Late adult presentation of ALCAPA syndrome: need for a new clinical classification? A case report and literature overview

Anomalous origin of the left main coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac anomaly that is usually diagnosed in infancy due to severe ischemia and heart failure. Adult or elderly presentation is extremely uncommon, as most untreated patients do not survive into advanced age without significant symptoms. This case report describes a 76-year-old patient in whom ALCAPA was incidentally discovered during elective coronary angiography. Despite the rarity of such late presentation, the patient remained largely asymptomatic, likely due to well-developed collateral coronary circulation. The case highlights important diagnostic considerations, management challenges, and the role of individualised treatment strategies in elderly patients with rare congenital coronary anomalies.