Asian Cardiovasc Thorac Ann 2008;16:73-75
© 2008 Asia Publishing EXchange Ltd
Right Coronary Artery Translocation in Tetralogy of Fallot
Wan-Jun Luo, MD,
Ri-Mao Huang, MD,
Yong Tang, MD,
Bei Li, MD
Department of Cardiothoracic Surgery, Xiang Ya Hospital, Central South University, Changsha, China
For reprint information contact: Wan-Jun Luo, MD, Tel: 86 731 432 7247, Fax: 86 731 431 0800, Email: luowanjun{at}yahoo.com, Department of Cardiothoracic Surgery, Xiang Ya Hospital, Central South University, Changsha 410008, Hunan, China.
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ABSTRACT
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We describe a simple and cost-effective technique to repair anomalous origin of the right coronary artery from the left coronary artery in tetralogy of Fallot. The proximal right coronary artery is re-implanted into the aorta after it is mobilized and transected. This technique avoids the use of conduits in infants or adults with tetralogy of Fallot and anomalous right coronary arteries, and maintains the growth potential of the translocated native coronary artery.
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INTRODUCTION
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Surgical repair has become a routine method of treating tetralogy of Fallot (TOF).1,2 A small number of patients have anomalous coronary distribution, which makes surgical repair technically difficult. We describe successful right coronary artery (RCA) translocation for repair of TOF with RCA arising from the left coronary artery (LCA).
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TECHNIQUE
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Repair of TOF is performed under standard moderately hypothermic cardiopulmonary bypass with bicaval cannulation and antegrade cold blood cardioplegia for myocardial protection. Coronary artery anatomy is carefully inspected after sternotomy and before cardiopulmonary bypass (Figure 1
). The right atrium is opened for placement of a left vent via the patent foramen ovale or through an incision in the atrial septum after aortic cross clamping. The proximal RCA is mobilized carefully for some distance, and its proximal small branches are clipped and transected to obtain adequate length for anastomosis. The proximal length of the mobilized RCA must be adequate for re-implantation into the ascending aorta, without tension or kinking. A vertical incision is made on the right ventricular outflow tract, and the infundibulum is enlarged as usual. The ventricular septal defect is closed using a Dacron patch with interrupted horizontal mattress sutures on its inferior and posterior margins. The remaining rim of the ventricular septal defect is closed with a continuous suture. A fresh autologous pericardial patch is used to enlarge the right ventricular outflow tract. A hole of 4.0 mm in diameter is made on the anterior wall of the ascending aorta using a punch. The RCA is transected near its origin from the LCA, and the opening in the LCA is closed using 5/0 polypropylene suture (Figure 2). The proximal end of the RCA is anastomosed to the ascending aorta using 7/0 polypropylene suture in a continuous fashion (Figure 3). After completion of the anastomosis, cardioplegic infusion is restarted to detect any leakage from the mobilized RCA. The patient is weaned off cardiopulmonary bypass when the intracardiac procedure is completed. After extubation, patients are prescribed oral aspirin for one month.
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Figure 1. Diagram showing the right coronary artery arising from the left coronary artery and crossing the right ventricular outflow tract.
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Figure 2. Diagram showing the proximal right coronary artery mobilized and transected near its origin from the left coronary artery; enlargement of the right ventricular outflow tract is performed using a pericardial patch.
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Figure 3. Right coronary artery translocation for repair of tetralogy of Fallot in a 3-year-old child; this picture was taken after cardiopulmonary bypass; the right coronary artery has been anastomosed to the ascending aorta (arrow).
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DISCUSSION
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We used this technique in 2 patients with TOF and RCA arising from the LCA; one was a 3-year-old boy and the other was a 19-year-old girl. They have been followed up for 1 and 3 years, respectively, with electrocardiograms and echocardiography. There has been no evidence of myocardial ischemia during follow-up. The girl has undergone exercise electrocardiography, which showed excellent cardiac function, but both patients declined postoperative coronary angiography.
Right coronary artery arising from the LCA is very rare in patients with TOF; the precise incidence has not been reported. Tchervenkov and colleagues1 found only one case in 20 patients with anomalous coronary arteries. We encountered only 3 patients with the RCA arising from the LCA in 410 patients with TOF treated between 1986 and 2006. If the RCA passes rightward across and in front of the infundibulum of the right ventricle, a right ventriculotomy and right ventricular outflow tract patch for TOF repair is usually impossible. An alternative technique is via a transatrial approach with placement of the outflow tract patch either above, below, or both, relative to the coronary artery.1,2 However, it is frequently impossible to use this technique when stenosis of the right outflow tract is severe and extensive, particularly in older children and adults with TOF, and a relatively large transannular patch is needed for adequate relief of the infundibular obstruction. In this condition, placement of a homograft conduit from the right ventricle to the pulmonary artery may be needed. This may require further revision because of conduit failure and mismatch due to growth of the patient. In addition, such conduits are costly and usually unavailable in a developing country. Other choices for repair of TOF with a coronary anomaly are pulmonary artery translocation or coronary artery bypass grafting using saphenous vein, left subclavian artery, or left mammary artery.1 These methods are technically difficult, particularly in children.
Using our technique, the RCA arising from the LCA was successfully translocated and re-implanted into the aorta. The relief of stenosis in the right outflow tract could be managed as easily as standard repair of TOF after coronary translocation, which could minimize the possibility of residual right outflow tract obstruction and avoid insertion of a conduit. This technique is relatively simple, reproducible, and cost-effective. The re-implanted native RCA has growth characteristics which reduce the need for surgical revision. Our preliminary experience showed that short- and midterm outcomes are satisfactory. However, further observation is needed to determine the long-term outcome.
The limitations of this technique should be stated. Firstly, it is not applicable to all coronary anomalies. In particular, when the left anterior descending artery arises from the RCA and crosses the right ventricular outflow tract, the short proximal left anterior descending artery cannot approach the aorta for anastomosis. Secondly, one should be cautious in using this technique in very young patients, because the small coronary artery after re-implantation may have a higher risk of stenosis or other problems. We do not recommend it as a first option in very young patients with TOF. However, nowadays in developing countries, most patients with TOF accept later surgery, and in our hospital, 60% of patients are > 3 years old at surgery, which allows the opportunity to perform this technique. Finally, the follow-up of our 2 patients is short and lacking postoperative coronary angiography, so we could not completely rule out the possibility of myocardial ischemia. Nevertheless, right coronary artery translocation offers an alternative technique of repair of anomalous origin of the right coronary artery from the left coronary artery in older children or adults with tetralogy of Fallot.
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REFERENCES
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- Tchervenkov CI, Pelletier MP, Shum-Tim D, Beland MJ, Rohlicek C. Primary repair minimizing the use of conduits in neonates and infants with tetralogy or double-outlet right ventricle and anomalous coronary arteries. J Thorac Cardiovasc Surg 2000;119:314–23.[Abstract/Free Full Text]
- Hekmat M, Rafieyian S, Foroughi M, Majidi Tehrani MM, Beheshti Monfared M, Hassantash SA. Associated coronary anomalies in 135 Iranian patients with tetralogy of Fallot. Asian Cardiovasc Thorac Ann 2005;13:307–10.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
