Question:
An infant presents with tachypnea, diaphoresis during feeds, and poor weight gain. ECG reveals deep Q waves in leads I and aVL with ST depression in lateral leads. Echocardiography shows dilated LV with reduced ejection fraction. Which is the most likely diagnosis?
An infant presents with tachypnea, diaphoresis during feeds, and poor weight gain. ECG reveals deep Q waves in leads I and aVL with ST depression in lateral leads. Echocardiography shows dilated LV with reduced ejection fraction. Which is the most likely diagnosis?
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ALCAPA Triad: Infant with feed-induced diaphoresis/angina + Dilated cardiomyopathy on echo + Deep wide Q waves with ST-T changes in leads I, aVL, $V_5$--$V_6$ (Anterolateral MI).
Updated On: Sep 3, 2026
- Dilated Cardiomyopathy
- Anomalous origin of left coronary artery from pulmonary artery
- TOF
- Myocarditis
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The Correct Option is B
Solution and Explanation
Concept:
Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA), also known as Bland-White-Garland syndrome, is a rare but critical congenital coronary anomaly.
It leads to progressive myocardial ischemia, anterolateral left ventricular infarction, and severe heart failure in early infancy.
Explanation:
• In the early neonatal period, high pulmonary vascular resistance (PVR) maintains antegrade perfusion of the anomalous LCA from the pulmonary artery with relatively desaturated blood.
• As PVR physiological drops during the first $4$--$8$ weeks of life, perfusion pressure in the pulmonary artery falls below systemic levels. This causes a coronary steal phenomenon, where blood flows retrogradely from right coronary collaterals through the LCA into the low-pressure pulmonary artery.
• This produces severe myocardial ischemia and infarction of the anterolateral left ventricle, manifesting clinically during feeds (infantile angina) with diaphoresis, irritability, pallor, tachypnea, and failure to thrive.
• The pathognomonic ECG findings are deep, wide Q waves ($>0.04\text{ s}$ duration, $>3\text{ mm}$ depth) with inverted T waves in lateral leads (I, aVL, $V_5$--$V_6$), representing anterolateral myocardial infarction.
• Echocardiography demonstrates a dilated left ventricle with impaired systolic function, fibroelastosis, and retrograde flow from the LCA into the main pulmonary trunk on color Doppler.
Final Answer:
The presentation of infantile heart failure with anterolateral infarction pattern (deep Q waves in I and aVL) and dilated LV is diagnostic of ALCAPA.
Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery (ALCAPA), also known as Bland-White-Garland syndrome, is a rare but critical congenital coronary anomaly.
It leads to progressive myocardial ischemia, anterolateral left ventricular infarction, and severe heart failure in early infancy.
Explanation:
• In the early neonatal period, high pulmonary vascular resistance (PVR) maintains antegrade perfusion of the anomalous LCA from the pulmonary artery with relatively desaturated blood.
• As PVR physiological drops during the first $4$--$8$ weeks of life, perfusion pressure in the pulmonary artery falls below systemic levels. This causes a coronary steal phenomenon, where blood flows retrogradely from right coronary collaterals through the LCA into the low-pressure pulmonary artery.
• This produces severe myocardial ischemia and infarction of the anterolateral left ventricle, manifesting clinically during feeds (infantile angina) with diaphoresis, irritability, pallor, tachypnea, and failure to thrive.
• The pathognomonic ECG findings are deep, wide Q waves ($>0.04\text{ s}$ duration, $>3\text{ mm}$ depth) with inverted T waves in lateral leads (I, aVL, $V_5$--$V_6$), representing anterolateral myocardial infarction.
• Echocardiography demonstrates a dilated left ventricle with impaired systolic function, fibroelastosis, and retrograde flow from the LCA into the main pulmonary trunk on color Doppler.
Final Answer:
The presentation of infantile heart failure with anterolateral infarction pattern (deep Q waves in I and aVL) and dilated LV is diagnostic of ALCAPA.
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