Left Ventricular Noncompaction in Advanced Heart Failure With an Anomalous Coronary Artery: A Case Report.

Left ventricular noncompaction (LVNC) involves abnormal development of the heart muscle, where the inner layer remains excessively trabeculated instead of compacting properly. Traditionally considered congenital, increasing reports of nonfamilial or sporadic LVNC suggest that adverse myocardial remodeling, such as from volume overload or preexisting cardiomyopathy, may contribute to its development. We present the case of a 77-year-old male with chronic atrial fibrillation and nonischemic cardiomyopathy who was found to have severe LVNC, identified on echocardiography and cardiac MRI using a noncompacted-to-compacted myocardial thickness ratio >2.3 at end-systole. Severe left ventricular dysfunction (ejection fraction (EF) <20%) was confirmed, and angiography revealed nonobstructive coronary disease with an anomalous left circumflex artery - an uncommon co-occurrence that underscores the importance of comprehensive imaging. The late presentation of LVNC in an older adult without a familial history expands the recognized demographic and suggests that structural and hemodynamic stressors may play a role in its development. Management included pharmacologic rate control for atrial fibrillation, electrical cardioversion, and guideline-directed therapy for heart failure with reduced EF, ultimately leading to implantable cardioverter-defibrillator placement for primary prevention of sudden cardiac death. Following these interventions, the patient showed modest improvement in functional status and symptoms and remains under close follow-up for device surveillance and serial imaging. This case broadens our understanding of LVNC by highlighting its potential for late onset, the necessity of multimodality imaging to detect coexisting anomalies, and the importance of a comprehensive treatment approach to optimize outcomes in older adults.