CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 8, September 2012 AFRICA e15 Case Report A young patient with coronary artery anomaly, whose left anterior descending artery originated from the pulmonary artery, underwent cardiac arrest TAYFUN SAHİN, SERDAR BOZYEL, ESER ACAR, ULAS BİLDİRİCİ, SADAN YAVUZ, OZGUR BARIS, ERTAN URAL, DİLEK URAL Abstract A rare congenital anomaly of the coronary arteries, in which the left coronary arterial system starts from the arteria pulmonalis, is known as Bland–White–Garland (BWG) syndrome. Isolated left anterior descending (LAD) or circum- flex (Cx) arteries originating from the pulmonary artery are even more rare. These anomalies may cause myocardial ischaemia, myocardial infarction, arrhythmia and sudden death. Even if the patient is asymptomatic, he/she should undergo corrective surgery. Here we present the case of an 18-year-old male who survived sudden cardiac arrest during exercise. We identified intra-myocardial blood flow from transthoracic echocardiography, and performed coronary and computed tomographic (CT) angiography, which showed that all the coronary arteries were ectatic and curly and there were disseminated collaterals among the coronary arteries. We diagnosed ‘anomalous left coronary artery from the pulmonary artery’ (ALCAPA) syndrome, as additionally, the LAD originated from the pulmonary artery. We treated the patient with a left internal mammarian artery – left anterior descending artery (LIMA–LAD) graft. Keywords: coronary artery anomalies, echocardiography, angiography, surgical treatment Submitted 18/10/10, accepted 3/5/12 Cardiovasc J Afr 2012; 23: e15–e18 www.cvja.co.za DOI: 10.5830/CVJA-2012-037 Bland–White–Garland (BWG) syndrome is a rare congenital coronary artery anomaly in which the left coronary arterial system originates from the arteria pulmonalis. Isolated left anterior descending (LAD) or circumflex (Cx) arteries originating from the pulmonary artery are even more rare. 1 These anomalies may cause myocardial ischaemia, myocardial infarction, arrhythmia and sudden death. Case report An 18-year-old male experienced sudden cardiac arrest during exercise at school. Cardiopulmonary resuscitation was performed and he was immediately revived. He was hospitalised and at first cranial pathology was suspected but a cerebral CT scan was normal. The patient was referred to our clinic with an early diagnosis of hypertrophic cardiomyopathy. He did not have any irregularities in his history. His heart rate was 74 beats per minute, and blood pressure was 110/70 mmHg. All other examination findings were normal. Electrocardiography (ECG) revealed a sinus rhythm and T-wave negativity in the derivation of V 1 –V 2 . His blood analyses were normal. Holter ECG examination showed a large ORS tachycardia attack at a rate of five beats/137 per minute. Transthoracic echocardiography (TTE) revealed a dilated left ventricle (left ventricular diastolic diameter = 58 mm, systolic diameter = 38 mm) and eccentric left ventricular hypertrophy with a normal ejection fraction. Colour flow transthoracic Doppler echocardiography (TTE) demonstrated blood flow in the myocardial wall, and the parasternal short-axis view showed abnormal flow towards the pulmonary artery, 1–2 cm below the pulmonary valve (Fig. 1A, B, C). Upon suspicion of a coronary artery anomaly, coronary and CT coronary angiography were performed. The ostium of the LAD artery was not seen in the coronary angiography. It showed that the right coronary artery was dilated and tortuous, and it provided extensive collaterals to the LAD artery, which drained into the main pulmonary artery. Pulmonary angiography showed that the left system originated from the pulmonary artery (Fig. 2). CT coronary angiography confirmed that the LAD artery originated from the main pulmonary artery (Fig. 3). Cardiac magnetic resonance imaging (MRI) demonstrated left ventricular hypertrophy and a sub-endocardial infarct in the apical anterior and anteroseptal zones. Surgical correction was planned. The LAD was detached from the pulmonary artery and connected to the aorta, and the left internal mammarian artery (LIMA) was anastomosed to the LAD artery (Fig. 4). Department of Cardiology, Medical Faculty of Kocaeli University, Kocaeli, Turkey TAYFUN SAHİN, MD, tayfunsa@yahoo.com SERDAR BOZYEL, MD ESER ACAR, MD ULAS BİLDİRİCİ, MD ERTAN URAL, MD DİLEK URAL, MD Department of Cardiovascular Surgery, Medical Faculty of Kocaeli University, Kocaeli, Turkey SADAN YAVUZ, MD OZGUR BARIS, MD