Asian Cardiovasc Thorac Ann 2003;11:87-89
© 2003 Asia Publishing EXchange Ltd
Anomalous Left Coronary Artery: Modified Direct Aortic Implantation
Anil Kumar Dharmapuram, MCh,
Narasinga Rao Pantula, MCh,
Raghavan Nair Suresh Kumar, DM1,
Yoosuph Abdul Nazer, MCh,
Ivatury Mrutyunjaya Rao, MCh
Department of Cardiac Surgery
1 Department of Cardiology, Al Mafraq Hospital, Abu Dhabi, UAE
For reprint information contact: Ivatury Mrutyunjaya Rao, MCh Tel: 971 2 503 1336 Fax: 971 2 582 1549 email: imrao{at}emirates.net.ae Department of Cardiac Surgery, Al Mafraq Hospital, P.O. Box 2951, Abu Dhabi, UAE.
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ABSTRACT
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The technique of direct transfer of an anomalous left coronary artery from the pulmonary artery to the aorta was modified. Using part of the lateral and anterior wall of the pulmonary artery as a flap in continuity with the coronary button as part of the transfer, a tension-free anastomosis is possible. This technique was employed in 3 consecutive infants, with good outcome.
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INTRODUCTION
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In the surgical management of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), direct implantation of the anomalous artery into the aorta is the method of choice. However, this is not easily achieved without tension.1 Several modifications of the direct implantation technique have been employed to avoid tension on the artery.2–4 A technique of direct implantation by incorporation of a flap of the lateral and anterior wall of the pulmonary artery in continuity with the coronary button is described.
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TECHNIQUE
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The heart is exposed through a median sternotomy and cardiopulmonary bypass is established with distal aortic cannulation and bicaval venous cannulae, with moderate hypothermia. The ductus is dissected and ligated. The right and left pulmonary arteries are dissected up to the hilum and looped. The left ventricle is vented through the right superior pulmonary vein. The aorta and main pulmonary artery are clamped and cold blood cardioplegia is infused into both great arteries after occluding the pulmonary arteries. The right atrium is opened and cardioplegic infusion is repeated after 20 minutes using a retrograde cardioplegia catheter placed in the coronary sinus under direct vision. The pulmonary artery is completely transected well above the level of the cusps. The left main coronary artery button is harvested with a cuff of tissue of the sinus of origin, along with a flap of the lateral and anterior wall of the pulmonary artery in continuity (Figure 1
). Distally, the artery is mobilized adequately from the right ventricle to obtain optimum length. The aorta is incised above the sino-tubular junction and the sinus facing the left coronary cusp is incised towards the base of the cusp. The coronary button along with the flap of the lateral and anterior wall of the pulmonary artery is anastomosed to the aorta, incorporating the button into the sinus, and the flap of the pulmonary artery wall into the lateral and anterior wall of the aorta (Figure 1). The pulmonary artery is reconstructed by direct end-to-end anastomosis.
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Figure 1. (A) Origin of the anomalous coronary artery from the left posterior pulmonary sinus. (B) The coronary button is harvested up to a flap of the lateral and anterior wall of the pulmonary artery. (C) The coronary artery is transferred to the aorta, into the sinus facing the left coronary cusp, with the flap on the anterior wall of the aorta.
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DISCUSSION
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We employed this technique in 3 consecutive infants (median age, 6 months; median weight, 6 kg). In 2 cases, the left coronary artery originated from the left posterior sinus, in the other infant it originated from the left anterior sinus. In all cases, tension-free anastomosis was achieved with no kinking, and the patient had a smooth postoperative course.
In ALCAPA, direct implantation of the anomalous left coronary artery into the ascending aorta is the preferred technique for establishment of a two-coronary artery system, when technically feasible.2 Vouhe and colleagues5 clearly demonstrated the efficiency of creating a multiple coronary system in such situations. Growing experience with arterial transfer in patients with transposition of the great arteries has made this the technique of choice in the setting of an anomalous coronary artery.3 In the technique of direct implantation, optimal results depend on avoidance of excessive tension or twisting of the coronary artery.2 In some infants, direct coronary translocation without tension or risk of thrombosis may be difficult because of key septal and collateral branches and the distance from the anomalous coronary artery to the aorta.4 To avoid tension on the artery, Laks and colleagues2 modified the technique by anastomosing the excised button of pulmonary artery from within the lumen of the aorta. Turley and colleagues3 used both short and long tubular reconstructions to provide conduits. Katsumata and Westaby4 described a vertical aortic trap door with a pulmonary arterial hood for ALCAPA in the posterior sinus, emphasizing the absence of tension and use of endothelialized autogenous arterial flaps in direct reimplantation.
Our technique is simple and avoids the long suture lines and flaps of most earlier modifications.3,4 Complete transection of the pulmonary artery above the level of the coronary button enabled us to harvest a horizontal flap from the lateral and anterior wall, in continuity with the coronary button. With adequate mobilization distally, a satisfactory length of the distal segment is achieved. At the proximal end, the medially based trap door created by the horizontal flap avoids tension on the anastomosis and prevents kinking of the coronary artery. This technique might be especially beneficial if the ALCAPA originates from the left posterior sinus. However, even in the case of anterior sinus origin, we could employ this technique easily without compromising the length of the coronary artery and without tension on the anastomosis.
We cannot be certain that the same technique would be reproducible in older children, especially when the left coronary artery arises from the anterior sinus. Nevertheless, by harvesting a horizontally based flap, we could reconstruct the pulmonary artery by direct end-to-end anastomosis in all cases, avoiding the need for pericardium or any prosthetic material. We believe that this should reduce the risk of anastomotic narrowing of the pulmonary artery. With growing experience of the arterial switch operation, complete transection of the pulmonary artery, total mobilization of the coronary artery, and direct implantation should be easier than construction of long tubes requiring long suture lines.3 Such a technique may be required occasionally when the coronary origin mandates mobilization over a very long distance, but we should be mindful of the long-term risk of restenosis or thrombosis due to a long suture line.
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REFERENCES
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- Cochrane AD, Coleman DM, Davis AM, Brizard CP, Wolfe R, Karl TR. Excellent long-term functional outcome after an operation for anomalous left coronary artery from the pulmonary artery. J Thorac Cardiovasc Surg
1999;117:332–42.[Abstract/Free Full Text]
- Laks H, Ardehali A, Grant PW, Allada V. Aortic implantation of anomalous left coronary artery: an improved approach. J Thorac Cardiovasc Surg
1995;109:519–23.[Abstract/Free Full Text]
- Turley K, Szarnicki RJ, Flachsbart KD, Richter RC, Popper RW, Tarnoff H. Aortic implantation is possible in all cases of anomalous origin of the left coronary artery from the pulmonary artery. Ann Thorac Surg
1995;60: 84–9.[Abstract/Free Full Text]
- 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;68:1090–1.[Abstract/Free Full Text]
- Vouhe PR, Baillot-Vernant F, Trinquet F, Sidi D, de Geeter B Khoury W, et al. Anomalous left coronary artery from the pulmonary artery in infants. Which operation? When? J Thorac Cardiovasc Surg
1987;94:192–9.[Abstract]
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ABSTRACT
INTRODUCTION
