Persistent pulmonary hypertension of the newborn. Many etiologies—from dystocia to sepsis—can lead to this condition also known as transient myocardial ischemia of the newborn infant. The clinical presentation may vary from mild oxygen dependency to need for ECMO. (a) Severe ischemia with widespread ST changes. (b) Moderate ischemia, the ST depression is less diffuse than case a. (c) Mild PPHN . (d) Usually the normalization takes a few days. Although this is the pathophysiology of almost all ischemic ECGs in the newborn, the echocardiogram has to rule out a congenital coronary anomaly

Slightly preterm baby boy with dystocia . Initially this was believed to be a PPHN patient: history, echo, and ECG were consistent with such diagnosis. A second echo unmasked an ALCAPA. Because of the pulmonary hypertension, the ALCAPA pathophysiology had no time to develop, and the ECG is not yet typical of ALCAPA. Once again, pay attention to not miss an overlap between PPHN and ALCAPA

(a) A 1-month-old boy with diaphragmatic hernia (DH) and ALCAPA . He underwent DH repair on the third day of life and subsequently developed heart failure. Initially the ST changes were attributed to the pulmonary hypertension typical of DH. Later, ALCAPA was suspected because the signs of ischemia worsened (Q waves and ST elevation, necrosis, and subepicardial ischemia) precisely when pulmonary pressure decreased, a behavior that makes sense in the ALCAPA pathophysiology: the decompressed pulmonary artery “steals” blood from the myocardium through the wrong left coronary artery. (b) Close-up, note the large Q and poor R wave

Another two cases of ALCAPA . The two patients, both 1-year-olds, were followed as DCM patients, close to being screened for heart transplant. A more careful echo raised the suspicion of ALCAPA. (a) The huge Q waves in limb left lateral leads can be noted, along the widespread ST changes. This is not the classic ECG of DCM! (b) Again a large Q wave in aVL and widespread ST changes (courtesy of Cristina Pedron)

(a) VF of a 32-year-old woman—mother of two children—while carrying a heavy box of apples. DC shock was effective. (b) The baseline ECG was not diagnostic (poor progression of R waves in the precordial leads and mild ST changes). (c) The diagnosis was ALCAPA. She had been protected for a long time by the proximal stenosis of the abnormal coronary artery arising from the pulmonary artery. This “pathology in the pathology” prevented the stealing of blood which is one of the mainstays in the pathophysiology of ALCAPA. Nevertheless, over the years, some silent and subtle ischemia and consequent fibrosis must have been at work, preparing the substrate for the VF