ABSTRACT
An asymptomatic 13‐year‐old male was referred for a murmur. Echocardiography was utilized as a preliminary screening instrument, and subsequent diagnoses were facilitated by imaging techniques. The diagnosis of ALCAPA was confirmed by catheterization angiography of the echocardiographic findings, which has been demonstrated to improve the diagnostic accuracy of asymptomatic ALCAPA.
Keywords: adolescent, ALCAPA, asymptomatic, case report, early surgery, multimodal imaging
Key Clinical Message
In asymptomatic adolescents, a heart murmur may be the only sign of ALCAPA. A multimodal imaging approach (echocardiography, CTA, and CMR) is essential for definitive diagnosis, risk stratification, and surgical planning, significantly improving outcomes.
1. Introduction
Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), or Bland‐White‐Garland syndrome, is a rare congenital anomaly (0.25%–0.5%) [1]. Symptomatic presentation in adolescents is exceedingly rare (3%–5% of cases), often with subtle or no symptoms. A heart murmur is often the first clue to the presence of ALCAPA on physical examination [2].
2. Clinical History
A 13‐year‐old patient was admitted to our hospital for further management of a grade 2/6 systolic murmur. The child exhibited no symptoms during the initial phase of the disease. Bedside electrocardiogram showed sinus arrhythmia. Transesophageal echocardiography (TTE) showed an anomalous left coronary artery originating from the pulmonary artery (diameter 0.5 cm), tortuous dilatation of the right coronary artery with abundant collateral flow via the septal branches, and an unenclosed patent foramen ovale (Figure 1A,B). Three‐dimensional CTA reconstruction confirmed the anomalous left coronary origin, generalized tortuosity and dilation of both coronary arteries, and minimal pericardial fluid (Figure 1C,D). Additional CTA views clearly depicted the proximal right coronary artery arising normally from the aorta and the anomalous left coronary artery entering the pulmonary artery (Figure 1E,F). Cardiac MRI corroborated the ectopic left coronary origin from the pulmonary trunk, the normal right coronary origin, and revealed right coronary thickening and tortuosity. Myocardial perfusion enhancement revealed subendocardial ischemia in the interventricular septum and basal anterior wall (Figure 1G). Coronary angiography revealed no sinus tract formation. The patient subsequently underwent successful left coronary‐aortic anastomosis to mitigate ischemia and preserve long‐term cardiac function (Figure 1H).
FIGURE 1.
(A) TTE revealed an aberrant blood flow originating from the pulmonary artery; (B) Abundant collateral flow is present at the septum, and a tortuous, widened right coronary artery is visible in the right atrioventricular groove; (C, D) Coronary computed tomography three‐dimensional reconstruction of posterior collaterals from the right coronary artery to the circumflex branch of left coronary artery; (E, F) Computed tomography angiography (CTA); (G) Magnetic resonance imaging reveals a thickened, tortuous right coronary artery; (H) Left coronary‐aortic anastomosis.
3. Discussion
In asymptomatic adolescents, a heart murmur is often the primary or sole diagnostic clue for ALCAPA. Echocardiography, as the essential initial screening tool, can provide direct diagnostic evidence and is well‐suited for routine examination. In this case, the murmur was linked to mild ventricular ischemia, a finding easily misattributed to other conditions, highlighting the critical need for systematic echocardiographic evaluation. Computed tomography angiography (CTA) serves as the anatomical gold standard, providing complete three‐dimensional visualization of the anomalous coronary origin and collateral circulation, which is indispensable for surgical planning [3]. However, CTA lacks the capacity to assess hemodynamics [4]. CMR primarily evaluates myocardial injury. Delayed enhancement sequences are identified in over 70% of patients with asymptomatic endocardial damage. The detection of subendocardial fibrosis provides a crucial basis for risk stratification of sudden death [5]. Contemporary evidence confirms that this multimodal imaging strategy enhances the diagnostic precision of asymptomatic ALCAPA to over 95%, avoids misdiagnosis rates of up to 60% [5], and guides the timing of surgical intervention. Prompt surgery after diagnosis remains paramount for preventing sudden death [3].
Author Contributions
Yi Cheng: conceptualization, writing – original draft, writing – review and editing. Jing Li: funding acquisition, visualization. Huiying Chen: data curation, validation. Xiao Wang: methodology, project administration. Xiaojing Ma: methodology, resources. Yue Cao: supervision, validation.
Funding
This study was supported by the Scientific Research Program of Wuhan Municipal Health Commission (WX21D58).
Ethics Statement
The case report was approved by the Ethics Review Committee of the Wuhan Asia General Hospital Affiliated Wuhan University of Science.
Consent
Due to the patient being a minor, this case report has obtained written informed consent from the patient's father for publication.
Conflicts of Interest
The authors declare no conflicts of interest.
Data Availability Statement
The data that support the findings of this case report are not publicly available due to containing information that could compromise the privacy of the patient. The data are, however, available from the corresponding author upon reasonable request and with permission from the institutional ethics committee.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this case report are not publicly available due to containing information that could compromise the privacy of the patient. The data are, however, available from the corresponding author upon reasonable request and with permission from the institutional ethics committee.