).

CONCLUSION

Degree of collateralization could be the key factor determining the time of presentation, clinical symptoms, and LV function, thus influencing clinical outcomes. Patients with infantile ALCAPA present with features of heart failure and have dilated and dysfunctional LV consequent to lack of collaterals, unlike adult-type ALCAPA.

Adult Anomalous Left Coronary Artery Arising From the Pulmonary Artery (ALCAPA) Syndrome as First Presentation With Atrial Fibrillation in a Marathon Runner

Anomalous left coronary artery arising from the pulmonary artery (ALCAPA) syndrome is a very rare congenital heart disease with an incidence of one in 300,000 and a high rate of mortality early in life if left untreated. Adult-type ALCAPA presents when significant collaterals develop from the right coronary artery (RCA) to the left coronary artery (LCA). Even with the collaterals, chronic sub-endocardial ischemia occurs in most cases, and patients die from sudden cardiac death. Here we present a case of a 38-year-old female who lived an active and healthy life and presented with chest pain and palpitations. Initial electrocardiography (EKG) showed atrial fibrillation with rapid ventricular response. Although initial cardiac enzymes were negative and there were no ischemic EKG changes, troponins became elevated over the course of the hospital stay and the patient underwent a left heart catheterization. Results revealed a dilated RCA extending to the left ventricle and an anomalous left main originating from the pulmonary artery with complete occlusion. The patient received medical management for acute coronary syndrome, including heparin infusion for 48 hours, aspirin, metoprolol, and atorvastatin. She was referred to a tertiary care facility for surgical correction of anomaly of the coronary arteries. The next day, the patient arrived in the emergency department with an acute onset of speech difficulty and left-sided weakness. A brain CT without contrast showed hematoma in the right frontal lobe. The patient underwent surgical evacuation of the hematoma with marked improvement of her weakness. The patient recovered after a successful surgical repair involving translocation of the left main coronary artery to the aorta. It has been reported that ALCAPA should be considered in a young adult with dilated cardiomyopathy and mitral regurgitation (MR). Other common presentations include acute myocardial infarction, angina, and dyspnea on exertion. Sudden cardiac death is not uncommon; however, it tends to decrease with age of diagnosis. Interestingly, our patient was known to have MR with regular follow-up at the cardiology clinic for years. Echocardiogram never showed any abnormalities other than MR. She never received further workup to address the reason of MR, although she has no underlying chronic conditions that can explain it. In relatively young patients with a healthy lifestyle presenting with chest pain, a broader look at etiologies should be considered. We would like to emphasize the importance of looking up for possible coronary artery disease, especially in young individuals.

Lung Ultrasound in Congenital Cardiac Abnormality: ALCAPA

Anomalous origin of left coronary artery from the pulmonary artery (ALCAPA) is a life-threatening ischemic congenital cardiac disease, resulting in myocardial dysfunction and heart failure within the first year of life. The authors report the case of a 1-mo-old infant with a radiological diagnosis of pneumonia handled with point-of-care lung ultrasound (POCUS) due to the persistence of dyspnea, despite a week of antibiotic therapy. Lung ultrasound showed a non-univocal interpretation of the lesion and gave indication to the second level instrumental diagnostics that confirmed the presence of ALCAPA. There is no case of lung ultrasound aiding to the early diagnosis of ALCAPA and no indirect ecographic signs of ALCAPA that have been described in literature yet.

Anomalous Origin of the Circumflex or Left Anterior Descending Artery From the Pulmonary Artery

Anomalous origin of the circumflex or left anterior descending artery from the pulmonary artery (ACxAPA and ALADAPA, respectively) are rare congenital coronary anomalies with clinical presentation varying from an asymptomatic murmur to sudden cardiac arrest. A systematic review was performed, and 46 cases of ACxAPA and 51 cases of ALADAPA were identified in 87 articles. Data were collected and analyzed from each case. A better understanding of ACxAPA/ALADAPA can provide information to providers who encounter this lesion as well as provide insight into coronary artery development which may help in the understanding of coronary artery anomalies.

Anomalous origin of coronary arteries from pulmonary artery in adults: a case series

Background

Anomalous origin of a coronary artery from the pulmonary trunk is a small group of rare congenital anomalies present in up to 1% of the population. These patients, in absence of an adequate collateral supply, may present with congestive heart failure secondary to ischaemia, arrhythmia, or sudden cardiac death in up to 90% of cases within the first months of life.

Case summary

We present four cases diagnosed in adulthood over 10 years in two high-volume centres. The first patient presented with dyspnoea and orthopnoea. The second with chest pain and episodes of non-sustained ventricular tachycardia. The third patient presented during her third pregnancy with chest pain, palpitations, and arrhythmia (non-sustained ventricular tachycardia). The fourth patient presented with sudden cardiac death.

Discussion

In all cases with anomalous origin of coronary arteries, it is recommendable to consider surgical correction to avoid the progression of ischaemia, congestive heart failure, arrhythmia, and sudden death.

Anomalous left coronary artery from the pulmonary artery (ALCAPA) as a concealed cause of severe mitral regurgitation in children and adults: Case reports

INTRODUCTION

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary artery anomaly and is a concealed cause of mitral regurgitation.

PRESENTATION OF CASE

We reported two cases of severe mitral regurgitation in whom the presence of ALCAPA was overlooked in the first cardiac surgery. In the first case, ALCAPA was diagnosed one year after the mitral annuloplasty and the surgical reimplantation was successfully performed. In the second case, ALCAPA was incidentally detected on multislice computerized tomography during preoperative workup for the second surgery to replace the dehiscent mitral prosthesis.

DISCUSSION

The clinical presentation of ALCAPA varies highly. It is not difficult to diagnose an ALCAPA in newborns and infants. Contrarily, ALCAPA in children and adults can be overlooked.

CONCLUSION

Physicians should always look for the presence of ALCAPA in patients who present with unexplained mitral regurgitation. The surgical strategy in patients with ALCAPA should be carefully individualised to achieve an optimal outcome and alleviate complications.

Characteristics and Surgical Outcomes of Patients With Late Presentation of Anomalous Left Coronary Artery From the Pulmonary Artery: A Multicenter Study

We sought to describe the clinical course and outcomes of patients who are diagnosed with anomalous left coronary artery from the pulmonary artery (ALCAPA) after infancy. We conducted a retrospective evaluation of patients who underwent ALCAPA surgery between January 2009 to March 2018 at 21 US centers. Clinical presentation, inpatient management, and postoperative outcomes of patients repaired ≥1 year of age were described. To characterize this cohort, we compared these data to patients repaired before 1 year of age. Of 248 ALCAPA patients, 71 (29%) underwent repair ≥1 year of age. Among this subset, the median age at diagnosis was 8.3 years. Chronic arrhythmia occurred in 7%. Patients had good postoperative recovery of left ventricle (LV) dysfunction (90%) and LV dilation (75%), although a low incidence of recovery of mitral regurgitation (40%). Compared to infants, older patients were more likely to present with cardiac arrest (11% vs 1%) and less likely to have moderate or worse LV dysfunction or mitral regurgitation. Older patients had significantly less postoperative extracorporeal membrane oxygenation use, and shorter ICU and hospital stay. In the older cohort, operative mortality occurred in only 1 patient and no patient died after discharge (median follow-up 2.7 years). Survival of patients who presented with ALCAPA beyond infancy was excellent, although chronic mitral regurgitation and chronic arrhythmia were not uncommon. Patients who underwent ALCAPA repair ≥1 year of age were less likely to present with LV dysfunction but more likely to present with cardiac arrest than younger patients.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) diagnosed in children and adolescents

Background

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare but potentially fatal congenital coronary anomaly associated with early infant mortality and sudden adult death. By the development or lack of coronary collateral, it can be classified as infantile or adult type. However, even with the compensatory mechanism in adult patients, there is an estimated 80 to 90% incidence of sudden death at the mean age of 35 years.

Methods

We enrolled 9 patients with ALCAPA within the age group 5 to 16 years.

Results

Only one patient developed symptoms (apsychia), whereas other patients were asymptomatic, and there was no evident left ventricular dysfunction found in any of the cases.

Conclusion

With the development of imaging techniques, asymptomatic adult-type ALCAPA patients could be identified and diagnosed in childhood or adolescence. As a potential cause of sudden death, ALCAPA should be surgically repaired soon after the diagnosis.

Effective myocardial perfusion and concomitant haemodynamic status determine the clinical diversity of anomalous left coronary artery from the pulmonary artery

BACKGROUND

Anomalous left coronary artery from the pulmonary artery is a rare congenital heart disease (CHD) with diverse clinical presentations despite the same anatomy. Factors determining this heterogeneous presentation are not well understood.

METHOD AND RESULTS

We retrospectively investigated 14 patients (12 females) who underwent surgical repair of anomalous left coronary artery from the pulmonary artery. These patients were divided into three groups based upon the severity of initial presentation: (1) severe, life-threatening condition (n = 5), (2) mild-to-moderate distress (n = 6), and (3) asymptomatic (n = 3). All patients presented with left ventricular dilation and retrograde flow in left coronary artery by echocardiogram. Eight patients in (1) and (2) presented with severe left ventricular dysfunction. All but one showed abnormal ECG consistent with myocardial ischemia or infarction. Asymptomatic patients had preserved left ventricular systolic function despite ischemic findings on ECG. In 13 patients after surgical repair, all but one normalised left ventricular geometry and systolic function, suggesting nearly full myocardial recovery upon improvement of myocardial perfusion; 8 patients had residual echogenic papillary muscle with variable degree of mitral regurgitation.

CONCLUSIONS

Evidence of myocardial ischemic injury was present in all patients with anomalous left coronary artery from the pulmonary artery regardless of their initial presentation. Retrograde flow in left coronary artery, implying collateral vessel development from right coronary artery to left coronary artery, was noted in all patients, yet only few patients had preserved systolic function at the time of diagnosis. The balance between effective myocardial perfusion and a deleterious fistulous flow provided by these collaterals and the simultaneous haemodynamic status are what determine the clinical diversity of anomalous left coronary artery from the pulmonary artery.

N-terminal pro-brain natriuretic peptide levels in patients with anomalous left coronary artery from pulmonary artery

Introduction

N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is used as an important biomarker for heart failure in children and adults. Previous researches have shown the value of NT-pro-BNP in various congenital heart defects (CHD). However, the level of NT-pro-BNP in patients with anomalous left coronary artery from the pulmonary artery (ALCAPA) has not been determined.

Materials and methods

Plasma NT-pro-BNP was measured in 23 patients diagnosed with ALCAPA before operation. Echocardiogram was also recorded for each patient.

Results

Patients with NT-pro-BNP above 300 pg/mL showed a statistically significant decrease in LVEF (p < 0.0001) and in age (p < 0.0001) compared to patients with NT-pro-BNP below 300 pg/mL. Age (r = 0.399, p = 0.012) and LVEF (r = 0.403, p = 0.011) showed a statistically significant correlation with NT-pro-BNP in linear regression when NT-pro-BNP more than 300 pg/mL. A negative correlation was shown between NT-pro-BNP and LVEF (r = 0.570, p < 0.0001) in all the patients. No significant correlation was observed between mitral regurgitation (MR) grade and NT-pro-BNP in a Spearman correlation test (r = 0.383; P = 0.071).

Conclusions

In patients with ALCAPA, NT-pro-BNP levels showed a negative correlation with age and LVEF when NT-pro-BNP above 300 pg/mL and no correlation with age and LVEF when NT-pro-BNP under 300 pg/ml. Further studies are needed to determine whether there is a correlation between MR grade and NT-pro-BNP levels.

Anomalous origin of the left coronary artery from the pulmonary artery in a patient of advanced age: a case report and analysis

A 61-year-old Chinese man presented with a nearly 30-year history of an anomalous origin of the left coronary artery. He had been diagnosed with an anomalous origin of the left coronary artery in 1989. He then underwent regular echocardiographic examinations and it was found that his heart was gradually enlarging. After a >20-year asymptomatic period, he developed recurrent chest discomfort and palpitation. Coronary computed tomography angiography suggested that the left coronary artery anomaly originated from the pulmonary artery; additionally, the right coronary artery was tortuous and thickened. Coronary angiography showed that the right coronary artery was huge and buckling. The patient underwent corrective surgery of the anomalous origin of the left coronary artery from the pulmonary artery, aortic valve mechanical valve replacement, mitral valve plasty, and tricuspid valve plasty in Fuwai Hospital (National Center of Cardiovascular Disease of China), and the anatomic results of the surgery were good.

The role of echocardiography in anomalous origin of coronary artery from pulmonary artery (ALCAPA): Simple tool for a complex diagnosis

Anomalous origin of coronary artery from pulmonary artery (ALCAPA) is a rare coronary anomaly usually presenting in the first year of life. Adult presentation suggests a wide range of differential diagnosis such as myocarditis, dilated cardiomyopathy, and coronary artery disease. We have presented here the major distinctive echocardiographic features of ALCAPA through 4 cases. Since echocardiography is often used as the first imaging modality in these clinical scenarios, recognizing the characteristics of ALCAPA in a routine echocardiographic examination can transform a readily available, low-cost tool into a valuable discriminative modality.