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(Circulation. 2001;103:e85.)
© 2001 American Heart Association, Inc.

Images in Cardiovascular Medicine

Changing Electrocardiographic Patterns During Medical Treatment in a Patient With Anomalous Left Coronary Artery Originating From the Pulmonary Artery

Dona Brekke, DO; Curt G. DeGroff, MD; Michael Schaffer, MD

From Pediatric Cardiology, University of Colorado Health Science Center, The Children’s Hospital, Denver.

Correspondence to Curt G. DeGroff, MD, Cardiovascular Flow Dynamics Laboratory, UCHSC, The Children’s Hospital, 1056 E 19th Ave, B100, Denver, CO 80218. E-mail degroff.curt{at}tchden.org

A6-month-old child with clinical signs of heart failure and cardiomegaly on chest radiograph was referred for evaluation. An echocardiogram and angiogram demonstrated an anomalous left coronary artery originating from the pulmonary artery (ALCAPA). After 3 days of intensive medical management including intravenous inotropes and diuretics, significant differences were found in the ECGs on the day of admission (Figure 1) versus before surgery on day 3 after admission (Figure 2).

View larger version (60K): [in this window] [in a new window]   Figure 1. ECG from day 1 of presentation in patient with ALCAPA. Typical prominent Q waves are present in lead V6. Conversely, typical abrupt loss of R waves in midprecordial leads and prominent Q waves in leads I and aVL associated with ALCAPA are not present.

View larger version (58K): [in this window] [in a new window]   Figure 2. ECG of patient on day 3 of presentation after medical management. Typical abrupt loss of R waves in midprecordial leads associated with ALCAPA is clearly seen. Typical prominent Q waves in leads I and aVL are present. Conversely, typical prominent Q waves in lead V6 (Figure 1) are not present. Note, Figure 1 is at full standard (10 mm/mV), and Figure 2 is at half standard (5 mm/mV).

Typical findings on the ECG for patients with ALCAPA have previously been well described. The abrupt loss of the R wave in the midprecordial leads associated with ALCAPA is not seen on the presenting ECG (Figure 1) but is seen on day3 (Figure 2). Prominent Q waves associated with ALCAPA in leads I and aVL are not present in the first ECG (Figure 1); they become prominent, however, on day 3 (Figure 2). Conversely, typical prominent Q waves in lead V₆ associated with ALCAPA are evident on the first ECG (Figure 1) but not on the ECG taken on day 3 (Figure 2).

Previous studies have indicated that individual patients with ALCAPA can present with any combination of the findings mentioned. Such ECG changes in the course of medical therapy, however, have not been reported. We speculate that such changes occurred as a result of decreased pulmonary pressures (confirmed by echocardiogram), encouraging a dynamic coronary steal phenomenon.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Brekke, D. Articles by Schaffer, M. Search for Related Content PubMed PubMed Citation Articles by Brekke, D. Articles by Schaffer, M. Related Collections Electrocardiology Acute myocardial infarction Pediatric and congenital heart disease, including cardiovascular surgery