Left anterior descending coronary artery originating from the pulmonary artery: a rarity suspected during echocardiography

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly that is often referred to as Bland-White-Garland syndrome. Isolated anomalous origin of the left anterior descending (LAD) or circumflex arteries is even rarer. A 38-year-old woman presented with typical angina of about two-year history. Physical examination findings were normal other than a grade 3/6 systolic murmur. Electrocardiography showed anterolateral ST-segment depression and T wave inversion, indicating anterior ischemia. Color flow transthoracic Doppler echocardiography showed dilated coronary arteries. Parasternal short axis views demonstrated an abnormal flow originating from the common pulmonary artery. Upon suspicion of a coronary anomaly, coronary angiography was performed. Both the left circumflex (Cx) and right coronary arteries (RCA) were found dilated, giving extensive collaterals to the LAD artery, which drained into the main pulmonary artery. Computed tomographic angiography confirmed that the LAD artery originated from the main pulmonary artery. Surgical correction was performed and the LAD artery was re-anastomosed to the aorta. Control coronary angiography performed one week after surgery showed patent LAD artery and diminished collateral supply from the RCA and Cx arteries.