Surgery for Anomalous Origin of Left Coronary Artery From Pulmonary Artery: The Utility of Intraoperative Transesophageal Echocardiography

Abstract

A 51-yr-old female patient, presented with 3-yr symptoms of intermittent chest pain and dyspnea New York Heart Association class II, which progressed to class IV since 1 mo.She was provisionally diagnosed as having anomalous origin of left coronary artery from pulmonary artery (ALCAPA) and severe mitral regurgitation (MR) on transthoracic echocardiography. Preoperative catheter studies and coronary angiography confirmed the diagnosis and revealed left ventricular (LV) ejection fraction of 46%. She was scheduled to undergo surgery for relocation of the left coronary artery (LCA) and mitral valve replacement. After induction of anesthesia, her heart was examined using transesophageal echocardiography (TEE). Withdrawing the probe slightly from the midesophageal (ME) five-chamber view and turning it to the right revealed a large retrograde-filling LCA connected to the main pulmonary artery (MPA) (Fig. 1). The flow was turbulent during the early part of systole and red (towards the transducer) during the rest of the cardiac cycle. ALCAPA, connected to the posterior sinus of the MPA, could also be visualized in the same view as in Figure 1 and also in the modified right ventricular inflow outflow view at 90 -100 degrees after probe anteflexion (Video 1; please see video clips available at www.anesthesiaanalgesia.org). The distance between the midpoint of the empty aortic sinus and attachment of the ALCAPA on the posterior sinus of the MPA was 13.9 mm. Antegrade blood flow was observed in the dilated right coronary artery (RCA) (Video 2; please see video clips available at www.anesthesia-analgesia.org), which was 6.2 mm in diameter. Multiple unusual color flow Doppler signals were detected within the interventricular septum in aortic valve long axis view, believed to represent high flow septal coronary collaterals between the RCA and the ALCAPA. ME fourchamber view revealed thickened mitral valve leaflets, calcific papillary muscles and enlarged LV. Features of severe MR were also present (Vena contracta 7 mm in ME long axis view; systolic flow reversal in the right and left superior pulmonary vein). LV dilation (LV end-systolic dimension 48 mm) and hypokinesia of the anterolateral wall were observed on transgastric navigation. On establishment of cardiopulmonary bypass (CPB) and cardioplegia delivery, the LCA was disconnected from the MPA, along with a button of tissue around it, and was relocated onto the aorta. The mitral valve was replaced with size-28 Star Edward prosthesis. In the post-CPB period, the ALCAPA and the RCA could be seen flowing antegrade from the aortic root in modified five-chamber view (Fig. 2). The LCA diastolic flow velocity on pulsed wave Doppler, measured in the aortic valve short axis view at the sector angle between 10 and 30 degrees, was 0.7 m/s. It remained constant on Doppler interrogation up to 7-8 mm in the course of the vessel from its attachment to the aorta. The LV contractility had improved and no fresh regional wall motion abnormalities were found. The mitral valve prosthesis was fu...