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

Clinical manifestations and computed tomography angiography features of anomalous left coronary artery from the pulmonary artery syndrome

OBJECTIVES

Anomalous left coronary artery from the pulmonary artery (ALCAPA) syndrome is a rare congenital coronary artery malformation with a high rate of clinical missed diagnosis and misdiagnosis. At present, there is a lack of reports on the clinical manifestations of ALCAPA and the imaging features of coronary computed tomography angiography (CTA). This study aims to summarize the clinical characteristics and coronary CTA imaging features of ALCAPA to improve the clinical diagnosis and treatment.

METHODS

The clinical data of 24 ALCAPA syndrome patients were retrospectively collected, analyzed and summarized from January 1, 2013 to February 1, 2023 in the Second Xiangya Hospital of Central South University. According to the left and right coronary collateral circulation, the patients were classified into infantile type (7 cases) and adult type (17 cases). The differences of clinical manifestations and CTA imaging features were compared between the 2 types of patients.

RESULTS

Of the 24 patients, a male-to-female ratio was at 1꞉5, and the median age of onset was 3.22 months for the infant type and 22.0 years for the adult type. The infantile type showed symptoms of left heart insufficiency at an early stage, while the adult type had a variety of clinical manifestations in 7 patients being asymptomatic and presented with a cardiac murmur on physical examination, 6 with symptoms of chronic myocardial ischemia, and 2 with malignant arrhythmias. CTA showed that 11 patients' the left coronary artery originated from the left posterior sinus of the pulmonary artery. All 7 infantile type patients had an enlarged left heart, left ventricular hypertrophy, reduced left heart function, lack of collateral circulation between the left and right coronary arteries, and normal coronary artery diameter. All 17 adult type patients showed dilated and tortuous coronary arteries with rich collateral circulation, and 7 adult type patients had preserved left heart function.

CONCLUSIONS

The clinical manifestations and CTA imaging features of patients with the 2 types of ALCAPA are different, while CTA performance is characteristic and can be used as a means of definitive diagnosis, staging, surgical evaluation, and postoperative follow-up of ALCAPA syndrome.

Advanced imaging in an adult dog with anomalous origin of the left coronary artery from the pulmonary artery and extensive collateral coronary circulation

A three-year-old, spayed female, Bichon Frise was diagnosed with an anomalous origin of the left coronary artery from the pulmonary artery, a rare congenital coronary artery defect which has only been reported in two other dogs. Echocardiography was initially performed, though the final diagnosis was made with angiography and computed tomography angiography. An extensive network of collateral coronary circulation allowed for communication between the dilated, tortuous right coronary artery, and the anomalous left coronary artery. Though collateral circulation likely prolonged the patient's life, it is suspected that coronary steal phenomenon and chronic myocardial ischemia ultimately led to fatal ventricular arrhythmias. The dog died suddenly at the age of six, three years after initial diagnosis.

Surgical Reconstruction of the Anomalous Left Coronary Artery From the Pulmonary Artery

The anomalous left coronary artery from the pulmonary artery is a rare congenital disease. Early surgical reconstruction is mandatory to prevent adverse cardiac events. Direct coronary button transfer, vein graft interposition, ligation, and coronary artery bypass construction are the most commonly used techniques. This case report presents a modified technique of Dacron graft interposition and reimplantation anomalous left coronary artery from the pulmonary artery on the ascending aorta.

Narrative Review of Anomalous Origin of Coronary Arteries: Pathophysiology, Management, and Treatment

Coronary artery anomalies (CAA) are a diverse group of congenital anomalies and are the second most common cause of sudden cardiac death in the young population after Hypertrophic Cardiomyopathy (HCM). Symptoms range from chest pain, syncope, or sudden cardiac arrest to completely asymptomatic. The prevalence of congenital coronary artery anomalies in the general population is estimated to be between 1% and 2%. CAA often gets underdiagnosed due to the lack of knowledge of the disease process. Approximately 5% of patients with acute myocardial infarction do not have atherosclerotic coronary artery disease or luminal narrowing due to other causes. Congenital coronary artery anomalies account for 50-60% of this 5% of patients. Most patients are asymptomatic for most of their lives, and chest pain is the most common symptom in symptomatic patients when referred for coronary angiography, typically when the diagnosis is typically made. The malignant coronary artery is a rare presentation of a coronary anomaly when associated with atherosclerotic coronary artery disease or valvular heart disease. Patients with symptoms of an abnormal coronary artery origin will receive medical treatment/observation, exercise restriction, coronary angioplasty with stent deployment, or surgical repair.

Rare case of anomalous origin of the left coronary artery from the pulmonary artery in a 4-year-old child

Anomalous origin of the left coronary artery from the pulmonary artery is an exceedingly rare and potentially fatal congenital coronary anomaly that typically presents early in infancy. We report an unusual case of anomalous origin of the left coronary artery from the pulmonary artery in a 4-year-old child who presented later in life with vague respiratory and gastrointestinal symptoms and was found to have severe global cardiac dysfunction with evidence myocardial ischaemia.

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.

Anomalous Origin of the Coronary Artery from the Pulmonary Artery in Children and Adults: A Pictorial Review of Cardiac Imaging Findings

Anomalous origin of the coronary artery from the pulmonary artery is a rare and potentially fatal congenital heart defect. Up to 90% of infants with an anomaly involving the left coronary artery die within the first year of life if left untreated. Patients who survive beyond infancy are at risk of sudden cardiac death. Cardiac CT and MRI are increasingly being used for the accurate diagnosis of this anomaly for prompt surgical restoration of the dual coronary artery system. Moreover, life-long imaging surveillance after surgery is necessary for these patients. In this pictorial review, multimodal cardiac imaging findings of this rare and potentially fatal coronary artery anomaly are comprehensively discussed, and representative images are provided to facilitate the understanding of this anomaly.

ACARPA, a rare case of ALCAPA

An anomalous circumflex coronary artery arising from the right pulmonary artery is very rare. Clinical presentation varies from absence of symptoms to arrhythmia and sudden cardiac death. Since prevalence is very low, no definite therapy has been delineated yet. A 19-year-old patient, previously treated for a vascular ring and mitral valve stenosis, was diagnosed with this anomaly through echocardiography revealing collateral coronary flow, with confirmation of this coronary anomaly on subsequent computed tomography examination. To alleviate the burden for arrhythmia in this young patient, he was successfully treated with surgical reimplantation followed by an uneventful recovery.

Surgical treatment for anomalous origin of the right coronary artery from the pulmonary artery: a case report with five-year follow-up

Background

Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a rare congenital heart disease affecting about 0.002% of the population. Knowledge of ARCAPA is almost collected from case reports. The aim of this study was to provide a rare case to better understand this rare congenital coronary anomaly.

Case presentation

We report a rare case of an 18-year-old male who was initially referred because of heart murmur. Dilated and tortuous coronary arteries were detected by echocardiography and congenital coronary anomaly was suggested. Further coronary CT angiography confirmed the diagnosis of ARCAPA. Although dual coronary system provides favorable long-term outcome, bypass surgery was considered technically difficult due to the huge mismatch of caliber between the right coronary artery and graft vessels. Eventually, simple right coronary artery ligation was performed. The patient was followed up for about 5 years without evidence of atherosclerosis or myocardial ischemia.

Conclusions

ARCAPA presents as a rare congenital heart disease with variable clinical manifestations. Surgical treatment is highly recommended to re-establish dual coronary system and prevent further complications. To our best knowledge, only about 200 cases of ARCAPA has been reported.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in adults: Collateral circulation does not preclude direct reimplantation

BACKGROUND

The adult type of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is characterized by late presentation due to collateral coronary flow. Patients often present with long time recurrent angina or dyspnea. Surgical correction can be a challenge due to the vast collateral coronary circulation.

CASE PRESENTATION

A previously healthy 41-year-old male presented in the emergency room referring typical angina and dyspnea. Coronary angiography revealed ALCAPA. Surgical correction was indicated. Under cardiopulmonary bypass, the left main coronary artery ostium was isolated and directly reimplanted in the aorta. The patient was discharged from the hospital without complications and asymptomatic. Control coronary angiography showed enlarged left main coronary artery and regression of the collateral circulation.

CONCLUSION

Even with a well-developed collateral circulation, detachment of the left coronary artery and direct implantation in the aorta is feasible, achieving good long-term results.

Long-Term Outcome of the Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery (ALCAPA) in Children After Cardiac Surgery: A Single-Center Experience

Background

The anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary artery anomaly. It induces left ventricular (LV) dysfunction and mitral valve regurgitation (MR). If untreated, survival beyond infancy is rare. The aim of our study was to analyze the outcome in children with ALCAPA after cardiac surgery.

Methods

We retrospectively reviewed all patients who were diagnosed at our institution with ALCAPA and underwent surgical repair from 1999 to the end of 2018 (for 20 years). We followed LV dimensions, function, the progress of MV regurgitation, and the somatic growth of children after surgical repair.

Results

Twenty-nine patients underwent ALCAPA repair while 15 (52%) patients were male. The median age at surgical repair was 5.3 (IQR: 3.8-7.4) months and the mean weight was 5.5±2 kg. Surgical repair was performed in form of coronary reimplantation in 26 (90%) patients and Takeuchi repair in three (10%) patients. Intensive care unit (ICU) stay was eight (IQR: 6-17) days and hospital stay was 15 (IQR: 12-21) days. The follow-up duration was 5±3.6 years. Echocardiographic parameters started to improve by six weeks after the repair, and they normalized by one year. At the time of surgery ejection fraction (EF) was 34±17%, fractional shortening (FS) was 15±10%, and LV inner diameter in diastole (LVIDD) z score was 5.7±2.8. These parameters improved by one year after surgery to 66±7%, 34±6%, and 0±1.3, respectively. However, somatic growth started to improve six months after surgical repair. MR was moderate to severe in seven (24%) patients at the time of surgery and regressed to no more moderate nor severe MR at the last follow-up. None of the 29 patients died.

Conclusions

LV systolic function and dimensions start to improve by six weeks after surgery and reach normal values by one year. MR regresses without intervention in correspondence with the regression of LV dimensional parameters. The somatic growth of children improves six months after repair.