Ann Thorac Surg 2001;72:2150-2152
© 2001 The Society of Thoracic Surgeons
How to do it
Pulmonary artery translocation: a surgical option for complex anomalous coronary artery anatomy
Mark D. Rodefeld, MDa,b,
Casey B. Culbertson, MDa,b,
Howard M. Rosenfeld, MDa,b,
Frank L. Hanley, MDa,b,
Lenardo D. Thompson, MD*a,b
a Divisions of Cardiothoracic Surgery and Cardiology, Children’s Hospital Oakland, Oakland, California, USA
b Division of Cardiothoracic Surgery, University of California, San Francisco, San Francisco, California, USA
Accepted for publication August 6, 2001.
* Address reprint requests to Dr Thompson, Division of Cardiothoracic Surgery, Children’s Hospital Oakland, 747 52nd St, Oakland, CA 94609, USA
e-mail: rodefeld{at}iupui.edu
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Abstract
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Rather than perform a difficult and potentially high risk coronary reimplantation in a patient with an aberrant right coronary artery coursing between the aorta and pulmonary artery, the main pulmonary artery was translocated toward the left pulmonary hilum to create additional space between the aortic and pulmonic trunks.
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Introduction
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Surgical therapy for children with anomalous origin of the coronary arteries most frequently involves coronary artery reimplantation. In the setting of complex coronary arterial anatomy, however, coronary translocation may be problematic. The risk of coronary manipulation may exceed the natural risk of the lesion itself. Should difficult and potentially high-risk coronary maneuvers be performed in this situation? We recently encountered a patient with a single ostium coronary artery in the left coronary sinus of valsalva from which the right coronary artery coursed anteriorly between the aorta and pulmonary artery. Right coronary reimplantation would have been difficult given the common origin of the right and left coronary arteries. Rather than undergo a relatively high risk coronary reimplantation in which not only the right but also the left coronary arterial system could have been potentially jeopardized, the main pulmonary artery was translocated toward the left hilum to create additional space between the aortic and pulmonic trunks.
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Technique
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An 11-year-old Hispanic boy was referred for evaluation of tachycardia. He had been healthy until 5 years of age when in Mexico he sustained third-degree burns. During his hospitalization he had three poorly documented cardiac events described as "light heart attacks" by the father. He recovered and was taking no long-term cardiac medications. One month before evaluation, he had a 15-minute episode of tachycardia with associated shortness of breath and fatigue that resolved spontaneously. An additional episode occurred 1 week before evaluation. Physical examination and electrocardiogram (ECG) were normal. Transthoracic echocardiogram demonstrated an aberrant right coronary artery that appeared to arise from the left coronary sinus of valsalva. Holter monitoring demonstrated no dysrhythmias.
To further delineate the anatomy, transesophageal echocardiography and cardiac catheterization were performed. These demonstrated a single coronary orifice that arose abnormally high above the sinus of valsalva and immediately bifurcated into the right and left coronary arteries with the right coronary artery coursing between the aorta and the pulmonary artery (Fig 1). No intramural component was seen. Notably both left and right ventricular end diastolic pressures were elevated (18 mm Hg) with preserved systolic function. Given the history of poorly documented myocardial ischemia as well as evidence of diastolic dysfunction, it was thought that the coronary anomaly should be addressed surgically.
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Fig 1. Schematic representation of coronary arterial pattern. A single coronary trunk gives rise to an early branching right coronary artery. The ostia of the right and left main coronary arteries are part of a "double-barrel" arrangement with common tissue origins. (L = left; LAD = left anterior descending; P = posterior; R = right.)
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In the operating room, dissection demonstrated a single coronary artery with early bifurcation of the right and left main coronary arteries. After aortic cross-clamp and cardioplegic arrest, aortotomy was performed and the aortic root was inspected. This confirmed a single coronary orifice in the anterior left coronary sinus that branched early into right and left systems in a "double-barrel" arrangement. Because of its common origin with the left arterial system, isolated right coronary reimplantation would be technically difficult due to an inadequate tissue margin around the right ostium. Reimplantation of the left and right ostia together was not considered as this maneuver would have moved the left coronary artery to an abnormal position. The aortotomy was closed and the cross-clamp removed. Perivascular soft tissue between the aorta and the pulmonary artery was debulked. The distal main pulmonary artery was then carefully transected at the branch pulmonary artery confluence. The left pulmonary artery was incised toward the left hilum (Fig 2). Pulmonary homograft tissue was fashioned to widely patch the native opening in the pulmonary artery confluence. The main pulmonary was then reanastomosed toward the left hilum resulting in a patulous pulmonary artery confluence to the right and left pulmonary arteries (Fig 3). The patient recovered uneventfully. Exercise stress testing at 5 months postoperatively showed no evidence of myocardial ischemia.
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Fig 2. The main pulmonary artery is carefully dissected off the pulmonary bifurcation. Patch augmentation of the right pulmonary artery beyond the bifurcation is critical to prevent right pulmonary artery stenosis. The left pulmonary artery is opened toward the hilum. The main pulmonary artery is translocated toward the left hilum and reanastomosed. (Ao = aorta; PA = pulmonary artery.)
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Fig 3. Completed translocation of the main pulmonary artery toward the left hilum to create additional space between the aorta and pulmonary artery. (Ao = aorta; PA = pulmonary artery.)
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Comment
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The short-term and long-term morbidity of surgical therapy for anomalous course of the coronary arteries is of particular concern in the asymptomatic patient at risk for myocardial ischemia and sudden death [1]. As the prevalence of coronary artery anomalies in the asymptomatic population is not known, the true incidence of coronary ischemic events in this group of patients is impossible to define. Studies have demonstrated an increased risk of sudden death in patients with anomalous coronary artery arising from the wrong aortic sinus and coursing between the aorta and pulmonary trunk [2–4]. The factor responsible for myocardial ischemia and sudden death is presumably impingement of the anomalous coronary artery between the aortic and pulmonic trunks. Coronary translocation and direct aortic reimplantation is the preferred surgical approach and can be performed safely in most cases. Occasionally, however, this may be a less attractive option because of technical factors related to coronary anatomy. Complex rerouting and patching maneuvers may be required that increase short-term risk and may carry implications for long-term morbidity. This situation is particularly encountered in the setting of a common origin of the major branch coronary arteries in which inadequate ostial tissue exists to create a "button" for reanastomosis. Coronary artery bypass grafting from systemic arterial sources remains a secondary option although this has been applied mainly to the adult age group and may be less than satisfactory in young children because of long-term patency issues [5, 6].
An alternative approach is to translocate the pulmonary artery, leaving the coronary circulation undisturbed, to create additional space between the aorta and the pulmonary artery thus reducing or eliminating compressive and angulation forces on the anomalous coronary artery. In our case the amount of space created between the great vessels was substantial. Whether this maneuver will eliminate the risk of coronary compression in the future is not clear and close follow-up is warranted. Pulmonary artery translocation has the additional advantage that it can be performed during beating-heart cardiopulmonary bypass, thereby avoiding myocardial ischemia. Furthermore, the risk of bleeding should be lessened because of the lower pulmonary arterial pressure. Patch augmentation of the pulmonary artery bifurcation is critical to avoid right pulmonary artery stenosis. We elected to use pulmonary homograft tissue to widely patch the pulmonary artery confluence although autologous pericardium can be used. In selected cases of anomalous course of the coronary artery with complex coronary anatomy in which the risk of coronary reimplantation may outweigh the anticipated benefits, especially in younger patients for whom surgical options may be limited, pulmonary artery translocation may be an attractive alternative.
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References
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Abstract
Introduction
