Ann Thorac Surg 2003;76:266-267
© 2003 The Society of Thoracic Surgeons
Case report
Simplified technique for correction of anomalous origin of left coronary artery from the anterior aortic sinus
John M. Karamichalis, MDa,
Luca A. Vricella, MDa,
Daniel J. Murphy, MDb,
Bruce A. Reitz, MDb*
a Department of Cardiothoracic Surgery, Stanford, USA
b Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, California, USA
Accepted for publication December 23, 2002.
* Address reprint requests to Dr Reitz, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Falk CVRB, Stanford, CA 94305-5407, USA
e-mail: breitz{at}stanford.edu
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Abstract
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Anomalous origin of the left main coronary artery from the right anterior coronary sinus has been associated with high incidence of sudden death in young adults. We describe a simplified approach to this rare congenital anomaly, which avoids the need for commissural post resuspension or relocation of the coronary button.
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Introduction
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Anatomic location of the coronary ostia in relation to the aortic sinuses is fairly constant, and may have an important role in optimizing coronary blood flow during exercise [1]. Anomalous origin of the left main coronary artery has been associated with sudden death at a young age [2]. This anomaly is rarely diagnosed during life, and few patients are treated surgically. We present a patient with an anomalous origin of the left main coronary artery from the anterior aortic sinus, as well as a simplified surgical approach to this rare anomaly.
A 14-year-old boy presented with acute chest pain on exertion, associated with dyspnea and cardiovascular collapse. Admission evaluation included a normal echocardiogram, elevated cardiac isoenzymes, and a chest roentgenogram consistent with pulmonary edema. Coronary angiogram demonstrated a left main coronary artery arising from the right anterior coronary sinus, and coursing between aorta and pulmonary artery. Because of the natural history of this anatomic variant, and its known association with sudden death, it was decided to attempt surgical correction. At the time of operation, the ostium of the left main coronary artery was found to be originating from the right sinus of Valsalva, to the right of the commissural post between left and right sinuses. The right coronary orifice was in its normal location. The course of the left main coronary artery was intramural for approximately 1 cm, until it emerged from the aortic wall between aorta and pulmonary artery (Fig 1).
At the time of surgical correction, the left coronary ostium was not unroofed and relocated as described by other authors [3]; such approach would have required resuspension of the commissure. A new ostium was created in its correct anatomic position by unroofing the intramural portion of the left main coronary artery from within the aortic root. This was easily accomplished by placing a pediatric right-angled clamp into the anomalous ostium, and in the intramural portion, a thin area in the left sinus was appreciated. This was entered in a longitudinal manner with a number 11 blade. The opening was then enlarged to an oval ostium of approximately 2.5-mm width by 4-mm length using a 2.5-mm aortic punch (Medtronic Inc, Minneapolis, MN, Fig 2).
The patient was weaned successfully from cardiopulmonary bypass and had an uncomplicated postoperative recovery. He was discharged on the third postoperative day and is symptom-free 5 months postdischarge. Stress echocardiogram performed 6 weeks postoperatively was normal.
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Fig 1. Anomalous origin of left main coronary artery from right sinus of Valsalva and intramural course. (AV = aortic valve, L = left coronary sinus, LMCA = left main coronary artery, N = noncoronary sinus, PA = pulmonary artery, R = right coronary sinus, RCA = right coronary artery.)
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Fig 2. Surgical correction of coronary anomaly by recreating a new ostium in the correct anatomic location. (AV = aortic valve, L = left coronary sinus, LMCA = left main coronary artery, N = noncoronary sinus, PA = pulmonary artery, R = right coronary sinus, RCA = right coronary artery.)
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Comment
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Anomalous origin of the left coronary artery from the right coronary sinus is a rare and potentially lethal condition. Unlike other congenital variants of coronary anatomy, this anomaly has been demonstrated to be associated with grave prognosis. Sudden, unexpected death typically occurs in males during or after exercise [2]. The mechanism of episodic exertional ischemia remains unclear. It is believed that, during exercise, alterations of the angle of the left coronary ostium with acute stretching of the intramural segment may result in luminal narrowing and subsequent ischemia. Furthermore, diastolic narrowing may occur from compression of the left coronary artery by the intercoronary commissure, particularly in diastole when the aortic valve is closed [3]. This anomaly should be suspected in otherwise healthy young individuals who present with exertional angina. Nevertheless, prodromal ischemic symptoms may not occur, and sudden death could be the first manifestation of this condition. Resting electrocardiogram is usually normal, and stress tests are not always positive. Coronary angiography is therefore crucial in establishing the diagnosis.
Surgical treatment should aim at restoration of the normal anatomic position of the left ostium. Several surgical techniques have been described to deal with this anomaly [3–6]. Use of autologous veins [4, 5] or an internal mammary artery [6] for bypass grafting to the left anterior descending or left main coronary arteries has been reported. The late results of coronary artery bypass grafting in young patients are not yet known.
The technique described avoids detachment of the intercommissural cusp as described by Mustafa and coworkers [3], avoiding longer bypass times and possibly long-term valvular complications associated with resuspension of the commissure. With this method, recreation of a new ostium at its correct anatomic position can be easily created, while leaving the aberrant ostium in its location. Normal coronary growth in children and prevention of sudden death should be expected.
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References
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- Bellhouse B.J., Bellhouse F.H. Mechanism of closure of the aortic valve. Nature 1968;217:86-87.[Medline]
- Taylor A.J., Rogan K.M., Virmani R. Sudden death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol 1992;20:640-647.[Abstract]
- Mustafa I., Gula G., Radley-Smith R., Durrer S., Yacoub M. Anomalous origin of the left coronary artery from the anterior aortic sinus: a potential cause of sudden death. J Thorac Cardiovasc Surg 1981;82:297-300.[Medline]
- Murphy D.A., Roy D.L., Sohal M., Chandler B.M. Anomalous origin of left main coronary artery from anterior sinus of Valsava with myocardial infarction. J Thorac Cardiovasc Surg 1978;75:282-285.[Abstract]
- Sacks J.H., Londe S.P., Rosenbluth A., Zalis E.G. Left main coronary bypass for aberrant (aortic) intramural left coronary artery. J Thorac Cardiovasc Surg 1977;73:733-741.[Abstract]
- Moodie D.S., Gill C., Loop F.D., Sheldon W.C. Anomalous left main coronary artery originating from the right sinus of Valsava. J Thorac Cardiovasc Surg 1980;80:198-205.[Medline]
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