Eur J Cardiothorac Surg 1999;15:209-212
© 1999 Elsevier Science NL
Anomalous origin of the left main coronary artery: anatomical correction and concomitant LIMA-to-LAD grafting1
Tamir Wolf*,
Gil Bolotin,
Ronnie Ammar,
Gideon Uretzky
The Department of Cardiothoracic Surgery, Carmel Medical Center, The Technion, Israel Institute of Technology, Haifa, Israel
Received 20 September 1998;
received in revised form 30 November 1998;
accepted 8 December 1998.
* Corresponding author. 7 Michal St., Haifa 34362, Israel. Tel.: +972-4-825-0256; fax: +972-4-834-3554; e-mail: mdwolf@tx.technion.ac.il
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Abstract
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A 55-year-old woman with angina pectoris and exertional dyspnea underwent surgical correction of an anomalous left main coronary artery (LMCA) originating from the right sinus of Valsalva. During the operation, the roof of the intramurally coursing LMCA was opened into the aortic lumen, and a neo-coronary ostium was created by suturing the circumference of the LMCA intima to the aortic intima. In addition, a left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery anastomosis was performed. Post-operative coronary angiography demonstrated two independent, patent orifices of both the LMCA and the right coronary artery. The technique presented herein, of combined anatomical correction and LIMA-to-LAD grafting, is feasible and leads to distinct angiographic and clinical improvement.
Key Words: Anomalous coronary artery • Anatomical correction • Grafting
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Introduction
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Anomalous origin of either coronary artery is a rare entity, its prevalence ranging from 0.2% revealed at autopsy to 0.28% revealed during angiographic assessment [1]. The clinical picture may range from asymptomatic to either ischemia, myocardial infarction, or sudden cardiac death. Surgically, the options are either to perform aortoplasty, i.e. creating a neo-ostium for the LMCA in the aorta, or to bypass the compressed segment. Presented is a case in which the surgical management of a patient with an anomalous origin of the LMCA included both aortoplasty and grafting.
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Case report
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A 55-year-old woman suffering from stable angina was admitted to the local hospital due to recurrent chest pain upon effort and exertional dyspnea during previous months. In former years, she had suffered repeatedly from episodes of pulmonary edema. Her past medical history included controlled hypertension and diabetes mellitus.
Coronary angiography revealed a LMCA arising from the right sinus of Valsalva and coursing posterior to the aorta (Fig. 1 ). Stress thallium imaging demonstrated a decrease in perfusion to the anterior wall. Echo-Doppler examination showed anteroseptal and inferior-wall hypokinesis to akinesis, and an ejection fraction of 42%. Upon arrival at our institution, the patient underwent transesophageal echocardiographic assessment. At its origin, near the right aortic cusp, the LMCA was visualized as a long vessel with a 4 mm lumen, coursing posterior to the aorta, between the aorta and the left atrium.
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Fig. 1. Preoperative coronary angiography revealing the common orifice of the left and right coronary arteries.
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Following cardiopulmonary bypass establishment, a transverse aortotomy was made, extending towards the non-coronary sinus. The orifice common to both the LMCA and the right coronary artery was observed (Fig. 2
a), and a 1.5-mm coronary probe was passed through the ostium, thereby lifting the distal intramural segment of the aberrant artery. The roof of the intramural LMCA was opened into the aortic lumen (Fig. 2b). Subsequent suturing of the circumference of the intima of the LMCA to the aortic intima created a neo-coronary ostium (Fig. 2c). After reassuring the patency of the neo-ostium, the aortotomy was closed. In addition, a LIMA-to-LAD anastomosis was performed, as destined in the pre-operative debate. The post-operative course was uneventful: the patient was discharged after 5 days, and reported a significant improvement in quality of life. Post-operative coronary angiography demonstrated two independent, patent orifices of both the left and the right coronary arteries, as well as a patent LIMA-to-LAD graft.
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Fig. 2. Diagram illustrating the anatomy of the anomalous LMCA and its course (a) and the technique used for the anatomic correction (b and c).
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Discussion
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Several possible courses of an anomalous LMCA arising from the right sinus of Valsalva have been observed thus far. These include a course anterior to the pulmonary artery, between the aorta and the pulmonary trunk, and, as in this case, posterior to the aorta. Although the exact mechanism of ischemia remains undefined, especially in patients with non-atherosclerotic coronary arteries, several mechanisms have been proposed: angulation [2], compression [3] and kinking [4]. Since first described by Mustafa et al. [5], the surgical method for anatomically restoring the anomalous artery has been perfected, and it is considered an adequate treatment against the above-mentioned mechanisms.
There are several advantages to this method. Increasing the size of the coronary orifice by creating a wide enough neo-ostium from within the aorta prevents slitting of the orifice. This is especially crucial in patients such as the one described above, in whom only one common orifice served both the left and right coronary arteries. As rightfully pointed out by van Son and Mohr [6], the technique employed herein avoids detachment of the intracoronary commissure, thus lessening the potential for aortic regurgitation. The other surgical option is to bypass the anomalous portion of the artery using either an internal mammary artery (IMA) [7] or saphenous vein [8] grafting.
Although both surgical techniques have yielded good results, either may impair prospective coronary blood flow. The neo-ostium created during the `unroofing procedure' may undergo rapid narrowing due to atherosclerosis at the aortoplasty site [9]. Moreover, the acute takeoff of the neo-ostium may limit blood flow, even without evidence of atherosclerosis [9]. Coronary artery bypass grafting does not serve as an anatomical correction and may, in the long run, be affected by atherosclerosis. Though this patient had non-atherosclerotic arteries, we believe that anatomical correction and concomitant LIMA grafting may minimize the long term disadvantages of both techniques. In addition the post-operative evidence of patent neo-ostial LMCA and LIMA-to-LAD anastomosis revealed during coronary angiography demonstrates good intermediate-term results despite the theoretical potential of competitive flow.
We suggest that this combined technique may prove beneficial as the surgical treatment for patients with this rare coronary anomaly.
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Footnotes
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1> Presented at the 12th Annual Meeting of the European Association for Cardio-thoracic Surgery, Brussels, Belgium, September 20–23, 1998. 
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References
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- Cheitlin M.D., De Castro C.M., McAllister H.A. Sudden death as a complication of anomalous left coronary artery origin from the anterior sinus of Valsalva. A not-so-minor congenital anomaly. Circulation 1974;50:780-787.[Abstract/Free Full Text]
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Abstract
Introduction
