**Introduction/Hypothesis:**
Introduction: Anomalous aortic origins of the coronary arteries (AAOCA) is a well-recognized variant occurring in an estimated 0.2-0.6% of individuals. While there are established recommendations on the risk stratification and management of AAOCA, less is known about the optimal management of the rarer anomalous origin of coronary arteries from the pulmonary artery (ACPA). We present a case of an anomalous left coronary artery from the PA (ALCAPA).

**Methods**
Case: A 58 year old man with a history of surgically repaired ALCAPA with reimplantation to the aorta and concurrent mitral valve annuloplasty, and paroxysmal atrial fibrillation was seen for evaluation of progressive heart failure symptoms. He initially presented 12 years prior at age 46 for chest pain and was found to have ALCAPA with no significant coronary stenoses. He was observed until age 49 when he underwent surgical Takeuchi repair with an intrapulmonary vessel from the aorta to the left main coronary artery (LMCA) and MV 30mm Medtronic annuloplasty ring. One year later he developed heart failure symptoms with preserved left ventricular (LV) function, managed with diuretics, and new atrial fibrillation treated with amiodarone. At age 55 he underwent surveillance cardiac computed tomography angiography (CCTA) and was found to have a large thrombosed RCA aneurysm which was observed. This was further characterized on invasive coronary angiography. He subsequently developed severe tricuspid regurgitation (TR) with associated congestive hepatopathy with fibrosis and was referred for repeat evaluation. 
He underwent multimodal imaging including transthoracic echocardiogram, CCTA, and cardiac magnetic resonance imaging (CMR). TTE demonstrated mildly reduced LV function (LVEF 40%) with regional wall motion abnormalities (RWMA), a moderately enlarged RV, with external compression from the RCA aneurysm causing severe TR. CCTA measured the thrombosed RCA aneurysm as 14.3 cm with associated RCA occlusion at that level and no distal flow into the distal RCA or branches. The reimplanted LMCA was also aneursymal up to 13mm. CMR demonstrated and LVEF of 36% with RWMA including dyskinesis of the apical septum, akinesis of the rest of the apex and inferior and inferolateral wall with associated thinning of the inferior and inferolateral wall, and transmural late gadolinium enhancement (LGE) of the mid-basal anteroseptum and inferolateral walls. The RV was dilated with moderately depressed systolic function (RVEF 28%) and transmural LGE of the RV free wall and apex with associated akinesis. 
Due to the mass effect from the large RCA aneurysm and diffuse LV and RV infarcted territories, he was referred for consideration of heart versus combined heart-liver transplant.

**Results**
Discussion: This case is an interesting presentation of ALCAPA in adulthood, as many patients present in infancy due to insufficient collateral blood supply. While this patient had robust collaterals from his RCA to his left system, this mechanism was also likely the culprit for his subsequent development of an RCA aneurysm. After the native LMCA was repaired and exposed to systemic pressures, competitive flow to the right system likely led to the aneurysm with subsequent ischemia and mass effect. The current recommended treatment of ALCAPA is surgical repair for all patients, however, this case suggests the need for further study of patients presenting later in life and possible consideration of alternative surgical techniques.

**Conclusion**
Conclusion: ALCAPA is a rare condition that typically presents in infancy and childhood, and is recommended to be surgically managed. In cases of adulthood presentations, the hemodynamic effects of surgical repair may be harder to predict and potentially devastating. Multimodality imaging may be helpful in the initial evaluation of adults for risk stratification and in post-repair surveillance to determine the hemodynamic effects of coronary flow on myocardial perfusion and function.



Stiff Competition: A Case of a Repaired Anomalous Left Coronary Artery from the Pulmonary Artery Leading to a Large Right Coronary Artery Aneurysm

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.