An Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA) is a rare coronary abnormality. Instead of oxygenated blood from a high-pressure system (Aorta) the coronary is perfused by deoxygenated blood from a low-pressure system (Pulmonary Artery). The pulmonary vascular resistance decreases in the weeks after birth, so while a neonate might be asymptomatic, myocardial ischaemia will occur at some point. Clinically the baby will show signs of distress, usually with feeding and the baby becoming pale/ grey and clammy due to anginal pain. Anaesthetising a baby with ALCAPA is high risk and should have the availability of cardio-pulmonary bypass or ECMO as backup.