Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) presenting with ventricular fibrillation in an adult: a case report

The Anterior Mitral Valve Leaflet Prolapse as a Key to Diagnosis of ALCAPA Syndrome

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA syndrome) is a rare congenital coronary abnormality carrying a poor prognosis. We present a clinical case series of ALCAPA-related anterior mitral valve leaflet prolapse and discuss its mechanism as a key to suspicion of ALCAPA syndrome.

Aberrant left coronary artery from the pulmonary artery with patent ductus arteriosus - a case report and review of the literature

BACKGROUND

Aberrant left coronary artery from pulmonary artery (ALCAPA) is a very rare congenital heart defect. Its coexistence with patent ductus arteriosus (PDA) is extremely rare. The high pressures created by the left-to-right shunt in the pulmonary arteries can delay symptoms and create a real challenge in diagnosing ALCAPA. Missing this diagnosis can have severe results, including extensive ischemia and sudden death.

CASE PRESENTATION

We present a case of an infant born with a large PDA. Initially treated conservatively, however, due to congestive heart failure and lack of weight gain, she underwent surgical ligation of the PDA at the age of four and a half months. Following surgery, she developed pulmonary edema. Echocardiography revealed decreased ventricular function. ECG revealed ST elevations on lateral leads, and serum troponin was significantly increased. The patient underwent cardiac magnetic resonance imaging (MRI), which revealed signs of wall ischemia and decreased function of the left ventricle (LV) with unclear coronary anatomy. Diagnostic catheterization revealed an ALCAPA. She underwent surgical intervention, and the left coronary artery was re-implanted in the aortic sinus. Follow-up revealed slow improvement of cardiac function.

DISCUSSION AND LITERATURE REVIEW

The coexistence of PDA and ALCAPA is a very rare occurrence. We found at least 10 reported cases in the literature. Delayed diagnosis might be detrimental. The prognosis of these patients is variable.

CONCLUSION

An unusual post-surgical course following PDA repair requires a high index of suspicion and appropriate evaluation for ALCAPA, preferably with angiography.

Anomalous origin of the right coronary artery from pulmonary artery in an adult presenting with rapid atrial fibrillation: a case report

Background

An anomalous origin of the right coronary artery from pulmonary artery (ARCAPA) is a very rare coronary anomaly.

Case summary

A 56-year-old man, presenting haemodynamically unstable due to very rapid atrial fibrillation, was found to have ARCAPA by coronary computed tomography angiography. He had normal left ventricular ejection fraction and without reversible ischaemia on an adenosine stress rubidium positron emission tomography. He was treated solely with betablockers and has been well since.

Discussion

Numerous case reports on ARCAPA have previously been published, but no previous reports have found rapid atrial fibrillation to be the primary symptom of presentation. Current evidence level concerning the treatment is low; nevertheless, surgical intervention should always be considered to prevent sudden cardiac death. The patient in this case was offered surgical intervention but declined.

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.

Early Presentation of Patients with Abnormal Origin of Left Coronary Artery from the Pulmonary Artery is a Predictor of Poor Mid-term Outcomes

Abnormal origin of left coronary artery from the pulmonary artery (ALCAPA) is one of the most common causes of myocardial ischemia and infarction in childhood. This study aimed to determine the correlation between age at clinical presentation, level of ventricular dysfunction, and post-repair outcomes. This is retrospective study from 1993 to 2018 including thirty-one patients. The study cohort was divided into two groups according to age (< 6 months, > 6 months). The significance level was set at p 0.05.The median follow-up time was 72 [24-168] months. Median age was 4.7 [2.3-16] months. Median weight was 6.2 [4.3-9] kg. There was severe left ventricular (LV) dysfunction (ejection fraction < 35%) in 64.5% of patients. Mitral regurgitation (MR) was moderate to severe in 13 patients (41.9%). Two patients (6.4%) required extracorporeal membrane oxygenation (ECMO) support before surgery and 6 (19.4%) after correction. Age < 6 months was significantly associated with severe clinical presentation, severe LV dysfunction, delayed sternal closure, prolonged respiratory mechanical support, and prolonged length of ICU stay (p = 0.024, p = 0.042, p = 0.002, p = 0.042, p = 0.022, respectively). After surgery, ejection fraction improved to a median of 57% [50.7-60.5]. MR regressed in 12 patients (92.3%). Mortality rate after surgery was 9.7%. All patients were free from reoperation at the last follow-up. Young age at diagnosis was significantly associated with a more severe clinical presentation and poorer outcomes. After re-establishment of a two-coronary circulation, both ventricular function and MR tend to normalize over time regardless of age at repair.

Cardiac-CT with the newest CT scanners: An incoming screening tool for competitive athletes?

Competitive athletes of all skill levels are at risk of sudden cardiac death (SCD) due to certain heart conditions. Prior to engagement in high-intensity athletics, it is necessary to screen for these conditions in order to prevent sudden cardiac death. Cardiac-CT angiography (CCTA) is a reliable tool to rule out the leading causes of SCD by providing an exceptional overview of vascular and cardiac morphology. This allows CCTA to be a powerful resource in identifying cardiac anomalies in selected patients (i.e. unclear symptoms or findings at ECG or echocardiography) as well as to exclude significant coronary artery disease (CAD). With the advancement of technology over the last few years, the latest generations of computed tomography (CT) scanners provide better image quality at lower radiation exposures. With the amount of radiation exposure per scan now reaching the sub-millisievert range, the number of CT examinations it is supposed to increase greatly, also in the athlete's population. It is thus necessary for radiologists to have a clear understanding of how to make and interpret a CCTA examination so that these studies may be performed in a responsible and radiation conscious manner especially when used in the younger populations. Our work aims to illustrate the main radiological findings of CCTAs and highlight their clinical impact with some case studies. We also briefly describe critical features of state-of-the-art CT scanners that optimize different acquisitions to obtain the best quality at the lowest possible dose.

Anomalous left coronary artery from the pulmonary artery: a rare cause of an out-of-hospital cardiac arrest in an adult-a case report

BACKGROUND

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital disorder resulting in ischaemia and myocardial infarction which can act as a potential substrate for life-threatening arrhythmias and sudden cardiac death.

CASE SUMMARY

A 19-year-old man was admitted to the hospital after successful resuscitation from an out-of-hospital cardiac arrest (OHCA) due to ventricular fibrillation occurring during jogging. In the diagnostic work-up of the OHCA, computed tomography identified an ALCAPA. The patient was referred to our tertiary hospital for surgical correction. Direct reimplantation of the left coronary artery in the aorta was performed. During follow-up, 24-h electrocardiogram revealed short episodes of non-sustained ventricular tachycardia (VT). The magnetic resonance imaging at initial admission showed focal wall thinning and transmural late gadolinium enhancement consistent with a previous anterolateral myocardial infarction. Therefore, the aetiology of the OHCA could be due to a scar-related mechanism and not necessarily due to a reversible cause and an implantable cardioverter-defibrillator (ICD) was considered indicated. Given the young age and the lower complication rates, a subcutaneous device was preferred over a transvenous ICD. However, as a subcutaneous ICD (S-ICD) lacks the possibility of anti-tachycardia pacing, programmed electrical stimulation (PES) was performed to test for inducibility of monomorphic, re-entrant VT. After a negative PES, an S-ICD was implanted.

DISCUSSION

ALCAPA is a potential cause of OHCA in young patients. Some of these patients keep an irreversible substrate for ventricular arrhythmias despite full surgical revascularization and might be candidates for (subcutaneous) ICD implantation.

Adult ALCAPA: from histological picture to clinical features

BACKGROUND

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary anomaly that results in high mortality if left untreated. Our aim was to extend our knowledge of the histological, angiographic, and clinical characteristics of ALCAPA in order to deepen our understanding of this rare entity.

CASE PRESENTATION

We were involved in the assessment, treatment, and pathological evaluation of two adult ALCAPA patients who were rescued from ventricular fibrillation and then surgically treated to establish a dual coronary artery system. Histological studies indicated various chronic ischemic changes in the myocardium, patchy fibrosis, and severely thickened arteriolar walls in both ventricles. The first patient is alive and well 11.5 years after surgical correction without any implantable cardioverter defibrillator (ICD) activations. The second patient required re-do surgery 9 months after the initial operation but subsequently died. Histologically, chronic ischemic alteration of the myocardium and thickened arteriolar walls persisted even after surgical correction, and coronary angiography (CAG) showed an extremely slow flow phenomenon even after surgical correction in both patients. The average postoperative opacification rate in the first case was 7.36 + 1.12 (n = 2) in the RCA, 3.81 + 0.51 (n = 3) in the left anterior descending (LAD) artery, and 4.08 + 0.27 (n = 4) in the left circumflex (LCx) artery. The slow flow phenomenon may represent persistent high arteriolar resistance in both ventricles.

CONCLUSIONS

Seldom reported or new findings in adult ALCAPA were identified in two cases. More frequent diagnosis of adult ALCAPA can be expected because of the widespread availability of resuscitation and more advanced diagnostic modalities. Accumulation of pathological and clinical findings and confirmation of the long-term follow-up results after treatment may contribute to expanding our knowledge of this rare entity and establishing optimal treatment.

Coronary Artery Anomalies and Associated Radiologic Findings

Coronary anomalies occur in about 1% of the general population and in severe cases can lead to sudden cardiac death. Coronary computed tomography angiography and magnetic resonance imaging have been deemed appropriate for the evaluation of coronary anomalies by accurately allowing the noninvasive depiction of coronary artery anomalies of origin, course, and termination. The aim of this article is to describe and illustrate a comprehensive array for the classification of coronary artery anomalies.

Collateral Deception: A Unique Presentation of an Anomalous Coronary Artery

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ARCAPA is a rare congenital anomaly.

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Anomalous coronary artery origins are often isolated and diagnosed incidentally.

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Echocardiography is the initial modality for diagnosing coronary artery anomalies.

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Diagnosis by echocardiography requires a high index of suspicion.

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Patients with suspected coronary anomalies should undergo advanced imaging.

Incidental Finding of the Anomalous Origin of Left Main Coronary Artery from Pulmonary Artery in an Adult Presenting with Arrhythmia-Induced Myocardial Ischemia

Anomalous origin of the left main coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary anomaly with high mortality. It is associated with cardiovascular complications and is usually diagnosed soon after birth. Those who survive into adulthood can present with signs of myocardial infarction, heart failure, mitral regurgitation, severe pulmonary hypertension, or sudden cardiac death. We present a 53-year-old female presenting with atrial fibrillation and found to have an incidental diagnosis of ALCAPA who refused surgical correction. We also review the epidemiology, diagnosis, age-based clinical presentations, and treatment options for ALCAPA.

A case of successful bystander cardiopulmonary resuscitation of an adult with Bland-White-Garland syndrome

In Japan and worldwide, the increase in educational interventions about resuscitation training significantly increases favorable neurological survival in out‐of‐hospital cardiopulmonary arrest cases treated with bystander cardiopulmonary resuscitation (BCPR) each year. This case with Bland‐White‐Garland syndrome having high‐quality BCPR by nurses demonstrates the importance of education about BCPR.

Cardiac computed tomography of an asymptomatic 48-year-old woman with ALCAPA syndrome

Untreated ALCAPA cases most often die in infancy. Adults with untreated ALCAPA commonly present with mitral regurgitation, severe left ventricular dysfunction, and sometimes myocardial infarction. Herein, we present an asymptomatic adult female with ALCAPA recognized through cardiac computed tomography (CT). In ALCAPA, like other coronary anomalies, cardiac CT is often instrumental in providing unique noninvasive and clinically relevant evaluation. Herein, we present an atypical presentation of an asymptomatic middle-aged adult female with ALCAPA.

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery: The Role of Multislice Computed Tomography (MSCT)

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary abnormality also known as Bland-White-Garland syndrome. The incidence of ALCAPA is about 1 in every 300,000 live births, and constitutes 0.24% and 0.46% of all congenital cardiac disease. It has a high infant mortality rate reaching up to 90% if left untreated. For many years, the diagnosis of ALCAPA was by angiography or autopsy. However, multislice computed tomography (MSCT) is a non-invasive imaging tool that allows accurate, non-invasive diagnosis of ALCAPA. Here we report a case of ALCAPA in a six-month-old girl who presented with a two-week history of cough, fever, tachypnea, and sweating during feeding. During admission, an echocardiogram was performed that revealed ALCAPA, which was confirmed using CT. We discuss the role of MSCT in its diagnosis.

A case of anomalous origin of the left coronary artery from the pulmonary artery presenting with sudden cardiac arrest due to coronary artery steal generated by excessive exercise

This case report describes a 43-year-old man who temporarily survived cardiac arrest that was prospectively related to ventricular fibrillation due to the anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Prior to admission to our hospital, he was asymptomatic for ALCAPA syndrome. Emergent coronary angiography revealed that the dilated right coronary artery was connected with extensive collateral vessels to the left coronary artery. The origin of the latter was in the pulmonary artery. Moreover, coronary steal phenomenon was identified by examining the pulmonary arterial blood oxygen saturation. The patient later died of acute decompensated acidosis. <Learning objective: It is common that oxygen saturation exams may be normal or show a slight increase within the pulmonary artery in this anomaly. However, moderate to severe left to right shunt was remarkably detected in this patient, which may have contributed to acute ischemia in addition to inadequate collateral flow.>.

Anomalous origin of left coronary artery from pulmonary artery associated with pulmonary hypertension

This is a report on a 10-year-old child with anomalous origin of left coronary artery (LCA) from pulmonary artery (ALCAPA), severe pulmonary hypertension (PH), old myocardial infarction and poor intercoronary collateralization. It discusses the echocardiographic pitfalls in this particular setting and introduces a new echocardiographic view (posterior pulmonary cusp view) for visualization of the anomalous origin of LCA from the posterior pulmonary cusp (PC) in patients with ALCAPA from the PC of the pulmonary artery. We describe three echocardiographic pitfalls that can mislead the echocardiographer and two helpful hints that guide the clinician to the correct diagnosis. The survival of this child shows that limited size of left ventricular myocardial infarction and severe mitral regurgitation in early infancy can result in a life-saving pulmonary hypertension which preserves viability and function of left ventricle despite lack of intercoronary collateral arteries. After one year follow-up, she is doing well on medical treatment.

Altered right ventricular function in the long-term follow-up evaluation of patients after delayed aortic reimplantation of the anomalous left coronary artery from the pulmonary artery

This study aimed to evaluate regional and global ventricular functions in the long term after aortic reimplantation of the anomalous left coronary artery from the pulmonary artery (ALCAPA) and to assess whether the time of surgical repair influences ventricular performance.The study examined 20 patients with a median age of 15 years (range 3-37 years) who had a corrected ALCAPA and 20 age-matched control subjects using echocardiography and tissue Doppler imaging (TDI). The median follow-up period after corrective surgery was 6 years (range 2.6-15 years). Seven patients underwent surgery before the age of 3 years (early-surgery group), whereas 13 patients had surgery after that age (late-surgery group). The TDI-derived myocardial strain of the interventricular septum (IVS), lateral wall of the left ventricle (LV), and lateral wall of the right ventricle (RV) in the basal and mid regions were examined, and a mean was calculated. The pulsed Doppler-derived Tei index was used to assess global left ventricular function. No significant differences were found between the early-surgery group and the control group regarding the regional myocardial strain or the Tei index. Compared with the early-surgery group, the late-surgery group had a significantly higher Tei index (mean 0.37; range 0.31-0.42 vs. mean 0.52; range 0.39-0.69; p < 0.005), a lower strain percentage of the lateral wall of the LV (mean 29; range 17-30 vs. mean 9; range 7-23), IVS (mean 23; range 21-31 vs. mean 19; range 13-25), and lateral wall of the RV (mean 23; range 21-31 vs. mean 19; range 13-25). The age at operation correlated significantly with the Tei index (r = 0.84, p < 0.001) and inversely with the mean strain of the lateral wall of the LV (r = -0.53, p = 0.028), IVS (r = -0.68, p = 0.003), and lateral wall of the RV (r = -0.68, p = 0.003). At the midterm follow-up evaluation after corrective surgery of ALCAPA, not only the left but also the right ventricular function seemed to be affected in patients with delayed diagnosis and late surgical repair but preserved among the younger patients with early diagnosis and corrective surgery.

Anomalous origin of the left coronary artery from pulmonary artery a late presentation-Case report and review of literature

An otherwise healthy 26-year-old female presented with sudden cardiac arrest. She was resuscitated with unsynchronized cardioversion for ventricular fibrillation. A left heart cardiac catheterization showed anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Cardiac computed tomographic angiography confirmed this abnormality. She underwent direct translocation of the left main coronary artery to the aorta, and after a stormy postoperative course was discharged home. ALCAPA is a rare congenital abnormality of the coronary system that is associated with early infant mortality and adult sudden death. The use of advanced cardiac imaging has resulted in an increase in the number of diagnosed ALCAPA cases, especially in the adult population, sometimes even in the asymptomatic. The extent of collateral circulation that develops between the right coronary artery and the left coronary artery determines the outcome; the more collateral circulation there is, the less the hypoxic damage to the ventricle. This not only informs us that people survive ALCAPA into adulthood but also highlights the importance for adult cardiologists to be aware of this interesting disease. Corrective surgery remains the treatment of choice. We present a rare case of ALCAPA, with first presentation in adulthood in the form of a malignant ventricular arrhythmia. <Learning objective: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital abnormality of the coronary system that is associated with early infant mortality and adult sudden death. Hence we feel it is most important to be aware of this entity, especially as the incidence of diagnosed ALCAPA is on the rise in adulthood. Also the images provided and the discussion have high educational value for generalists and cardiologists alike.>.

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery: Diagnosis with CT Angiography

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly. It is associated with early infant mortality and sudden death in adults. Traditionally, ALCAPA has been diagnosed by angiography or autopsy; however, the development of cardiac computed tomography (CT) and magnetic resonance imaging (MRI) has allowed noninvasive evaluation of the coronary anatomy by direct visualization of the origin of the left coronary artery (LCA) from the pulmonary artery. We report a case of 10-year-old girl who has been on follow up for dilated cardiomyopathy for 4 years. The definitive diagnosis of ALCAPA is reached by multislice computed tomography (MSCT). The MSCT scan showed an anomalous origin of LCA from the pulmonary trunk, with a tortuous and dilated right coronary artery and right-to-left collateralization. Consequently, the patient was successfully treated with surgery.

A rare case of adult type ALCAPA syndrome: presentation, diagnosis and management

We report a case of a 43 year-old previously fit and healthy woman presenting with cardiac arrest secondary to an anomalous origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA) Syndrome, a very rare congenital anomaly that it is extremely unusual to survive to adulthood if left uncorrected. To our knowledge, this is the first case of its type to be diagnosed and reported in an Australian hospital. Suspicion of this anomaly on conventional coronary angiography is essential given the life threatening nature of this condition.

ALCAPA Presents in an Adult with Exercise Intolerance but Preserved Cardiac Function

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly that usually manifests as severe left-sided heart failure and mitral valve insufficiency during the first one to two months of life. The majority of these cases die in infancy if not corrected early upon presentation. Adulthood presentation is rare and most of the untreated patients who reach adulthood present with left ventricular dysfunction, severe mitral regurgitation, and sometimes myocardial infarction. Here we report a case of a 20-year-old woman with a history of exercise intolerance since childhood that was misinterpreted as asthma until a 2D-Echo revealed ALCAPA with RCA collaterals to the left anterior descending artery, preserved LV ejection fraction, and absence of apparent mitral valve abnormality. One month after the ALCAPA diagnosis, she successfully underwent surgical reconstruction of left main and pulmonary artery without any major complications. She had normal left ventricular function without apparent ischemic cardiac symptoms eighteen months after procedure.

One train may hide another: anomalous origin of the left coronary artery from the pulmonary artery revealed by supraventricular tachycardia

We report the case of a 1-month-old boy with an unusual association of supraventricular tachycardia and anomalous origin of the left coronary artery from the pulmonary artery. Although signs of infarction were visible on the first electrocardiogram, the presence of an arrhythmia did not immediately suggest a coronary anomaly. Echocardiography allowed the diagnosis, thus leading to appropriate care.

Anomalous origin of the left main coronary artery from the main pulmonary artery in an elderly patient

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) syndrome is an extremely rare diagnosis in elderly patients. We describe a 73-year-old female with ALCAPA who underwent successful repair of this coronary anomaly.

Bland-White-Garland syndrome in adults: sudden cardiac death as a first symptom and long-term follow-up after successful resuscitation and surgery

Two cases (a 23-year-old man and a 33 year-old-woman) with Bland-White-Garland (BWG) syndrome (an anomalous origin of the left coronary artery from the pulmonary artery) are presented. Their first symptom was survived sudden cardiac death. Both patients underwent surgical repair. One patient received an implantable defibrillator because of serious structural changes in the left ventricle and symptomatic non-sustained ventricular tachycardia; the second patient is free of therapy. During long-term follow-up (10.5 and 4.5 years, respectively), ventricular tachyarrhythmias did not recur. Both cases show good long-term prognosis in resuscitated adult patients after surgical repair for BWG syndrome regardless of the presence of structural changes.

Anomalous left coronary artery origin from the pulmonary artery: an unusual late presentation of Bland-Garland-White syndrome

A 43-year-old woman presented with exertional dyspnea. On investigation, she was found to have ischemic left ventricular dysfunction on the basis of an anomalous left coronary artery originating from the pulmonary artery. She underwent successful surgical correction of this congenital anomaly that usually presents in childhood.