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Ann Thorac Surg 1999;68:1090-1091
© 1999 The Society of Thoracic Surgeons

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Anomalous left coronary artery from the pulmonary artery: a simple method for aortic implantation with autogenous arterial tissue

^a Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Oxford, England, UK

Address reprint requests to Dr Katsumata, Oxford Heart Centre, John Radcliffe Hospital, Oxford OX3 9DU, England
e-mail: katsu{at}ahf.org.uk

	Abstract

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We describe a technique to transfer an anomalous left coronary artery originating in the left posterior pulmonary sinus to the aorta. Both autogenous aortic and pulmonary arterial flaps create an extended left main stem without the disadvantages of standard rerouting techniques and full potential for growth remains.

	Introduction

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Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is readily correctable by surgical repair in infancy [1]. Direct implantation of the ALCA into the aorta is desirable, but not easily achieved without tension [2]. The alternative transpulmonary tunnel technique may cause late pulmonary stenosis [3]. We describe a simple method to implant a low, lateral ALCA into the aorta by extending the left main coronary artery. Autogenous aortic and pulmonary arterial flaps create a new inflow to the ALCA maintaining full potential for growth.

	Technique

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A 5-month-old female with gross cardiomegaly was referred for surgical correction of ALCAPA after intensive medical treatment for heart failure.

The heart was exposed through a median sternotomy and cardiopulmonary bypass established with bicaval cannulation and ascending aortic return. The ALCA was identified as arising from the left posterior pulmonary sinus. The aorta and main pulmonary artery were clamped and cold crystalloid cardioplegia infused into the aortic root. The pulmonary artery was then transected just below its bifurcation to fashion a long arterial cuff to cover a bridging aortic flap to the anomalous coronary. The orifice of the ALCA was situated low in the lateral part of the left posterior pulmonary sinus. This was mobilized as illustrated in Figure 1. The aorta was then three quarters transected 10 mm above the sinotubular junction. An inferiorly based rectangular flap was mobilized to create a window towards the facing sinus (Fig 2). The base of the flap stopped 2 mm above the sinotubular junction so that aortic valve function was not compromised. The pulmonary cuff was sutured to the aortic flap, thereby creating an extended left main stem and closing the aortic window (Figure 3). The aorta was then reanastomosed. The defect created in the pulmonary sinus was repaired with an autogenous pericardial patch and the pulmonary artery reconstituted by direct anastomosis.

View larger version (22K): [in this window] [in a new window]   Fig 1. The left lateral view of the pulmonary artery. The anomalous left coronary artery in the left posterior pulmonary sinus is mobilized with a long pulmonary arterial cuff. The main pulmonary artery is transected just below the bifurcation to allow sufficient length. (PA = pulmonary artery; LAD = left anterior descending coronary artery; LCX = left circumflex coronary artery; * = PA flap.)

View larger version (34K): [in this window] [in a new window]   Fig 2. An rectangular vertical aortic flap bridges between the anomalous coronary and the aorta. (Ao = ascending aorta; RCA = right coronary artery; * = PA flap.)

View larger version (29K): [in this window] [in a new window]   Fig 3. The pulmonary cuff is sutured to aortic flap and ascending aorta to close the window and create a new elongated left main stem. (Ao = ascending aorta; LAD = left anterior descending coronary artery; RCA = right coronary artery.)

	Comment

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Anomalous left coronary from the pulmonary artery is a lethal condition which usually presents with severe heart failure in infancy. Only rarely do patients survive and present in adult life [4].

Creation of a two-coronary system eliminates the "steal" phenomenon and restores physiological antegrade flow to the ischemic left ventricular myocardium. Left coronary mobilization with direct implantation into the aorta can be achieved with low early mortality and excellent long-term outcome [1, 2]. However, direct coronary translocation without tension and risk of thrombosis may be difficult in some infants because of key septal and collateral branches and the distance from the ALCA to the aorta. Because of this, an aortopulmonary window and transpulmonary baffle technique (Takeuchi operation) is frequently used [3]. In turn the baffle method may prove difficult when the ALCA is located immediately adjacent to a pulmonary cusp [5]. Late complications also include supravalvular pulmonary stenosis, and baffle thrombosis.

Recently a tubular extension of the ALCA using a circumferential pulmonary arterial flap was described by Tashiro and associates [6], and adopted by others [7]. This method is feasible in most patients but may also provide difficulties when the ostium of the ALCA is close to a pulmonary valve commissure or deep in the pulmonary sinus.

Sese and associates first described a horizontal "trap-door" technique [8], for cases where the ALCA was situated in an anterior pulmonary sinus. A laterally based flap was mobilized from the aorta as a bridge to the ALCA. Our vertical aortic trap door with a pulmonary arterial hood provides a simple and effective alternative for ALCAPA in the posterior sinuses. Complete absence of tension and use of endothelialized autogenous arterial flaps help to avoid thrombosis. Normal arterial growth in response to flow is likely.

	References

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1. Vouhé P.R., 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]
2. Cochrane A.D., Coleman D.M., Davis A.M., Brizard C.P., Wolfe R., Karl T.R. Excellent long-term functional outcome after an operation for anomalous left coronary artery from the pulmonary artery. J Thorac Cardiovasc Surg 1999;117:332-342.[Abstract/Free Full Text]
3. 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]
4. Westaby S., Davies G.J. Successful mitral valve replacement and myocardial revascularization in an adult with ALCAPA. J Thorac Cardiovasc Surg 1986;91:188-191.[Abstract]
5. Smith A., Arnold R., Anderson R.H., et al. Anomalous origin of the left coronary artery from the pulmonary trunk. J Thorac Cardiovasc Surg 1989;98:16-24.[Abstract]
6. Tashiro T., Todo K., Haruta Y., Yasunaga H., Nagata M., Nakamura M. Anomalous origin of the left coronary artery from the pulmonary artery. J Thorac Cardiovasc Surg 1993;106:718-722.[Abstract]
7. Turley K., Szarnicki R.J., Flachsbart K.D., et al. Aortic implantation is possible in all cases of anomalous origin of the left coronary artery from the pulmonary artery. Ann Thorac Surg 1995;60:84-89.[Abstract/Free Full Text]
8. Sese A., Imoto Y. New technique in the transfer of an anomalously originated left coronary artery to the aorta. Ann Thorac Surg 1992;53:527-529.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Takahiro Katsumata Stephen Westaby Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Katsumata, T. Articles by Westaby, S. Search for Related Content PubMed PubMed Citation Articles by Katsumata, T. Articles by Westaby, S.