anomalous origin of the left coronary artery from the pulmonary artery ( alcapa ) is a rare coronary anomaly comprising 0.2 - 0.5% of all congenital cardiac malformations . although alcapa has high mortality of 90% within the 1st year of life , 10 - 15% of patients survive to adulthood in case of existence of extensive intercoronary collaterals.1 ) in the past , alcapa was diagnosed exclusively by cardiac catheterization and angiography.2 ) however , recent technical advances in echocardiographic imaging and multidetector computed tomography ( mdct ) coronary angiography enabled better visualization of the anomalous origin of coronary artery and associated findings . in korea , there have been several reports of adult type alcapa.3 - 5 ) most of them are diagnosed by invasive coronary angiography with or without diagnostic clue of echocardiography . here , we report a 35-year - old female patient with alcapa initially visualized by echocardiography and mdct coronary angiography . a 35-year - old female visited outpatient department presenting with intermittent chest discomfort for 3 weeks . there was no family history of heart disease or sudden death . on physical examination , transthoracic echocardiography showed left coronary artery ( lca ) arising from main pulmonary artery and abundant septal color flow doppler signals ( fig . there was abnormal turbulent flow adjacent to the right atrium thought to be of giant tortuous right coronary artery ( rca ) . the ratio of the proximal rca diameter to the aortic root diameter was markedly increased ( rca : aorta ratio = 0.217 ) . left ventricular function and regional wall motion was normal . mdct coronary angiography showed lca originating from the left side of the pulmonary artery and remarkably dilated and tortuous rca consistent with the findings of echocardiography ( fig . rca was extraordinarily dilated and tortuous with abundant collateral channels draining into the pulmonary artery through lca ( fig . treadmill exercise test showed st - segment depression in lead ii , iii , avf and v6 presenting inducible myocardial ischemia ( fig . patient was undergone direct re - implantation of the anomalous coronary artery into the aorta and pericardial patch closure of main pulmonary artery without any complication ( fig . transient left ventricular hypertrophy was found for several days after the operation , which was supposed to be from increased blood flow to lca from aorta . at present , six months after surgical correction of alcapa , patient is in good condition without any complication and cardiac symptom . the most common is alcapa , followed by anomalous rca from the pulmonary artery ( arcapa).6 ) most of patients die within the 1st year of life . even though 10 - 15% of patients survive to adulthood , they are prone to sudden death secondary to malignant ventricular arrhythmias , myocardial ischemia or global cardiomyopathy with an estimated incidence of 80 - 90% at a mean age of 35 years . after first description of alcapa by brooks7 ) in 1885 , small number of alcapa cases were reported from place to place . in korea , o et al.3 ) reported 45-year - old man with alcapa diagnosed by invasive coronary angiography without any clue from transthoracic echocardiography in 1993 . infants with alcapa usually suffer from symptoms of heart failure or myocardial ischemia / infarction manifested as perioral cyanosis , shortness of breath , diaphoresis . in adult patients with alcapa , non specific systolic murmur can be heard commonly on physical examination and ischemic t wave changes are found in electrocardiography in most cases . the clinical diagnosis of alcapa is not easy because this lesion is rare and clinical findings are frequently indistinguishable from those of other cardiac pathology . up to recently , definite diagnosis of alcapa has been made by conventional coronary angiography.8 ) however recent advances of imaging technique such as echocardiography , mdct , and magnetic resonance imaging enabled noninvasive morphological assessment of the coronary arteries . rha et al.5 ) reported a 65-year - old woman with alcapa confirmed by coronary angiography with a clue of dilated rca in transthoracic echocardiography . after conventional coronary angiography , they also performed mdct coronary angiography for three dimensional visualization of coronary anomaly . echocardiographic findings of alcapa include dilated rca and detection of pulmonary artery to lca shunt with abundant septal collaterals by both pulse wave and color flow doppler imaging.2 ) in our case , detection of above echocardiographic findings was not so difficult . subsequent mdct coronary angiography visualized three dimensional coronary anatomy consistent with echocardiographic findings , which was verified by conventional coronary angiography . because patients with alcapa have potential risk of sudden death due to malignant arrhythmias or myocardial ischemia , surgical intervention is the definitive treatment for alcapa.9 ) sometimes , adult patient with alcapa is often clinically asymptomatic or presents with only atypical chest discomfort without obvious abnormality in routine screening test . the detection of unusual color flow signals should raise one 's suspicion coronary artery abnormality . our case gives us emphasis on the need of close attention during echocardiographic study including color flow doppler exam of ventricular septum and identification of origin of coronary arteries .
anomalous origin of the left coronary artery from the pulmonary artery ( alcapa ) is a rare congenital anomaly associated with very high mortality during infancy . 
 we report a 35-year - old female patient with alcapa initially visualized by echocardiography . 
 she visited outpatient department presenting with intermittent chest discomfort for 3 weeks . 
 transthoracic echocardiography showed left coronary artery arising from main pulmonary artery and abundant septal color flow doppler signals . 
 transesophageal echocardiography clearly revealed markedly dilated and tortuous right coronary artery showing windsock appearance . 
 multidetector computed tomography and coronary angiography enabled visualization of anomalous left coronary artery originating from left side of main pulmonary trunk . 
 after treadmill exercise test which showed st - segment depression presenting inducible myocardial ischemia , patient underwent direct re - implantation of the anomalous coronary artery into the aorta without any complication .