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Reimplantation of Anomalous Left Coronary Artery on Beating Heart

Department of Cardiothoracic Surgery National University Hospital 5 Lower Kent Ridge Road Singapore 119074, Republic of Singapore

We read with interest the paper by Talwar and colleagues.¹ Although anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital anomaly, it has a dismal prognosis unless detected early and treated surgically. With medical therapy alone, survival is close to 0% at 5 years.² Surgical intervention varies from coronary artery ligation to cardiac transplantation. The ideal operation in most cases aims to establish a twocoronary artery system by direct reimplantation of the anomalous left coronary artery (ALCA) into the aorta or uses Takeuchi repair (intrapulmonary artery aortocoronary tunnel repair). Other procedures include saphenous vein bypass to the ALCA, subclavian-left coronary artery anastomosis, and internal mammary artery grafting to the ALCA. Like many others, Talwar and colleagues¹ repaired the ALCA on an arrested heart. This leads to global myocardial ischemia, adding further injury to the failing myocardium in most ALCA cases.

We believe that in most cases, operating on a beating heart may prevent myocardial damage and yield better results. Others have shown that the extent of ischemic myocardial damage is the most important determinant of outcome after a corrective operation.³ El Oakley and colleagues⁴ reconstructed a two-coronary artery system on a beating heart in 3 cases of ALCA. These patients were operated upon via a median sternotomy and the ALCA was mobilized with a large button of pulmonary artery wall around the anomalous coronary ostium. In the first patient, a cuff of pulmonary artery was used to fashion a tube extension to the aorta. In the second and third cases, the ALCA was anastomosed directly to the left side of the ascending aorta. The pulmonary artery was reconstructed with autologous pericardium. The pro-cedures were performed on a beating heart under normothermic cardiopulmonary bypass, without snaring the venae cavae. There was no operative mortality and the patients were discharged after 8 to 15 days. Post-operative echocardiography findings of patent aorto-coronary anastomoses and improved ventricular function were confirmed by angiography on follow-up. Prevention of further ischemic injury by avoiding both aortic cross-clamping and global myocardial ischemia may improve operative results. We believe that beating-heart surgery may have an important role to play in the future manage-ment of patients with ALCA.

References

1. Talwar S, Bhan A, Sharma R, Choudhary SK, Airan B, Saxena A, et al. Two-coronary repair for anomalous left coronary artery from pulmonary artery. Asian Cardiovasc Thorac Ann 2000;8:27–31.[Abstract/Free Full Text]

2. Kalou-Guikahue M, Sidi D, Kachaner J, Villain E, Cohen L, Piechaud JF, et al. Anomalous left coronary artery arising from the pulmonary artery in infancy: is early operation better? Br Heart J 1988;60:522–6.[Abstract/Free Full Text]

3. Ardehali A, Laks H, Allada V. Management of the anomalous origin of the left coronary artery from the pulmonary artery. Advances in cardiac surgery. Chicago: Mosby, 1996:137–47.

4. El Oakley R, Al Saeedi A, Al Faraidi Y, Zanouna YA, Abdullhamid J, Jubair K. Reimplantation of anomalous left coronary artery on a beating heart. J Thorac Cardiovasc Surg 1999;117:395–6.[Free Full Text]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Li Zhang Reida El Oakley Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by See, J. Y. Articles by El Oakley, R. Search for Related Content PubMed Articles by See, J. Y. Articles by El Oakley, R.