Intrapulmonary Aorta to Coronary Artery Graft and Prosthetic Mitral Valve Replacement for Late-Diagnosed Anomalous Left Coronary Artery from the Pulmonary Artery.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly typically diagnosed in infancy. Adult presentation is uncommon and often discovered incidentally. Management becomes more complex in the setting of prior cardiac surgeries, particularly mechanical valve replacement. We report a case of a 26-year-old male with a history of mitral valve repair in 2003 and mechanical mitral valve replacement in 2016, who presented with progressive fatigue and exertional dyspnea. Transthoracic echocardiography revealed severe patient-prosthesis mismatch. Preoperative computed tomography incidentally diagnosed ALCAPA, which had not been detected in previous surgeries. The patient underwent successful redo mitral valve replacement and ALCAPA revascularization using a 5-mm polytetrafluoroethylene vascular prosthesis tunneled through the pulmonary artery. Postoperative recovery was uneventful, and follow-up echocardiography demonstrated satisfactory mitral valve function, patent graft flow, and no significant pulmonary valve gradient. This case highlights the importance of preoperative multimodality imaging in redo cardiac surgery and demonstrates the feasibility of coronary artery revascularization using an intrapulmonary vascular prosthesis for an adult with ALCAPA in a surgically complex setting.