Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery Initially Visualized by Echocardiography and Multidetector Computed Tomography Coronary Angiography
A 35-year-old female visited outpatient department presenting with intermittent chest discomfort for 3 weeks. She had been generally in healthy condition and had no known coronary risk factors. There was no family history of heart disease or sudden death. On physical examination, grade 3 systolic murmur was heard at left sternal border. There was no specific abnormality in plain chest radiography. Electrocardiography showed precordial T wave inversion thought to be juvenile pattern. Transthoracic echocardiography showed left coronary artery (LCA) arising from main pulmonary artery and abundant septal color flow Doppler signals (). There was abnormal turbulent flow adjacent to the right atrium thought to be of giant tortuous right coronary artery (RCA). Transesophageal echocardiography clearly revealed markedly dilated and tortuous RCA showing windsock appearance (). The ratio of the proximal RCA diameter to the aortic root diameter was markedly increased (RCA: aorta ratio = 0.217). Left ventricular function and regional wall motion was normal. MDCT coronary angiography showed LCA originating from the left side of the pulmonary artery and remarkably dilated and tortuous RCA consistent with the findings of echocardiography (). In coronary angiography, we could not engage LCA. RCA was extraordinarily dilated and tortuous with abundant collateral channels draining into the pulmonary artery through LCA (). Treadmill exercise test showed ST-segment depression in lead II, III, aVF and V6 presenting inducible myocardial ischemia (). Patient was undergone direct re-implantation of the anomalous coronary artery into the aorta and pericardial patch closure of main pulmonary artery without any complication (). Transient left ventricular hypertrophy was found for several days after the operation, which was supposed to be from increased blood flow to LCA from aorta. At present, six months after surgical correction of ALCAPA, patient is in good condition without any complication and cardiac symptom.