Angiogram: ALCAPA, but with a twist!

It is ALCAPA alright. But, look at the still frame below. There is a coronary artery originating from the aortic root as well! You will see it when you see the angiogram again. Needs more views to solve this.

Okay, this is not a standard case. Normally-arising vessel from left coronary sinus of aorta was mainly LCX with a rudimentary LAD. The one arising from PA, was supplying major part of LV. We mulled over what to do with this patient. Finally, she had a CABG to LCA from PA with ligation of origin of LCA from PA. Reimplanting this to aortic root is another option.

ALCAPA - Importance of Color Doppler Signal & Unfortunate artifact in 2D

Following 3 images are from a 14 yr old boy complaining of exercise-related dizziness, palpitation and chest discomfort.


Figure 1: Parasternal short axis view...unfortunately has an artifactual drop out which was misleading. Here, LCA appears to be clearly originating from aorta. However, the color Doppler signal in second image raises a red-flag.




Figure 2: This image with color flow Doppler signal in LCA indicates "wrong" direction of flow in LCA. This finding lead to performance of an angiogram (Figure 3).


Figure 3: RAO view of selective left coronary angiogram showing retrograde filling of left coronary system which ultimately drains into Main Pulmonary Artery. Venous catheter is in MPA.

Retrospectively, there is a "drop-out" of the thin membranous separation between Aorta and LCA which is originating from MPA, but travel close to the wall of aorta. This emphasizes the importance of showing coronary origins both by 2D and color Doppler.

Also, such demonstration with 2D and color Doppler will eliminate possibility of mistaking transverse sinus of the pericardium around the great arteries for coronary arteries by 2D. Color Doppler will show fail to demonstrate flow in transverse sinus (folds of pericardium).