Asian Cardiovasc Thorac Ann 2008;16:252-253
© 2008 Asia Publishing EXchange Ltd
Repair of Anomalous Left Coronary Artery from the Right Pulmonary Artery
Paul Modi, FRCS,
Qiang Chen, MD,
Tim Murphy, FRCA,
Ash Pawade, FRCS
The Royal Hospital for Children, Bristol, United Kingdom
For reprint information contact: Paul Modi, FRCS, Tel: 44 117 928 2979, Fax: 44 117 929 9737, Email: paulmodi{at}doctors.org.uk, The Royal Hospital for Children, Bristol, BS2 8HW, United Kingdom.
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ABSTRACT
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Surgical correction of anomalous left coronary artery from the right pulmonary artery is achieved by either direct implantation of the left coronary artery into the aorta or creation of a conduit between the two. We modified a technique originally described by Tashiro for the main pulmonary artery, by using a circumferential section of right pulmonary artery wall to create a conduit with a side-to-side anastomosis onto the aorta.
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INTRODUCTION
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Anomalous origin of the left coronary artery (LCA) from the pulmonary artery (PA) describes a condition in which the LCA arises from either the left or right pulmonary sinuses of Valsalva or, rarely, the left or right PA. It results in profound myocardial ischemia caused by the absence of normal coronary flow and steal of the coronary circulation into the PA. Treatment should aim to reestablish a dual coronary blood supply from the aorta.1 We used a circumferential ring of autologous right PA to lengthen the anomalous coronary artery, thus avoiding tension on the aortocoronary anastomosis and allowing for growth.
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TECHNIQUE
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A 3-year-old boy, who was well and acyanotic, underwent elective investigation of a cardiac murmur. Transthoracic echocardiography showed a dilated left atrium with severe mitral regurgitation, abnormal chordal attachment, and a short immobile posterior leaflet. Cardiac catheterization and computed tomographic angiography revealed an anomalous LCA arising from the right PA and associated with severe mitral regurgitation. The patient was explored through a median sternotomy. As expected, the right coronary artery was very dilated with extensive collateralization over the myocardium. The anomalous LCA originated from the inferior wall of the right PA between the right margin of the aorta and the left margin of the superior vena cava (Figure 1
). It was felt that transfer of a simple cuff of right PA may lead to tension or kinking of the aortocoronary anastomosis.
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Figure 1. Intraoperative picture showing the anomalous left coronary artery (arrowed) arising from the right pulmonary artery (RPA). Ao = aorta.
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The LCA and both PAs were fully mobilized, and the ligamentum arteriosum was ligated and divided, thus facilitating direct end-to-end anastomosis of the right PA later in the procedure. Cardiopulmonary bypass was commenced with bicaval venous cannulas and ascending aortic return, with moderate systemic hypothermia (28°C). A vent was inserted through the right superior pulmonary vein. Tourniquets were placed around both PAs and snared when cardiopulmonary bypass was started to abolish the coronary steal. With the heart beating, the right PA was transected on both sides of the orifice of the anomalous left coronary artery to create a circumferential cuff of PA tissue incorporating the origin of the LCA at its inferior end. The edges of the cuff were sutured together to form a hood of PA tissue elongating the coronary artery, leaving a 4-mm diameter orifice on the distal aortic aspect of the tube (Figure 2). A side-biting clamp was applied to the right side of the aorta and a 4-mm punched aortotomy was made just above the noncoronary aortic sinus. The coronary artery hood was anastomosed side-to-side to its edges using a continuous 7/0 polypropylene suture. The aorta was cross clamped and cold blood cardioplegia was infused into the aortic root. Mitral annuloplasty was performed with 3 plicating sutures via a transatrial approach. There was trivial residual mitral regurgitation on intraoperative testing. The heart was de-aired, the aorta was unclamped and continuity of the right PA reestablished by end-to-end anastomosis using a 6/0 polypropylene suture. Cardiopulmonary bypass was discontinued uneventfully on 5 µg·kg–1·min–1 dopamine with a left atrial pressure of 5 mm Hg. Transthoracic echocardiography revealed mild mitral regurgitation. The child made a good recovery and was discharged home on the 7th postoperative day. At the 2-year follow-up, he was well with normal growth and no functional limitation. Echocardiography revealed good biventricular function (fractional shortening, 45%), mild mitral regurgitation, normal coronary blood flow, and no evidence of PA obstruction (velocities: right PA, 1.3 m·sec–1; left PA, 1.4 m·sec–1).
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Figure 2. Surgical technique using a circumferential cuff of right pulmonary artery as a hood to extend the right pulmonary artery.
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DISCUSSION
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Surgical approaches should aim to reimplant the anomalous LCA into the aorta to allow myocardial recovery, decrease the incidence of late sudden death, provide long-term patency and allow for growth.1 However, the major shortcoming of this technique is tension applied to the aortocoronary anastomosis, resulting in an increased incidence of stenosis and obstruction.2 When the anomalous LCA arises from the main PA, Tashiro and colleagues3 described a technique using a circumferential section of main PA wall with a side-to-side anastomosis. However, when the anomalous LCA arises from a branch PA, reported techniques have used either a generous circular button of branch PA wall around the coronary orifice or unroofing of an intramural course.4,5 This is the first report of the application of Tashiro’s technique to a branch PA. It makes implantation on the aorta technically easier, provides flexibility in selecting the site of anastomosis and avoids kinking. The aortocoronary anastomosis was constructed on a beating heart to decrease the duration of global myocardial ischemia. The use of autologous and viable tissue allows for future growth by avoiding prosthetic material, and is thus applicable in very young patients. Our midterm follow-up suggests that this provides a durable repair in this rare condition.
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REFERENCES
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INTRODUCTION
