Ann Thorac Surg 2007;84:2132-2133. doi:10.1016/j.athoracsur.2007.04.001
© 2007 The Society of Thoracic Surgeons
How To Do It
An Alternative Procedure for Correction of Anomalous Origin of Left Coronary Artery From the Pulmonary Artery
Qingyu Wu, MD*,
Zhonghua Xu, MD
Cardiac Center, First Hospital of Tsinghua University, School of Medicine, Tsinghua University, Beijing, China
Accepted for publication April 2, 2007.
* Address correspondence to Dr Wu, Cardiac Center, First Hospital of Tsinghua University, School of Medicine, Tsinghua University, No. 6 Jiu Xian Qiao 1st Rd, Beijing, 100016, China (Email: wuqingyu{at}mail.tsinghua.edu.cn).
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Abstract
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Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital cardiac malformation that is commonly associated with mitral insufficiency. Direct implantation of the anomalous origin of the left coronary artery from the pulmonary artery into the aorta is ideal, but it may not be fit for some patients whose anomalous left coronary arteries arise remotely from the ascending aorta. To solve the same technical problem in a boy with anomalous origin of the left coronary artery from the pulmonary artery in combination with moderate mitral insufficiency, we successfully elongated the anomalous coronary artery by creating a tube-shape graft using part of the pulmonary arterial wall. Simultaneous mitral annuloplasty was performed after a dual-coronary repair.
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Introduction
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Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital anomaly with a mortality of 90% by 1 year of age without surgical intervention [1]. Nowadays the procedure of choice for correction of anomalous origin of the left coronary artery from the pulmonary artery depends on the establishment of a dual coronary artery system by direct reimplantation of the anomalous left coronary artery (LCA) into the ascending aorta [2, 3]. However, reimplantation is not possible for the excessive distance between the orifice of the anomalous LCA and the aorta. We describe our present strategy to elongate the anomalous LCA by creating a tube-shape graft using part of the pulmonary arterial wall in continuity with the origin of the LCA.
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Technique
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Surgery was performed through a median sternotomy. The pericardium was opened to the left of the midline to preserve a pericardial flap for later use. Myocardial protection was achieved by anterograde cardioplegic solution through the aortic root after cross-clamping. Both the branch pulmonary arteries were snared to prevent the cardioplegia from entering the lungs. After the origin of the LCA from the posterior aspect of the pulmonary artery was carefully inspected and confirmed, the pulmonary artery was transected above the level of the pulmonary valve. First, we acquired a sleeve of its posterior wall excising an adjacent main pulmonary arterial wall along with the open left coronary orifice (Fig 1). Second, the upper and lower edges of this pulmonary flap were continuously sewn closed with a 5-0 Prolene suture (Ethicon, Somerville, NJ) to form a tube-shaped autologous graft with a 3-mm internal diameter in continuity with the origin of left coronary. The LCA was mobilized to the bifurcation. Third, the open end of the graft was sutured end-to-side into the left posterior wall of the ascending aorta with a continuous 5-0 Prolene suture (Ethicon). The pericardium was used to close the defect in the pulmonary artery and the aortic cross clamp was removed after removing the air (Figs 2A,
2B). The reimplanted LCA was placed posterior to the pulmonary artery and must be ensured to have no tension or kinking. Through a combined transseptal superior approach, simultaneous mitral annuloplasty was performed in this patient who had moderate mitral insufficiency secondary to prolapse of the anterior leaflet. The annulus was only narrowed at the posterolateral commissure between the anterior and posterior mitral valve leaflets. After the repair, the mitral leaflet was normally coapted and no significant regurgitation was seen by transesophageal echocardiography.
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Fig 1. The main pulmonary artery was transected above the level of the pulmonary valve. We acquired a sleeve of its posterior wall excising an adjacent main pulmonary arterial wall along with the open left coronary orifice. Inset: The partially excised pulmonary arterial wall in continuity with the origin of LCA. (LCA = left coronary artery; RCA = right coronary artery.)
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Fig 2. (A) The upper and lower edges of this pulmonary flap were continuously sewn closed with a 5-0 Prolene suture (Ethicon, Somerville, NJ) to form a tube-shaped autologous graft with a 3-mm internal diameter in continuity with the origin of left coronary. (B) The open end of the graft was sutured end-to-side into the left posterior wall of the ascending aorta with a 5-0 Prolene suture (Ethicon). The defect in the pulmonary artery was repaired with a fresh autologous pericardial patch. (LCA = left coronary artery; RCA = right coronary artery.)
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Comment
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Today, surgical correction of anomalous origin of the left coronary artery from the pulmonary artery basically depends on the re-establishment of a two-coronary system by direct reimplantation of the anomalous LCA into the ascending aorta [2, 3]. If this is unable to sufficiently mobilize the LCA to reach the aorta, other surgical options may be recommended to overcome this problem [4–6]. In this case we created a tube-shaped graft using part of the pulmonary arterial wall to elongate the LCA. The advantage of the autologous graft was likely to have potential growth and a good postoperative patency. We considered that this procedure offered a very effective surgical option in successful transfer of the anomalous LCA into the aortic root, especially when the anomalous origin of the left coronary artery from the pulmonary artery might not reach the aorta, despite extensive mobilization. In addition, although there remains controversy as to whether or how the mitral valve is handled at the time of reimplantation operation [7, 8], this patient who was associated with moderate mitral insufficiency still had a simultaneous mitral annuloplasty performed after a dual-coronary repair. The satisfactory results were achieved at hospital discharge and a 6.5-year follow-up after surgery, respectively. Accordingly, we recommend this coronary artery elongation procedure using part of the pulmonary arterial wall and simultaneous mitral valve repair, if needed.
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Acknowledgments
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We gratefully acknowledge the contributions of Peng Liu who drew the illustrations.
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References
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- Schwerzmann M, Salehian O, Elliot T, et al. Images in cardiovascular medicineAnomalous origin of the left coronary artery from the main pulmonary artery in adults: coronary collateralization at its best. Circulation 2004;110:e511-e513.[Free Full Text]
- Cochrane AD, Coleman DM, Davis AM, et al. 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]
- Barth MJ, Allen BS, Gulecyuz M, et al. Experience with an alternative technique for the management of anomalous left coronary artery from the pulmonary artery Ann Thorac Surg 2003;76:1429-1434.[Abstract/Free Full Text]
- 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]
- Katsumata T, Westaby S. Anomalous left coronary artery from the pulmonary artery: a simple method for aortic implantation with autogenous arterial tissue Ann Thorac Surg 1999;68:1090-1091.[Abstract/Free Full Text]
- Amanullah MM, Hamilton JR, Hasan A. Anomalous left coronary artery from the pulmonary artery: creating an autogenous arterial conduit for aortic implantation Eur J Cardiothorac Surg 2001;20:853-855.[Abstract/Free Full Text]
- Isomatsu Y, Imai Y, Shin’oka T, et al. Surgical intervention for anomalous origin of the left coronary artery from the pulmonary artery: the Tokyo experience J Thorac Cardiovasc Surg 2001;121:792-797.[Abstract/Free Full Text]
- Michielon G, Di Carlo D, Brancaccio G, et al. Anomalous coronary artery origin from the pulmonary artery: correlation between surgical timing and left ventricular function recovery Ann Thorac Surg 2003;76:581-588.[Abstract/Free Full Text]
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Abstract
Introduction
