An anomalous left coronary artery originating from the pulmonary artery (ALCAPA) is a rare congenital coronary abnormality often associated with myocardial infarction, congestive heart failure and sudden death. Survival to adulthood in individuals with this coronary anomaly is quite uncommon. Since mortality approaches 90% in infancy with untreated ALCAPA, early recognition and surgical correction are essential. Using both echocardiographic myocardial blush and coronary arteriography, we describe the new diagnosis of uncorrected ALCAPA in a 72-year-old woman and review contemporary methods for the diagnosis and management of this particular coronary anomaly.