Out-of-Hospital Cardiac Arrest as the First Manifestation of ALCAPA in a 9-Week-Old Infant: Survival to Discharge After Emergency Repair and VA-ECMO

Background and Clinical Significance: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) usually presents with heart failure at 2–3 months of age; cardiac arrest as the first manifestation is rare and often recognized only at autopsy. Case Presentation: A previously healthy girl collapsed at home at 65 days of age. After dispatcher-assisted parental resuscitation, the emergency team found asystole and achieved return of spontaneous circulation after approximately 4 min of professional resuscitation; the total low-flow time was not recorded. She was in cardiogenic shock (left ventricular ejection fraction 19.8%, high-sensitivity troponin T 2620 ng/L) with acute kidney injury and coagulopathy consistent with disseminated intravascular coagulation. Echocardiography showed a dilated right coronary artery and no flow from the aorta into the left coronary artery. Emergency repair on day 1 was followed by venoarterial extracorporeal membrane oxygenation (VA-ECMO) for 4 days and continuous renal replacement therapy. The Simpson ejection fraction reached about 50% by day 9, fell to 37–40% during respiratory deterioration and was 45–50% on day 27; mitral regurgitation, graded as massive during VA-ECMO, regressed to trace without valve surgery. She was discharged on day 42 with impaired diastolic indices; no formal neurological assessment was documented. Conclusions: ALCAPA should be considered in every infant with unexplained cardiac arrest, and post-resuscitation echocardiography should assess the coronary origins. Emergency repair with VA-ECMO can achieve survival to discharge despite multiorgan failure, but long-term cardiac and neurodevelopmental follow-up is required.