ABC | Volume 114, Nº4, Suplement, April 2020

Clinicoradiological Correlation Arq Bras Cardiol 2020; 114(4Suppl.1):40-42 Atik et al. ALCAPA in a 75 year old woman vascular network leading to an increase in left atrium, in combination with ischemic events, as detected by the ECG, would orient towards the diagnosis of anomalous origin of the LCA from the PA trunk. This elaborated clinical diagnosis could not be made earlier due to the lack of symptoms, but also to the lack of a duly performed and evaluated symptomatic/ clinical examination, with adequate accuracy. The diagnosis in this case was established by the cardiac catheterization. Differential diagnosis: Other heart diseases that combine with continuous murmur refer to persistent arterial channel, aortopulmonary window and arteriovenous fistulas in general. However, the signs of myocardial ischemia described and evident at the ECG, in combination with altered stress testing, do not occur in the other anomalies just mentioned, unless there is a blockage of the coronary arteries caused by atherosclerosis. Approach: In face of the impact of hyperflow on the pulmonary circulation, and also on left heart cavities, in addition to myocardial ischemia, we considered the possibility of removing the junction point of the left coronary artery and the pulmonary trunk by means of a simple terminal ligature of the coronary artery. With this in view, we would mainly preserve the ventricular function, as well as eliminate left ventricular volume overload. As a consequence, we would prevent long-term adverse events. Nevertheless, since the patient presents asymptomatic and – according to herself – her clinical picture has changed very little since her diagnosis, around 13 years ago, we decided to adopt an expectant strategy. Refusal to surgery has also occurred in similar cases reported in the literature. 1-3 Comments: This patient’s natural evolution until advanced age, with no symptoms and a few adverse manifestations, is undoubtedly a very rare phenomenon. This favorable evolution, under good clinical and hemodynamic conditions, was primarily due to the exuberant collateral circulation from the RC, which managed to ensure adequate coronary circulation as a whole. The anterolateral ischemia revealed by the ECG was not combined with other elements that could be harmful to the patient. From now on, there may be the new onset of arrhythmias, myocardial dysfunction and even thrombosis and embolism events. These acquired traits, which have an effect on the evolution, should have manifested earlier. About 90% of these patients die within the first years of life, if they are not surgically treated, and very few reach higher age. 1-3 It is important to highlight that these patients can benefit from surgical treatment even in adulthood, leading to the decrease of volume overload and of ischemic events, as in a study reported elsewhere with a sample of 50 patients, with an average age of 31.6 ± 15.6 years. 4 Figure 2 – Cinecoronariography demonstrates filling of left coronary (LC) artery and pulmonary artery trunk (PAT) from the right coronary (RC) artery, a characterization of coronary artery anomalies. The arteries are dilated and extremely tortuous, with several collateral pathways and no obstruction. COLLATERALS PAT LC RC 41