Eur J Cardiothorac Surg 2005;27:927-929
© 2005 Elsevier Science NL
Reconstruction of left main coronary artery with subclavian artery free graft in an infant
Rafael R. Guerreroa,
James L. Wilkinsonb,
Christian P. Brizarda,*
a Department of Cardiac Surgery, Royal Children's Hospital, Flemington Road, Parkville, Melbourne, Vic. 3052, Australia
b Department of Cardiology, Royal Children's Hospital, Flemington Road, Parkville, Melbourne, Vic. 3052, Australia
Received 1 December 2004;
received in revised form 8 February 2005;
accepted 11 February 2005.
* Corresponding author. Tel.: +61 3 9345 5200; fax: +61 3 9345 6386. (E-mail: christian.brizard{at}rch.org.au).
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Abstract
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We report the case of a 3-month-old infant with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) with absent left main coronary artery (LMCA). She underwent repair by reimplantation technique with the construction of a short LMCA using two opposite flaps. Two months later she was re-admitted in cardiac failure. Occlusion of the reconstructed LMCA was found by angiogram. At reoperation the right subclavian artery was used as a free interposition graft to reconstruct the LMCA. The post-operative course was uneventful. At 8 months she was asymptomatic and LMCA patency was demonstrated by angiogram.
Key Words: Congenital • Coronary
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1. Introduction
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The procedure of choice for the treatment of ALCAPA is the creation of a dual coronary system by direct reimplantation of the anomalous coronary artery into the ascending aorta.
This may be difficult in the presence of a short LMCA or when the ALCAPA originates from the anterior-left pulmonary sinus.
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2. Case report
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A 3-month-old infant with ALCAPA presented with profound left ventricular (LV) dysfunction and severe mitral valve regurgitation (MR). The diagnosis was confirmed with angiography. The LMCA was absent and the left anterior descending (LAD) and circumflex (Cx) artery arose directly from separate ostia low in the left pulmonary sinus.
Surgical repair consisted of reimplantation, with the construction of a short LMCA using long opposing flaps from the pulmonary artery (PA) and aortic walls. The aortic trapdoor was posterior and inferiorly hinged. The sides of the conduit were completed using two small triangular pieces of aortic free wall (Fig. 1). The defect of the main PA was reconstructed using autologous pericardium and an anterior mitral commisuroplasty associated with posterior mitral leaflet chordal shortening. The patient was extubated on post-operative day one with mild MR. On the fifth post-operative day the MR had increased in severity, but this was treated conservatively. She was discharged home on day twenty.
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Fig. 1. Initial reconstruction technique. Construction of a left main stem using opposing flaps of pulmonary and aortic wall.
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She presented 2 months later with worsening MR, and no improvement in LV function. Ongoing myocardial ischaemia was suspected and a selective coronary angiogram demonstrated occlusion of the reconstructed LMCA (Fig. 2a). She was referred for reoperation.
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Fig. 2. (a) Angiography demonstrating occlusion of the reconstructed left main stem coronary. (b) Angiogram 8 months after repair showing a patent left coronary artery with no evidence of stenosis.
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After redo sternotomy, the right subclavian artery (RSA) was dissected. Approximately 1cm of the second and third portion of the RSA, distal to the vertebral artery, was harvested after heparinization. Cardiopulmonary bypass was established at 28°C. Myocardial protection was achieved with antegrade cold blood cardioplegia. After transecting the main PA, the aorta and reconstructed LMCA were dissected. The LMCA seemed to have retracted and was compressed by the repaired main PA. The ascending aorta was transected and a coronary probe was inserted revealing a patent but severely stenotic LMCA. The LAD and Cx were patent. The LMCA was entirely resected. Its bifurcation was bevelled and an end-to-end anastomosis was performed with the trimmed RSA free graft using continuous 9/0 nylon suture. The proximal end was sutured end-to-side to the ascending aorta. The coronary reconstruction was tested by direct injection of cardioplegia.
The ascending aorta was reconstructed. The mitral valve (MV) was inspected and a small wedge resection of the anterior leaflet together with a limited posterior annuloplasty was performed.
At 8 months follow-up, she was asymptomatic with good left ventricular function and mild MR on echocardiography. A repeated angiogram showed a patent LMCA with no evidence of stenosis (Fig. 2b).
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3. Discussion
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Several reports have confirmed that the direct reimplantation of the anomalous coronary into the ascending aorta has good early and late results [1–3]. However, stenosis or total occlusion of the LMCA occasionally can be seen after repair. Factors related to this complication are the origin of the left coronary from the lateral aspect of the PA, a short LMCA and compression by the repaired PA. In addition, the vicious circle of ischaemia, LV distension and increased PA pressure may play a role in stretching the reimplanted coronary artery [4].
Reoperation of survivors for failed or stenosed reimplantation is rare and the surgical strategy is generally tailored to the individual patient.
Huddleston et al. reported two cases in which revascularization of the LCA system was required, 2 and 6 years post-repair. A patch angioplasty and a left internal mammary artery by pass were successfully used. Montigny et al. reported the long-term patency of the left subclavian artery to ALCAPA anastomosis in four patients, when used as a primary repair [5].
Our patient was reoperated as an infant, 2 months after her initial repair. The RSA was selected as a conduit because of its arterial origin and matching size.
3.1. Lessons
- 1. Despite the trend and common utilization of direct reimplantation technique, some rare cases may be better suited for the Takeuchi technique, which has an excellent long-term patency [1]. This patient could have been one of them.
- 2. Mitral valve repair is not classically indicated; however, a successful repair generates an easier post-operative course. We now have a lower threshold for MV repair in ALCAPA patients.
- 3. When MR reappears or worsens or LV function deteriorates, stenosis or occlusion of the ALCAPA reimplantation should be suspected, and coronary angiography indicated.
- 4. In infants every effort should be made to use homologous arterial graft for coronary reconstruction.
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References
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- Cochrane AD, Coleman DM, Davis AM, Brizard CP, Wolfe R, Karl TR. Excellent long-term functional outcome after an operation for anomalous left coronary artery from the pulmonary artery. J Thorac Cardiovasc Surg 1999;117:332-342.[Abstract/Free Full Text]
- Ando M, Mee RB, Duncan BW, Drummond-Webb JJ, Seshadri SG, Igor Mesia CI. Creation of a dual-coronary system for anomalous origin of the left coronary artery from the pulmonary artery utilizing the trapdoor flap method. Eur J Cardiothorac Surg 2002;22:576-581.[Abstract/Free Full Text]
- Barth MJ, Allen BS, Gulecyuz M, Chiemmongkoltip P, Cuneo B, Ilbawi MN. Experience with an alternative technique for the management of anomalous left coronary artery from the pulmonary artery. Ann Thorac Surg 2003;76:1429-1434.[Abstract/Free Full Text]
- Huddleston CB, Balzer DT, Mendeloff EN. Repair of anomalous left main coronary artery arising from the pulmonary artery in infants: long-term impact on the mitral valve. Ann Thorac Surg 2001;71:1985-1988.[Abstract/Free Full Text]
- Montigny M, Stanley P, Chartrand C, Selman E, Fournier A, Davignon A. Postoperative evaluation after end-to-end subclavian-left coronary artery anastomosis in anomalous left coronary artery. J Thorac Cardiovasc Surg 1990;100:270-273.[Abstract]
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Abstract
1. Introduction
