Asian Cardiovasc Thorac Ann 2006;14:e80-e82
© 2006 Asia Publishing EXchange Ltd
Re-operation for Tetralogy of Fallot with Single Right Coronary Artery
Mitsugi Nagashima, MD,
Harumitsu Sato, MD,
Yosihisa Hohjo, MD,
Yoshiki Okamoto, MD,
Takashi Miura, MD,
Tetsuo Tomino, MD
Department of Cardiovascular Surgery, Ehime Prefectural Central Hospital, Japan
For reprint information contact: Mitsugi Nagashima, MD Tel: 81 8 9947 1111 ext. 2250 Fax: 81 8 9943 4136 Email: mitsugi{at}aqua.plala.or.jp, Department of Cardiovascular Surgery, Ehime Prefectural Central Hospital, 83 Kasuga-cho, Matsuyama-city, Ehime-prefecture 790-0024, Japan.
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ABSTRACT
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A 7-year-old girl with tetralogy of Fallot in association with a single right coronary artery, was successfully re-operated on for right ventricular outflow tract obstruction. To identify the course of the abnormal coronary arteries during the re-operation, a probe was directly inserted into the coronary arteries after aortotomy. Ventriculotomy was successfully performed under the guide of the probe, without damaging the coronary arteries. Double outflow technique was applied for the relief of the right ventricular outflow tract obstruction.
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INTRODUCTION
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The incidence of abnormal coronary arteries crossing the right ventricular outflow tract in tetralogy of Fallot (TOF) has been reported to be about 10%.1 This anomaly considerably affects surgical results due to the risk of the ventriculotomy damaging the anomalous coronary artery, usually the left anterior descending artery (LAD).1 Furthermore, obliteration of the coronary anatomy at re-operation predisposes those anomalous coronaries identified in the primary operation to injury from the ventricular incision.
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CASE REPORT
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A 7-year-old girl had undergone transatrial-transpulmonary repair for TOF with a single right coronary artery. Two years later, cardiac catheterization showed right ventricle (RV) pressure equivalent to that of the left ventricle (LV) (Figure 1
). In addition, deterioration of tricuspid regurgitation was detected on echocardiogram. Accordingly, a RV outflow tract reconstruction was scheduled.
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Figure 1. Preoperative angiogram; A: Right ventricular (RV) injection showing severe subpulmonary stenosis (arrow), B: Single right coronary angiogram showing the left anterior descending artery and left circumflex artery crossing the RV outflow tract. Another catheter is placed in the RV outflow tract to the main pulmonary artery.
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A median re-sternotomy was performed. The aorta was incised transversely after being clamped. A single coronary orifice from the right coronary sinus was confirmed. A vessel probe (1.5 mm in diameter) was passed into the coronary artery to determine the course of its three branches. The probe was easily identified by putting a finger above it from the outer and inner of the RV. Ventriculotomy at the free wall of the RV outflow tract a few millimeters proximal to the LAD was safely done under the guide of the probe in the LAD. Muscle and fibrous tissue around the subpulmonary area was resected through the inner RV. However, it was not large enough to relieve the RV outflow tract obstruction. The main pulmonary artery (PA) was also longitudinally incised. A rectangular-shaped (2.5 x 4 cm) segment of autologous pericardium was anastomosed to the most proximal edge of the PA incision. The other end of the pericardium was anastomosed to the superior margin of the ventriculotomy. Thereby, the pericardium was positioned over the course of both the LAD and left circumflex artery.
A hood of 2/3 piped Gore-Tex (8 mm radius) tube was circumferentially sutured to the edge of the ventriculotomy, both edges of the pericardium and the edge of the PA incision (Figure 2). After completion, the RV pressure was 50% of systemic pressure. The patient was discharged in good general condition 1 month after the operation.
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Figure 2. Surgical schema; A: A vessel probe guides the course of the abnormal coronary artery, this ensures safety and accessibility of the ventriculotomy; B: A pericardial patch bridges the right ventricular outflow tract to the main pulmonary artery. A hood of 2/3 piped Gore-Tex tube was applied to the anterior part of the extracardiac route.
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One year later, postoperative cardiac catheterization revealed that RV pressure had decreased to 40% of systemic pressure. Tricuspid regurgitation was diminished and the double root from the right ventricular outflow tract to the main PA was well projected on right ventriculogram (Figure 3). There was no obvious evidence of growth in the autologous pericardium of the extracardiac conduit, although the major and minor radii of this conduit were 10.5 and 4.8 mm respectively.
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Figure 3. Postoperative right ventriculogram - right ventricular (RV) injection in diastole showing the double root from the RV outflow tract to the pulmonary artery.
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DISCUSSION
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Anomalous coronary artery distribution in TOF, especially with major coronary arteries crossing the RV outflow tract, has been reported to adversely affect post-surgical mortality and morbidity.1 Recently, many techniques designed to avoid surgical damage of the abnormal coronary artery have been published. RV-PA extracardiac conduit was first described as a procedure to relieve RV outflow obstruction in TOF with anomalous coronary anatomy. However, this technique required re-operation to exchange the extracardiac conduit. O’Blenes reported a main PA translocation method.2 The main PA was mobilized and divided just distal to the annulus. The distal end of the main PA was translocated on the ventriculotomy anterior to the abnormal coronary. A monocusp patch was applied on the anterior wall of the main PA. Brizard reported the use of the displaced transannular ventriculotomy method.3 An incision was longitudinally performed in the main PA and the incision was extended into the RV outflow tract, parallel to the abnormal coronary and toward the interventricular septum. Van Son advocated the double route method using the reversed flap of the anterior wall of the main PA.4 A horseshoe shaped flap was created on the anterior wall of the main PA. It was turned down and anastomosed to the superior margin of the ventriculotomy. An oval-shaped patch was sutured to the edge of the opened pulmonary artery, then to the edges of the reversed PA flap and finally to the remaining edge of the ventriculotomy. This technique facilitated construction of double roots from the RV to the PA.
We chose a van Son method and modified it. As the main PA was small, autologous pericardium was used as a posterior route for the RV to the PA with anticipation of potential growth, instead of adapting the flap of the anterior wall of the main PA.
At re-operation, as it is difficult to determine the course of the coronary arteries, the risk of surgical damage to abnormal coronary arteries increases. To overcome this problem, the aorta was opened and the anatomy of the coronary artery was inspected by inserting a small caliber probe into the coronary artery and palpating it from the outside or inside of the RV. This procedure facilitated identification of the course of the coronary artery and led to a safe and reliable ventriculotomy. It has been reported that direct insertion of the probe into the coronary artery may cause coronary ostial stenosis presumably due to intimal injury of the coronary arteries.5 This case should be carefully followed for this problem.
In conclusion, a successful re-operation was performed on a patient with TOF associated with a single right coronary artery. Insertion of a coronary probe into the abnormal coronary arteries after aortotomy was useful to identify the course of the coronary arteries, and facilitated a safe ventriculotomy at re-operation.
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REFERENCES
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- Hurwitz RA, Smith W, King H, Girod DA, Caldwell RL. Tetralogy of Fallot with abnormal coronary artery: 1967 to 1977. J Thorac Cardiovasc Surg 1980; 80:129–34.[Abstract]
- O’Blenes SB, Freedom RM, Coles JG. Tetralogy of Fallot with anomalous LAD: repair without conduit. Ann Thorac Surg 1996;62:1186–8.[Abstract/Free Full Text]
- Brizard CP, Mas C, Sohn YS, Cochrane AD, Karl TR. Transatrial-transpulmonary tetralogy of Fallot repair is effective in the presence of anomalous coronary arteries. J Thorac Cardiovasc Surg 1998; 116:770–9.[Abstract/Free Full Text]
- van Son JA. Repair of tetralogy of Fallot with anomalous origin of left anterior descending coronary artery. J Thorac Cardiovasc Surg 1995;110:561–2.[Free Full Text]
- Winkelmann BR, Ihnken K, Beyersdorf F, Eckel L, Skupin M, Marz W, et al. Left main coronary artery stenosis after aortic valve replacement: genetic disposition for accelerated arteriosclerosis after injury of the intact human coronary artery? Coron Artery Dis 1993;4:659–67.[Medline]
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