Phantom killer, deeply hidden Left coronary artery originating from the pulmonary artery (ALCAPA) is a very rare congenital heart disease with an incidence of 1 in 300,000, accounting for 0.26-0.50% of congenital heart disease, and 90% of children die within 1 year of age. However, the disease is insidious in children, and most pediatric patients are seen because of the discovery of heart murmurs or symptoms of heart failure such as shortness of breath and feeding difficulties. X-rays mostly show an enlarged heart shadow without specificity, and echocardiograms (color ultrasound) mostly show enlarged left heart, reduced heart function, endocardial thickening and mitral regurgitation, etc. Therefore, clinicians are prone to misdiagnose the disease based on clinical manifestations as well as cardiac ultrasound examinations as the relatively common “heart bomb”, mitral valve disease, cardiomyopathy, or coronary fistulae, thereby delaying diagnosis and treatment. In fact, all these clinical signs and ultrasound manifestations are due to myocardial ischemia. As we all know, the heart is like an engine with full horsepower, working all the time without “striking”, and the engine that cannot rest needs a constant input of high-quality fuel from the oil pipeline. Under normal circumstances, the coronary arteries originate from the ascending aorta. Therefore, for pediatric heart failure, the origin of the left coronary artery from the pulmonary artery is like a ghost killer wearing various disguises to deal a fatal blow to the child. Since the origin of the left coronary artery from the pulmonary artery is rare and often wears various disguise masks, what can we do to tear off its mask and expose the truth of its evil? We should focus on three hurdles. First, we should improve our awareness of the disease, in other words, we should know the existence of this disease, and when a child presents with heart failure, especially for infant patients suspected of heart bomb, cardiomyopathy, or coronary artery fistula, we should be vigilant and routinely consider or exclude the left coronary artery originating from the pulmonary artery, which is the most important first hurdle. Secondly, the level of ultrasound diagnosis should be improved, because echocardiography is the most commonly used means of examination for pediatric precordial disease, and only by mastering the ultrasound image characteristics of the left coronary artery originating from the pulmonary artery can the correct diagnosis be made. The second hurdle. Finally, although the gold standard for the diagnosis of this disease is cardiovascular imaging, as an invasive test, there are certain risks, especially for infants and children, and it is difficult to carry out widely. CT, on the other hand, has become a widely used test because it is noninvasive, provides clear images, and can provide further information for surgical planning. Therefore, for suspected or ultrasonically diagnosed left coronary artery originating from the pulmonary artery, CT examination should be performed to determine the abnormal origin of the coronary artery and its course, which is the third hurdle. Our clinical experience has shown that a good understanding of these three hurdles can effectively tear off the mask of its camouflage and restore its truth to minimize misdiagnosis and leakage. Coronary artery reimplantation, myocardial revival Once the “ghost killer” of the left coronary artery originating from the pulmonary artery is locked, we must not hesitate to perform targeted removal of it as soon as possible. In our clinical work, we have found that a delay of even one week can reduce the left ventricular ejection fraction (LVEF) of a child by 15%. Therefore, parents who are afraid of surgery because they think their child is too young and the risks of surgery are too great should change their understanding and send their child to a competent pediatric cardiac center as soon as the disease is diagnosed, the sooner the better, because even a short delay can lead to a deterioration of the child’s condition, which not only increases the risks and costs of surgery, but also affects the long-term outcome of the child. The surgical approach to this disease is constantly changing, initially ligating the abnormal coronary arteries in patients with adequate collateral circulation, a surgical approach with high mortality due to inadequate collateral circulation in the vast majority of children. In the late 1970s, Takeuchi proposed a window between the aorta and the pulmonary artery, using the pulmonary artery wall for intrapulmonary tunneling; however, severe suprapulmonary stenosis in late stages hampered the use of this procedure. The left coronary artery retransplantation into the aorta was first successfully applied in 1974, as this procedure was accepted by most cardiac centers because of its dual anatomical and physiological radicalization. Due to the experience of coronary artery grafting from a large number of arterial transfers, coronary artery reimplantation became the current procedure of choice. The pediatric center of Fu Wai Hospital completes more than 100 cases of large artery reversal every year, with a success rate of 99.5%, and has accumulated very rich experience in pediatric coronary artery transplantation. In addition, for those children whose disease is not detected in time and whose ventricular function is significantly reduced (e.g., LVEF below 30%), many cardiac surgeons also believe that there is no chance of corrective surgery, or even that only heart transplantation can be considered. In this case, the pediatric center of Fu Wai Hospital has been able to regenerate “ventricular function” and rejuvenate myocardial function by combining postoperative cardiac assisted therapy with corrective treatment. The pediatric cardiac center at Fu Wai Hospital has become the largest and most effective cardiac center in the world for this disease. We have a green channel for this type of children, and we will provide the best medical service for them as quickly as possible.