JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO.

24, 2018 ª 2018 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

IMAGES IN INTERVENTION

Sudden Cardiac Arrest in Adult Due to

Anomalous Origin of Left Main Coronary
Artery From Pulmonary Artery
Bharat Marwaha, MD, Owais Idris, MD, Mobasser Mahmood, MD, Archana Gundabolu, MD, Syed Sohail Ali, MD, Tarif
Kanaan, MD, Hemindermeet Singh, MD
coronary artery giving collateral flow to left coronary artery.
Aortic root angiogram as depicted in Figure 2

A
and Online Video 1 revealed the anomalous origin of left
main coronary artery originating from pulmonary artery
nomalous origin of left main coronary artery
along with collateral flow from right to left coronary artery.
Coronary computed tomography confirmed the finding of an
from the pulmonary artery is a rare and potentially fatal anomalous left coronary artery (LCA) originating from the
congenital cardiac anomaly that affects 1 in every 300,000 main pulmonary trunk (Figure 3).
live births. A 38-year-old man with no past medical history
Cardiothoracic surgery recommended transferring the
was admitted after a sudden cardiac arrest during sexual
patient to an advanced center where he under went open
intercourse. Upon emergency medical service arrival, he
surgical repair with re-implantation of the LCA system into
was noted to be in ventricular fibrillation. He was
the aorta after placement of an interposition graft in the main
resuscitated after multiple rounds of de fibrillations and
pulmonary artery to prevent compression of the coronary
cardiopulmonary resuscitation. The electrocardiogram
pathway. Post-operative echocardiogram showed an
showed left ventricular hypertro phy with repolarization
ejection fraction of 48%. Post-op cardiac magnetic
changes. Troponin T trended up to 1.34 ng/ml. The patient
resonance imaging showed a dilated LCA with net
underwent therapeutic hypothermia for 24 h along with
antegrade flow on phase contrast imaging. Patient was dis
aspirin 81 mg and intravenous heparin 12 U/kg/h. A
charged home on optimized medical therapy in a stable
2-dimensional echocardiogram revealed a left ventricular
condition.
ejection fraction of 20%. On day 3 of admission, he was
Anomalous origin of left main coronary artery from the
extubated. Selective right coronary angiography as shown
pulmonary artery is well tolerated in fetal
in Figure 1 and Online Video 2 revealed the large right

From the Department of Cardiovascular Disease Fellowship Program, Mercy St. Vincent Medical Center, Toledo, Ohio. The authors have
reported that they have no relationships relevant to the contents of this paper to disclose.

Manuscript received September 6, 2018; accepted September 11, 2018.

ISSN 1936-8798/$36.00 https://doi.org/10.1016/j.jcin.2018.09.025

JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO. 24, 2018
Marwaha et al.
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Anomalous Origin of the Left Main

FIGURE 1 Selective Right Coronary Angiogram

Coronary angiogram revealing the collateral flow to the left coronary artery (Online Video 2). LM ¼ left main artery; RCA ¼ right coronary
artery.

FIGURE 2 Aortogram

Aortic root injection showing left main coronary artery originating from the pulmonary artery along with collateral flow from right to left
coronary artery (Online Video 1). PA ¼ pulmonary artery; other abbreviations as in Figure 1.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 11, NO. 24, 2018
Marwaha et al.
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DECEMBER 24, 2018:e203 – 5
Anomalous Origin of the Left Main

FIGURE 3 Coronary CTA

Coronary computed tomography angiography (CTA) showing the origin of LM from the PA. Abbreviations as in Figures 1 and 2.

life, but reduction in the pulmonary artery pressure

after birth leads to significant myocardial ischemia in the
LCA territory leading to heart failure, left ventricular
hypoplasia, and mitral regurgitation. American College of
Cardiology/American Heart Association guidelines
recommend the reconstruc tion of dual coronary artery with
re-implantation of coronary artery to aorta as the preferred
option of management and every 3 to 5 years follow-up with
echocardiogram post-surgery (Class 1, Level of Evidence:
C).
ADDRESS FOR CORRESPONDENCE: Dr. Bharat Mar waha,
Department of Cardiovascular Disease Fellow ship
Program, Mercy St. Vincent Medical Center, 2213 Cherry
Street, Toledo, Ohio 43608. E-mail: bmarwaha@mercy.com.

KEY WORDS ALCAPA, anomalous coronary artery, cardiac arrest

APPENDIX For supplemental videos, please see the online version of

this paper.