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J Thorac Cardiovasc Surg 1999;117:395-396
© 1999 Mosby, Inc.

BRIEF COMMUNICATIONS

REIMPLANTATION OF ANOMALOUS LEFT CORONARY ARTERY ON A BEATING HEART

Reida El Oakley, FRCS, MDa, Abdulraoof Al Saeedi, FRCSa, Yahya Al Faraidi, FRCSa, Youssef Abou Zanouna, FRCPIb, Jassim Abdullhamid, FRCPE, FACCb, Khalid Jubair, FRCSa, Riyadh, Saudi Arabia

From the Departments of Cardiac Surgerya and Pediatric Cardiology,b Prince Sultan Cardiac Centre, Riyadh, Kingdom of Saudi Arabia.

Received for publication May 29, 1998. Accepted for publication Sept 30, 1998. Address for reprints: Khalid Jubair, FRCS, Department of Cardiac Surgery, Prince Sultan Cardiac Centre, PO Box 7879, Riyadh 11159, Kingdom of Saudi Arabia.

Surgical management of anomalous left coronary artery (ALCA) varies from simple ligation of the anomalous artery to cardiac transplantation.Go 1 The ideal operation in most cases aims to construct a 2-coronary artery system; this can be achieved by a number of procedures that require global myocardial ischemia during an operation.Go Go 2-5 Because preservation of the residual ventricular function optimizes the chances of recovery after such procedures,Go Go 1,5 operating on a beating heart in these cases may prevent myocardial damage and yield better results. We report the surgical techniques and the clinical and angiographic results of the first 2 patients with ALCA who had a 2-coronary artery system re-established on a beating heart.

Patients and methods
The clinical details of the 2 patients who underwent the procedure are outlined in Table I. In both cases the diagnosis was confirmed with cardiac catheterization. The patients were then referred for implantation of the ALCA. With general anesthesia, the heart was exposed through a median sternotomy. Cardiopulmonary bypass was established using 2 venous cannulas and an aortic return. The ALCA was mobilized for 1 to 1.5 cm from its origin and was occluded with a small vascular clamp. The anomalous coronary arteries that arose from the left sinus of the pulmonary artery, in both cases, were excised with a generous cuff from the pulmonary artery wall. In the first patient, the cuff was used to fashion a tube extension to the aorta. In the second patient, the ALCA was anastomosed directly to the left side of the ascending aorta. The pulmonary artery was reconstructed with a piece of autologous pericardium. Both procedures were performed on a beating heart on normothermic cardiopulmonary bypass without snaring the cavae. There was no risk of systemic air embolism because neither of the patients had atrial or ventricular septal defects. Left side vent was not required because the patients had no aortic regurgitation and remained in sinus rhythm throughout the procedure. The patients came off cardiopulmonary bypass with inotropic support (dopamine, 10 µg/kg per minute). The first patient had an uneventful intensive care unit stay and was extubated after 3 days, whereas adult respiratory distress syndrome developed in the second patient, who was treated with ventilation for 7 days. The patients were discharged from the hospital after 8 and 15 days, respectively. Postoperative echocardiographic findings of good left coronary antegrade flow and improved ventricular function (Table IGo) were confirmed by angiography (Fig 1) after 6 months and 8 weeks, respectively.


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  		Table I. Clinical details of the first 2 patients who underwent reimplantation of anomalous left main coronary artery on a beating heart
 


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  		Fig 1. Late phase of aortic injection 6 months (panel A; patient 1) and 2 months (panel B; patient 2) after reimplantation of the anomalous left main coronary artery on a beating heart.

 
Discussion
The ideal repair of ALCA is reconstruction of a 2-coronary artery system.Go Go 1,2 This can be achieved by a number of techniques: direct implantation of ALCA into the ascending aorta, Takeuchi repair (aortopulmonary tunnel operation), subclavian–left coronary artery anastomosis, and coronary artery bypass grafting with an internal thoracic artery or a vein graft.Go Go 2-5 All these procedures have been performed by applying global myocardial ischemia during the operation. Perioperative deaths of patients with ALCA vary from 0% to 75%.Go Go 1,5 The extent of ischemic myocardial damage is the most important determinant of outcome after a corrective operation.Go Go 1,5 Prevention of further ischemic injury by avoiding aortic crossclamp and global myocardial ischemia may improve the operative results of patients with ALCA. Early encouraging reports on coronary artery bypass surgery on a beating heart in adults has prompted us to apply similar principles in reimplantation of ALCA. We found that reimplantation of ALCA into the aorta can be achieved on a beating perfused heart without rendering the myocardium ischemic.

However, there are a few potential limitations to this technique. First, the application of a partial clamp to a small aorta could jeopardize the right coronary artery flow. This can be avoided by adequate mobilization of the aorta, applying a small partial clamp, and closely observing for electrocardiographic signs of acute myocardial ischemia. Second, mobilization of the ALCA and its main branches and reconstruction of the pulmonary artery with a pericardial patch on a beating heart may prolong cardiopulmonary bypass time. Detailed knowledge of the coronary artery anatomy of individual patients and the use of tube grafts in pulmonary artery reconstruction could minimize the duration of cardiopulmonary bypass. Third, undue tension on the coronary artery can be avoided by using an extrapulmonary tube extension as described in the first case and by adequate mobilization of the left coronary artery and its main branches. Despite these potential limitations, we believe that reimplantation of ALCA on a beating heart could have an important role to play in the management of patients with anomalous origin left coronary artery.

Note: Since the submission of this article, another 8-month-old girl with anomalous left coronary artery and severe ischemic cardiomyopathy has successfully undergone reimplantation of ALCA on a beating heart.

References

  1. Ardehali A, Laks H, Allada V. Management of the anomalous origin of the left coronary artery from the pulmonary artery. In: Karp RB, Laks H, Wechsler A, editors. Advances in cardiac surgery. Chicago: Mosby; 1996. p. 137-47.
  2. Bunton R, Jonas RA, Lang P, Rein AJT, Castaneda AR. Anomalous origin of the left coronary artery from pulmonary artery: ligation versus establishment of a two coronary system. J Thorac Cardiovasc Surg 1987;93:103-8. [Abstract]
  3. Cooley DA, Duncan JM, Gillette PC, McNamara DG. Reconstruction of coronary artery anomaly in an infant using the internal mammary artery: 10 year follow-up. Pediatr Cardiol 1987;8:257-9. [Medline]
  4. Takeuchi S, Imamura H, Katsumoto K, et al. New surgical method for repair of anomalous left coronary artery from pulmonary artery. J Thorac Cardiovasc Surg 1979;78:7-11. [Abstract]
  5. Vouhé PR, Baillot-Vernant F, Trinquet F, et al. Anomalous left coronary artery from pulmonary artery in infants: which operation and when. J Thorac Cardiovasc Surg 1987;94:192-9. [Abstract]



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 Asian Cardiovasc. Thorac. Ann.Home page
J. Y. See, L. Zhang, R. El Oakley, J. Y. See, L. Zhang, and R. El Oakley
Reimplantation of Anomalous Left Coronary Artery on Beating Heart
Asian Cardiovasc Thorac Ann, September 1, 2000; 8(3): 302 - 302.
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