Fig.1: ECG showing deep Q-waves in V5 and V6.

Fig 2: Aortic root angiogram showing right coronary artery with retrograde filling of ALCAPA.

Fig 3: Selective RCA angio on lateral view showing RCA with retrograde filling of ALCAPA.

This patient is 10 months old boy who presented with history of tachypnea, poor feeding, irritability and crying specifically during feeds for the past few months and was admitted to PICU as a case of heart failure. His clinical examination showed normal peripheral perfusion, normal S1 & S2, II/VI systolic murmur at apex and liver was 3 cm below right costal margin. CXR showed cardiomegaly with plethoric lungs and ECG (Fig.1) showed deep Q-waves in V5, V6 and left ventricular hypertrophy by voltage criteria. Echocardiogram was performed which showed mild LV dilatation, fair contractility with FS of 28%, left coronary artery couldn't be visualized and right coronary artery was dilated with retrograde coronary flow into main pulmonary artery. Clinical diagnosis of anomalous left coronary artery from pulmonary artery (ALCAPA) was made and coronary angiography (Fig. 2, 3) was performed to confirm the diagnosis.

    Final diagnosis of anomalous left coronary artery from pulmonary artery was made and patient had successful surgical re-implantation.

                                                                             Muhammad Dilawar, MD; Ayman Khella, MD
                                                                             Department of Cardiology and Cardiovascular Surgery
                                                                             Hamad Medical Corporation, Doha, Qatar