**Introduction/Hypothesis:**
A complex case of a 59 year old male with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) diagnosed at age 39 status post combined Takeuchi repair with interpulmonary baffle and mitral valve annuloplasty who presented with massive thrombosed right coronary artery pseudoaneurysm exerting mass effect on the right atrium and right ventricle and chronic myocardial infarcts in multiple vascular territories with resultant severe tricuspid regurgitation and left-sided heart failure.

**Methods**
Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac anomaly accounting for less than 0.5% of all  left ventricle congenital heart diseases, though it is the most common congenital coronary artery anomaly presenting in children. It usually presents in infancy with congestive heart failure symptoms occurring in 85% of patients within the first 2 months of life. ALCAPA often results in left ventricular myocardial ischemia due to perfusion of the left coronary artery (LCA) with low-pressure, deoxygenated blood from the pulmonary system. This can result in LAD territory ischemia and infarction leading to poor left ventricle (LV) function and mitral regurgitation. Up to 90% of cases of ALCAPA are fatal if not surgically treated. Surgical techniques include direct transfer of the LCA to the aortic root, bypass grafting, and Takeuchi repair with interpulmonary baffle from the aorta to the anomalous LCA origin. The mortality despite surgery is 5-10%, usually related to poor LV function.

**Results**
This patient presented to Mayo Clinic Florida for tricuspid regurgitation, worsening heart failure, and possible hepatic cirrhosis. Initial imaging workup with echocardiogram and cardiac CT and MRI demonstrated post surgical changes of Takeuchi repair with interpulmonary baffle and mitral valve annuloplasty, massive thrombosed large right coronary artery pseudoaneurysm with occlusion of the right coronary artery and mass effect on the right atrium and right ventricle, severe tricuspid regurgitation, transmural infarct in the RV free wall and LAD-territory, 4 chamber dilitation, and depressed systolic function with LVEF of 36%.

**Conclusion**
The treatment for this patient was heart transplant occurring approximately 8 months after initial consultation with the cardiac transplant team with a good clinical outcome for the patient to this date. In conclusion, ALPACA is a congenital cardiac anomaly associated with high mortality if undiagnosed and untreated. Surgical correction of the anomalous LAD origin can greatly reduce mortality; however, some patients may experience poor left ventricle function due to myocardial infarct occurring prior to surgical correction and may require cardiac transplant as in this case.



ALCAPA with Massive RCA Aneurysm After Takeuchi Repair

This course will explore basic and cutting-edge imaging techniques to improve patient care and hone individual skills in performance and interpretation of echocardiography, nuclear cardiology, cardiac computed tomography, and cardiovascular magnetic resonance imaging. Days will reinforce how cardiovascular imaging may improve comprehension in ischemic heart disease, structural heart disease, cardiomyopathies, and heart failure. Experts will utilize novel techniques to reinforce key topics including taped interventional cases and a strong emphasis on case presentations.