An unusual presentation of anomalous left coronary artery from the pulmonary artery (ALCAPA) syndrome in a 70-year-old man: a case report

BACKGROUND: We present a rare case of anomalous origin of the left coronary artery from the pulmonary artery syndrome in an elderly man, and we describe coronary computed tomographic angiographic imaging findings to improve diagnostic confidence for the evaluation of this uncommon coronary artery anomaly. CASE PRESENTATION: A 70-year-old Caucasian man came to our hospital with slight limitation of physical activity (New York Heart Association class II). He was asymptomatic for angina, syncope, and palpitations. Cardiac magnetic resonance imaging was performed after echocardiography because a hypertrophic cardiomyopathy was suspected; a plausible coronary artery anomaly was demonstrated as collateral evidence. Subsequently, coronary computed tomographic angiography showed the anomalous origin of left coronary artery from the pulmonary artery; the coronary vessels appeared markedly dilated and tortuous. Dilated intercoronary vessels along the epicardial surface of the heart and dilated bronchial arteries, corresponding to collateral pathways, were observed. Left ventricular hypertrophy, delayed subendocardial enhancement, and mitral insufficiency were better evaluated on magnetic resonance images. Invasive coronary angiography confirmed the main findings. Given the patient’s age and clinical performance, surveillance with medical management was considered appropriate, and surgical repair was avoided. CONCLUSIONS: Confidence with the anatomic pattern and clinical significance of this anomalous condition is necessary to improve cardiac imaging evaluation ability. In our patient, coronary computed tomographic angiography proved to be a reliable imaging approach, superior to invasive coronary angiography in terms of diagnostic performance and patient safety.