How to cite this article: Goel S, Baloria KA, Selot N, Panigrahi B. TEE images of adult anomalous left coronary artery from pulmonary artery. Ann Card Anaesth 2010;13:162-4
How to cite this URL: Goel S, Baloria KA, Selot N, Panigrahi B. TEE images of adult anomalous left coronary artery from pulmonary artery. Ann Card Anaesth [serial online] 2010 [cited 2022 Jan 29];13:162-4. Available from: https://www.annals.in/text.asp?2010/13/2/162/62939
A 32-year-old female presented to the hospital with dyspnoea and chest pain (on exertion) since one year. Electrocardiography showed Q wave in lead I and aVL. Transthoracic echocardiography (TTE) showed dilated right coronary artery (RCA), continuous flow in the proximal main pulmonary artery (MPA), scarring in the antero-lateral papillary muscle and mild hypo kinetic distal interventricular septum with 60% ejection fraction. A computed tomography (CT) angiography traced the origin of the left coronary artery (LCA) from the MPA. [Figure 1] Cardiac catheterization revealed dilated RCA [Figure 2] and left to right shunt at the level of MPA. This completed the diagnosis of the anomalous origin of left coronary artery from pulmonary artery (ALCAPA) .
The patient was scheduled for closure of anomalous LCA ostium from MPA along with left internal mammary artery anastomosis to the left artery descending artery. She was induced using standard opioid based technique. Transesophageal echocardiography (TEE) probe was inserted atraumatically after induction of anesthesia. Mid esophageal short axis [Figure 3] and long axis aortic valve view showed the dilated RCA [Figure 4]. Upper esophageal short axis aortic arch view showed MPA on the right side of the imaging sector with ostium of LCA distal to the pulmonary valve [Figure 5]. Color Doppler revealed retrograde flow from the ostium of LCA to MPA (blue color) [video file [[Figure 6] and 6A]. Though the preoperative TTE mentioned continuous flow in MPA, we found retrograde flow to MPA during systole. (Video file attached)- . A transgastric mid-papillary view showed brightness in the antero-lateral papillary muscle [Figure 7]. Thus, TEE confirmed the diagnosis in this case. Surgery and the postoperative course were uneventful. Postoperative TTE showed no residual flow in the MPA.
ALCAPA is a rare but serious congenital cardiac anomaly accounting for 0.25-0.50% of all congenital heart diseases. ALCAPA is of two types based on the survival pattern - adult and infantile type. In the infantile type, the collateral circulation is poorly developed and therefore, if left untreated, the mortality rate in the first year of life is 90% secondary to myocardial infarction and mitral valve insufficiency leading to congestive heart failure. In the adult type, delayed presentation is due to development of good collateral circulation. However, there is an estimated 80-90% incidence of sudden death at a mean age of 35 years in this group.
Electrocardiogram-gated multi detector CT angiography and magnetic resonance (MR) imaging play important roles as noninvasive modalities in assessment of the ALCAPA syndrome. They enable the direct visualization of the LCA arising from MPA and reversed flow from the left coronary artery into the MPA. They also replace the need of cardiac catheterization which is an invasive procedure. These modalities, though very accurate, are expensive and not easily available.
On the other hand, 2-D echocardiography is also a noninvasive diagnostic modality which provides fairly accurate diagnosis. Both 2-D images and color Doppler may identify origin of LCA from MPA by showing turbulent flow at the ostium. LCA ostium which is sometimes not visible on TTE could be seen well on TEE. It also demonstrates the retrograde flow from the LCA to the MPA. The presence of retrograde flow is dependent on the development of collaterals between the left and right coronary artery system. If collateralization has not occurred, as may be the case with pediatric age group, this finding may be absent. Abnormal dilation of the RCA reflects development of extensive collateral between left and right coronary artery system. Another finding which is not sensitive but highly specific is abnormal "brightness" of the left ventricular papillary muscles. TEE monitoring is commonly used during cardiac surgery. However, we could not find TEE images during our literature search and hence this study aimed to present TEE images of ALCAPA.
Backer CL, Stout MJ, Zales VR, Muster AJ, Weigel TJ, Idriss FS, et al. Anomalous origin of the left coronary artery. A twenty year review of surgical management. J Thorac Cardiovasc Surg 1992;103:1049-58.
Chang RR Allada V. Electrocardiographic and echocardiographic features that distinguish anomalous origin of the left coronary artery from pulmonary artery from idiopathic dilated cardiomyopathy. Pediatr Cardiol 2001;22:3-10.
Correspondence Address: Sanjay Goel Consultant, Cardiac Anesthesia, Max Heart and Vascular Institute, 2 Press Enclave, Saket, Delhi- 110017 India
Source of Support: None, Conflict of Interest: None