The anomalous pulmonary origin of coronary arteries potentially induced ischemia and even sudden cardiac death, which is determined by coronary involvement and collateral development2. In adult ALADAPA, LCX originates from the aorta and well-developed collaterals can minimize the risk of myocardial ischemia, which raised the question whether surgical correction was necessary for this community.
In our case, the patient presented with progressive palpitations and was treated surgically. Jujjavarapu and colleagues reported that in direct implantation, it can be technically difficult to mobilize the LAD to reach the aorta in adults. So proximal ligation of the anomalous artery with LIMA grafting was conducted as alternative in our case. Myocardial function and viability were assessed by using CMR before and during the short-term follow-up.
The ECV % value increased in the anomalous LAD region with abundant and tortuous collateral vessels before surgery, six months after the repair, our observation proved that the collateral circulation decreased significantly on CCTA images (Fig. 1G), and the ECV % value of the corresponding regions decreased to varying degrees. It is noteworthy that these intramyocardial collaterals may inflate CMR-based ECV % measures. ECV% did not indicate myocardial fibrosis in this scenario, but it still can reflect intramyocardial collaterals development and changes with treatment.
Furthermore, post-operative elevation of EF % confirmed the improved global LV function, but strain analysis showed the apical segments with hypokinesis (Fig. 1H). In some segments, hibernating myocardium recovered quickly, whereas, in the apex, myocardial irreversible injury complicated with thrombus presented on CMR-LGE images, which was generally considered to be related to poorer clinical outcomes.
Rich inter-coronary collateralisation allows these patients to reach adulthood and protects the myocardium from irreversible damage, conversely, diminishing the inter-coronary collateral flow is an important risk factor for necrosis of hibernating myocardium3. Surgery corrected coronary steal phenomenon but also diminished inter-coronary collaterals, thus it is difficult to identify whether surgical correction could improve the left ventricular perfusion and to what extent.