Surgical Management of Adult-Onset Artery From the Pulmonary Artery (ALCAPA): A Narrative Review of Surgical Techniques

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary anomaly in which the left coronary artery originates from the pulmonary artery, resulting in myocardial ischemia due to coronary steal after postnatal reduction in pulmonary artery pressure. Most patients present in infancy with heart failure, but a subset survives into later childhood or adulthood through extensive collateralization from the right coronary artery. Late presenters typically demonstrate a dilated, tortuous right coronary artery with retrograde flow into the pulmonary artery. Surgical correction is recommended at all ages; however, optimal management in older patients remains debated. This review summarizes the existing literature and discusses surgical strategies for adult-onset ALCAPA. Surgical repair of adult-onset ALCAPA aims to eliminate coronary steal and restore a physiologic two-coronary system. The choice of technique depends on anatomic factors, including the origin of the left coronary artery, its distance from the aorta, vessel length, and the extent of intercoronary collaterals. Direct reimplantation of the left coronary artery into the aorta is preferred when feasible, as it provides durable restoration of normal coronary physiology, though it may be limited by tension or inadequate coronary length. The Takeuchi procedure offers an alternative when reimplantation is not possible but carries risks such as baffle stenosis and pulmonary artery obstruction. Coronary artery bypass grafting may be considered in selected adults, though competitive flow from collaterals and long-term graft durability remain concerns. Additionally, new techniques such as modified Cabrol and modified Takeuchi may offer even greater promise for the future but will require further research to establish their place in the field.