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Ann Thorac Surg 1998;65:555
© 1998 The Society of Thoracic Surgeons

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Case Reports

Intraaortic Balloon Pump After Treatment of Anomalous Origin of Left Coronary Artery

Department of Cardiac Surgery, Royal Liverpool Children’s Hospital-Alder Hey, Liverpool, England, United Kingdom

Accepted for publication September 25, 1997.

Dr Pozzi, Department of Cardiac Surgery, Royal Liverpool Children’s Hospital-Alder Hey, Eaton Rd, Liverpool L12 2 AP, England (e-mail: mpozzi@liverpedcard.u-net.com).

	Abstract

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The same system of intraaortic balloon pumping has been used in 2 infants after surgical repair of anomalous origin of the left coronary artery from the main pulmonary artery. Intraaortic balloon pumping was started in the first patient on the second postoperative day, whereas in the second patient it was started before the patient was weaned from cardiopulmonary bypass. Both patients survived. In the first patient intraaortic balloon pumping improved the low cardiac output, which had failed to respond to maximal inotropic support, whereas in the second it maintained hemodynamic stability.

	Introduction

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Anomalous origin of the left coronary artery from the main pulmonary artery is a severe congenital cardiac anomaly in which the ventricular function is seriously compromised. If the condition is left untreated the mortality is 80% to 90% within the first year of life because of severe congestive heart failure [1] [2] [3] [4]. Some successful results have been achieved with different surgical techniques; however, the immediate postoperative mortality remains high and often it is necessary to support the left ventricle (LV) with mechanical assistance devices [5] [6] [7] [8]. We report 2 cases of anomalous origin of the left coronary artery from the main pulmonary artery in which the ventricular function was successfully supported postoperatively by intraaortic balloon pumping (IABP) (Datascope System 97; Datascope Medical Co Ltd) using 2.5-mL balloons filled with helium.

	Case Reports

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Patient 1
A 5-month-old girl weighing 5.8 kg was referred with signs of myocardial infarction (Q waves in leads 1, AVL, V₅, and V₆). The echocardiogram revealed left ventricular dilatation, poor systolic ventricular function with fractional shortening less than 20%, and minimal mitral valve regurgitation.

At cardiac catheterization the left ventricular end-diastolic pressure was 15 to 20 mm Hg and aortography opacified a dilated single right coronary artery. The left coronary artery opacified retrogradely from the right coronary artery. The coronary anomaly was corrected by an intrapulmonary tunnel. After cardiopulmonary bypass (CPB) was discontinued the patient was hemodynamically stable (blood pressure, 90/50 mm Hg; central venous pressure, 10 to 12 mm Hg; left atrial pressure, 12 to 14 mm Hg) on 7.5 µg · kg^-1 · min^-1 of dobutamine. Forty-eight hours later low cardiac output developed over a period of a few hours, with systolic blood pressure dropping to 45 to 55 mm Hg and requiring increasing doses of inotropes (up to the following doses: adrenaline, 3.5 µg · kg^-1 · min^-1; noradrenaline, 1.5 µg · kg^-1 · min^-1, enoximone, 9.8 µg · kg^-1 · min^-1) to maintain the blood pressure at around 60 mm Hg. This was associated with deterioration of LV function as demonstrated by echocardiography. There was no change in the electrocardiogram.

Because there was such severe ventricular failure, refractory to inotropic support, we decided to insert the IABP to support the LV. The balloon catheter was introduced through a pursestring suture in the ascending aorta and this was tightened with a plastic snugger fixed with several metal clips; this allowed the skin to be closed with a silicone membrane, leaving the snugger inside the chest. The balloon was positioned in the descending aorta as confirmed by roentgenography. The augmentation was minimal initially but improved over the first 24 hours and was maintained up to a rate of 196 beats/min.

The clinical condition of the patient improved gradually after the institution of IABP. Blood pressure stabilized at 70 to 80/50 mm Hg, central venous pressure and left atrial pressure decreased to 10 and 7 mm Hg, respectively. She appeared peripherally well perfused, with warm peripheries and good pulses. Urine output increased to 1.1 mL · kg^-1 · h^-1 initially and subsequently to 3.9 mL · kg^-1 · h^-1. The adrenaline and noradrenaline infusions were weaned and discontinued after 20 hours. Once hemodynamic stability was achieved, the dose of dobutamine was reduced to 5 µg · kg^-1 · min^-1 and we started weaning the patient from the balloon pump 50 hours after insertion. Initially augmentation was reduced to 50% and then the rate was reduced to 1:2 and finally to 1:3 for a maximum of 30 minutes before removal of the balloon 72 hours after insertion, and at that time the chest was closed. Anticoagulation was achieved with heparin infusion maintaining an activated clotting time of 180 to 200 seconds. No complication was observed. The echocardiogram at the time of discharge showed little improvement in the paradoxal septal motion and mitral regurgitation, but the indices of left ventricular function had improved to an ejection fraction of 0.48 and fractional shortening of 20%. One year later the echocardiogram demonstrated good LV function (ejection fraction, 0.80; fractional shortening, 42%) and no mitral regurgitation.

Patient 2
The second patient was a 4-month-old boy weighing 4.3 kg. An electrocardiogram revealed Q waves in leads I, II, and AVL through V₆ leads suggesting anterolateral myocardial infarction. An echocardiogram showed left ventricular dilatation and poor contractility (fractional shortening <21%) with associated mild mitral valve regurgitation and calcified papillary muscles. Dilatation of the right coronary artery and the anomalous origin of the left coronary artery from the main pulmonary artery with retrograde flow were demonstrated. Because of the good quality of imaging from the echocardiogram, cardiac catheterization was not required.

The patient underwent aortic reimplantation of the left coronary artery. Because of the very poor LV function and the favorable outcome of the previous patient, we had planned to electively insert the IABP through the ascending aorta before discontinuing CPB. The first attempt to wean the patient from CPB with IABP support was unsuccessful, so CPB was reestablished and the heart was assisted for 1 hour. The second attempt at weaning from CPB was successful. The sternum was left open, the skin was closed with a silicone membrane, and the patient was transferred to the intensive care unit receiving dobutamine, 15 µg · kg^-1 · min^-1, and enoximone, 10 µg · kg^-1 · min^-1.

The postoperative course was slow. For the first 3 days the circulation remained borderline with systolic pressure around 65 mm Hg and central venous pressure and left atrial pressure at 15 and 16 mm Hg, respectively, but over the following 24 hours the blood pressure improved to 95 mm Hg and central venous pressure and left atrial pressure to 8 and 10 mm Hg. The weaning from IABP support was started on the fourth postoperative day and completed 24 hours later. At that time the chest was also closed without difficulty. In this patient there was also no complication. The echocardiogram before discharge showed little improvement of LV function, but after 5 months there was improved LV contractility, decreased ventricular size, and an ejection fraction of 0.50.

	Comment

Top Abstract Introduction Case Reports Comment Acknowledgments References

 
The IABP was inserted as an emergency in the first patient when low cardiac output developed refractory to inotropic support 48 hours postoperatively. In the second patient the IABP was prophylactically inserted in the operating room in an attempt to prevent the development of low cardiac output. The balloon catheter was easily and quickly inserted through the ascending aorta. This approach avoids the risk of ischemic damage to the leg, almost inevitable in small patients when the femoral approach is used. There is now a wide range of pediatric balloons, which make it possible to extend the use of this mechanical device in children. Recent improvements in the balloon pump enable good augmentation at the high rates essential for effective pediatric use. Gradual improvement of all hemodynamic parameters allowing a progressive weaning from the inotropic support was observed after insertion of IABP. Improvement of urine output was observed soon after IABP was started and despite the fact that the tip of the balloon was necessarily (because of the length of the balloon in relation to the length of the descending aorta) positioned beyond the origin of the renal arteries. The experience with our first patient confirmed the experience of other authors that after repair of anomalous origin of the left coronary artery severe low cardiac output caused by LV failure has to be expected and that the institution of prophylactic measures to support the LV can prevent the development of low cardiac output and allow a better recovery, as shown by our second patient [6]. Our suggestion is that the IABP can be an effective means of LV support in this condition. Elective insertion before weaning from CPB especially in patients with poor myocardial function is recommended.

	Acknowledgments

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We thank Dr Robert Arnold for his critical review.

	References

Top Abstract Introduction Case Reports Comment Acknowledgments References

 

1. Arciniegas E, Farooki ZQ, Hakimi M, Green EW Management of anomalous left coronary artery from the pulmonary artery. Circulation 1980;62(Suppl 1):180-189.
2. Askenzai J, Nadas AS Anomalous left coronary artery originating from the pulmonary artery. Report of 15 cases. Circulation 1975;51:976-987.[Abstract/Free Full Text]
3. Neirotti R, Nijveld A, Ithuralde M, et al. Anomalous origin of the left coronary artery from the pulmonary artery: repair by aortic reimplantation. J Cardiothorac Surg 1991;5:368-372.
4. Wilson CL, Dlabal PW, Holeyfield RW, Akins CW, Knauf DG Anomalous origin of left coronary artery from the pulmonary artery. J Thorac Cardiovasc Surg 1977;73:887-893.[Abstract]
5. Bunton R, Jonas RA, Lang P, Rein AJJT, Castañeda A Anomalous origin of left coronary artery from pulmonary artery. J Thorac Cardiovasc Surg 1987;93:103-108.[Abstract]
6. Vouhé PR, Baillot-Vernant F, Trinquet F, et al. Anomalous left coronary artery from the pulmonary artery in infants. J Thorac Cardiovasc Surg 1987;94:192-199.[Abstract]
7. Takeuchi S, Imamura H, Katsumoto K, et al. New surgical method for repair of anomalous left coronary artery from pulmonary artery. J Thorac Cardiovasc Surg 1979;78:7-11.[Abstract]
8. Hamilton DI, Ghosh PK, Donnelly RJ An operation for anomalous origin of left coronary artery. Br Heart J 1979;41:121-124.[Abstract/Free Full Text]

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