Anomalous origin of the left coronary artery from the pulmonary artery: Early results with direct aortic reimplantation

Abstract

Anomalous origin of the left coronary artery from the pulmonary artery Early results with direct aortic reimplantationBetween January 1991 and June 1993, eleven children with anomalous origin of the left coronary artery from the pulmonary artery underwent direct aortic reimplantation of the left coronary artery at the German Heart Institute Berlin. The patients' ages ranged from 2.5 months to 10.5 years; six were infants. Three infants were intubated and their lungs ventilated before the operation, and one was resuscitated 2 days before the operation. The electrocardiograms of eight patients indicated deep Q waves. All but three of these patients had insufficient collaterals between the right and left coronary arteries. The entire group exhibited reduced left ventricular ejection fraction (minimum 15 %) including mitral valve incompetence, which was moderate in six patients and severe in three. AU six infants underwent emergency operations, and the remaining children, who were older, underwent elective operations involving moderate hypothermic perfusion and cold crystalloid cardioplegia. Aortic crossclamping time ranged from 22 to 79 minutes (mean 54 minutes). A two-coronary artery system was established in all patients by direct reimplantation of the anomalous left coronary artery into the ascending aorta. Three patients who also exhibited severe mitral valve incompetence underwent modified Kay mitral valve annuloplasty. A delayed sternal closure procedure (closure performed 1 to 10 days after the operation) was used on eight patients. A 10-month-old patient was successfully treated after the operation with a centrifugal left heart assist device and a 9-year-old patient receivedextracorporeal membrane oxygenation because of severe heart failure. No postoperative deaths occurred. Left ventricular end-diastolic volume decreased dramatically after the operation and returned to near normal values 1 to 9 months postoperatively. At the same time, the preoperatively depressed left ventricular ejection fraction returned to normal and mitral valve incompetence decreased or vanished in eight patients. Color Doppler echocardiograms (eleven patients) and coronary angiograms (three patients) indicated that the reimplanted left coronary artery was patent in all eleven patients during the follow-up period. Reimplantation of the left coronary artery into the ascending aorta is an effective

An alternative technique for direct implantation of an anomalous left coronary artery arising from the pulmonary artery with complex coronary arteries

“…ALCAPA is a rare congenital anomaly that is usually lethal without surgical intervention. More recently, the concept of establishing a dual-coronary system has been advocated and widely accepted [ 2]. …”

Anomalous Origin of the Left Coronary Artery from the Right Pulmonary Artery

“…Cardioplegic arrest of the heart requires that pulmonary run‐off be controlled before injection of the cardioplegic solution into the aortic root 12 . This is best achieved by simultaneously occluding the branch pulmonary arteries 10,15 . Retrograde cardioplegia is an additional useful adjunct 10,12 …”

“…The management of the regurgitant mitral valve at the time of ALCAPA repair has raised some controversy 13,15 . Whereas some authors believe that mitral valve regurgitation should be repaired at the time of coronary transfer, 16 most believe that moderate regurgitation will improve with improving LV function after coronary transfer alone 10,14,15 . We, like others, 13,15 advocate mitral valve repair only for severe MR in the setting of ventricular dysfunction.…”

Repair of ALCAPA in a 4-kg Patient Followed by Successful Weaning and "Off-Pump" Explantation of an Apical Venting Pulsatile LVAD

“…Repair of ALCAPA carries a high risk for postcardiotomy heart failure 4–6 . Because of isolated cardiac failure and considering possible hemorrhagic and neurological complications of ECMO, implantation of an LVAD has developed into the strategy of choice in this condition 1 .…”