Mildly Dilated Left Coronary Artery in 6 year old

My father in law was diagnosed at 62 with ALCAPA. He had immediate corrective surgery. He had bypass surgery recently because the one artery was constricted. I share this because this is why we had our sons get echos recently. My eldest was diagnosed as an infant with a murmur and a PFO. At 3 years old, the cardiologist said not to worry about it anymore, and we only had to come back if it presented a problem. It never has. During this last echo, less than a week ago... his PFO was gone, and his echo was normal and everything appeared healthy. However, in my younger son, they found a PFO, and found "mild dilation of the left coronary artery". I can find nothing online about it, at least nothing I can understand. What does this mean? What questions should I ask the cardiologist when we get in to see one (as it's Friday, I won't be able to make an appointment till Monday)? Is this potentially something serious? Is this something we need to see a doctor to "clear", but is likely not that serious? What are some possible causes? If there is any information out there about it, I am desperate for it. Our GP was unable to answer any questions, just said it's not something she's ever seen in a child before.

[Jeffrey R Boris, M.D.]

Dear Nerdzilla,

Let's talk about a couple of things here.  First, the easy one:  a patent foramen ovale (PFO) is supposed to be there in all babies in utero.  It is a small connection between the two upper chambers of the heart (the atria).  It typically closed by age 1 year after birth.  However, 25% of all adults have it remain open.  Overall, we do not worry about this.

Now coronary artery dilation:  without seeing your son, I cannot say exactly what is going on here.  I can say that the diagnosis of coronary artery dilation has gotten a bit more exact with time.  We have normal values based on body surface area, called Z-scores.  I would first make sure that this value is greater than a Z-score of +2.  Then, it depends on how much larger.  If it's a little bit, I typically don't worry; if it's a lot, then it requires some investigation.  Different reasons for coronary dilation include: a history of Kawasaki disease or some other similar inflammatory process, anomalous left coronary artery arising from the pulmonary artery (ALCAPA, as your FIL had) or some other abnormal coronary connection, or just the fact that the coronary artery is more "dominant", which means that there is extra flow going through it because either the opposite coronary artery is small or has some of the branches that would normally arise from the opposite coronary arisng from this one.  Overall, since your son has gone on this long and has had no symptoms, this is likely not emergent at this point.  If he were to develop onset of shortness of breath with activity, chest pain, abnormal heart beats, or passing out with activity, this should be evaluated sooner.

[Nerdzilla78]

If it was ALCAPA, would it have been detected on the echo? Would other abnormal coronary connections have been detected?

[Jeffrey R Boris, M.D.]

Dear Nerdzilla78,

The majority of the time, ALCAPA can be seen by echo and suspected by ECG.  However, this is not always the case, and it has been missed.  And, yes, other abnormal coronary connections can be detected, but they are not always seen, either.

[Nerdzilla78]

Thank you, Dr. Boris. We have an appointment mid-July with a pediatric cardiologist in our area, and hopefully will have more information then. I did get a copy of the reports. The interpretation section says: "PFO, mildly dilated left coronary artery and LAD." Below that, it lists EVERYTHING else as normal, including connections and relationships. It specifically states that the Left Coronary Artery is top normal in diameter at 3-3.4MM (not sure if that means that it dilates from 3MM to 3.4MM or if it's somewhere in that range, or what, but it does state top normal, so I'm assuming that means the high side of the normal measurement range), and the LAD was 3MM. The origin of the left coronary artery was normal. It states nothing specific about the LAD and it's measurement, whether it's normal, top normal, or dilated. He's 53 pounds and 47.25 inches tall.

Can you tell me what this could mean for him down the road? Assuming this is all there is wrong (the dilation, no other issues)? Does the dilation cause damage to the arteries (which is what I read on the Kawasaki's pages- figured that was the only place I could find info, so I'd look there)?

I'll be sure to ask the cardiologist who performs his next echo to check specifically for ALCAPA, or other abnormal connections. Thank you for your help.

[Jeffrey R Boris, M.D.]

I think that more information is necessary before determining any kind of prognosis..

[Nerdzilla78]

Thanks. I understand that it's extremely difficult to give information on a limited basis, on the internet, with a person you've not had the opportunity to examine. I appreciate the info you've been able to give me. I have one final question. Is a "coronary anomaly" definition limited strictly to malformations (like my FIL had) or could what my son has also be considered anomalous? (please note that I am not asking you to diagnose my son specifically, just a general question about what an anomaly is considered to be- malformations/misconnections or would something like dilation be included?)