Superior pulmonary arterial flap for the repair of the left coronary artery from the non-facing pulmonary sinus

Superior pulmonary arterial flap for the repair of the left coronary artery from the non-facing... Abstract OBJECTIVES The anomalous left coronary artery arising from the non-facing pulmonary sinus origin is uncommon but poses a great challenge as its distance precludes direct aortic implantation. We describe an innovative technique for aortic implantation of this anomaly in a 2-month-old infant. METHODS Using a longitudinal pulmonary arterial flap, coronary tube extension was constructed without pulmonary commissure disturbance. RESULTS Myocardial recovery after 2-coronary artery system restoration was excellent. CONCLUSIONS With this approach, coronary transfer using autologous tissue with growth potential is possible. Anomalous origin of the left main coronary artery from the pulmonary artery, Aortic implantation, Non-facing pulmonary sinus INTRODUCTION Anomalous origin of the left main coronary artery from the pulmonary artery (ALCAPA) is a rare but potentially lethal congenital heart defect. Approximately 65% of children with ALCAPA die within the first year of life due to left-sided myocardial failure, ischaemic mitral insufficiency or sudden cardiac death [1]. Diagnosis of ALCAPA, regardless of clinical status, is an indication for timely surgical correction. Various surgical techniques aiming at 2-coronary system restoration have been reported for different anatomical locations of the ectopic coronary ostium. The anomalous left coronary artery usually arises from the left posterior (facing) pulmonary sinus of Valsalva. The non-facing pulmonary sinus origin is uncommon but poses a great challenge as its distance precludes direct aortic implantation. Alternative techniques for this entity have their own advantages and limitations. In this report, we describe an alternative surgical technique, superior pulmonary arterial flap left main coronary extension for aortic implantation. MATERIALS AND METHODS A 2-month-old female infant with a body weight of 4.7 kg presented with congestive heart failure for 3 days. Transthoracic echocardiography was performed (Fig. 1), and it revealed an abnormal origin of the left coronary artery arising from the non-facing pulmonary sinus with left ventricular dilatation (ejection fraction of 0.34) and moderate-to-severe mitral valve regurgitation. ALCAPA was diagnosed, and a cardiac surgeon was consulted for urgent surgical correction. Figure 1: View largeDownload slide Preoperative transthoracic echocardiography. (A) The LCA arises from the non-facing pulmonary sinus. (B) The RCA arises from the right aortic sinus. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; RCA: right coronary artery; RVOT: right ventricular outflow tract. Figure 1: View largeDownload slide Preoperative transthoracic echocardiography. (A) The LCA arises from the non-facing pulmonary sinus. (B) The RCA arises from the right aortic sinus. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; RCA: right coronary artery; RVOT: right ventricular outflow tract. The operation was performed through a median sternotomy. A piece of pericardium was harvested and soaked in glutaraldehyde solution. Using the ascending aortic cannulation and right atrial drainage, the hypothermic cardiopulmonary bypass was commenced, and both pulmonary arteries were occluded soon after. The ductus arteriosus was ligated and divided. The left heart was vented through the right superior pulmonary vein. After aortic cross-clamping, cold blood cardioplegia was infused to the aortic root and the main pulmonary artery. Transverse pulmonary arteriotomy was performed on the right side of the main pulmonary artery. The origin of the left coronary artery at the base of the anterior pulmonary sinus was carefully inspected and confirmed (Fig. 2A). The left coronary orifice, along with the sinus and left anterior pulmonary artery wall, was excised superiorly towards the left pulmonary artery creating a good length extension sleeve of coronary ostium (Fig. 2B). The pulmonary artery was transected for exposure. Both edges of the flap were sewn together to form tubular extension of the left coronary artery, which was implanted to the created circular defect on the posterior aortic wall just above the empty left sinus using fine continuous sutures (Fig. 2C). The pulmonary artery continuity was restored over the reconstructed left coronary artery. The pulmonary trunk defect was patched with a piece of treated pericardium beginning from the sinus (Fig. 2D). Completion of the repair was performed under beating heart condition after the aortic clamp removal. The mitral insufficiency was left untouched, in the light of improvement after coronary transfer. The patient came off the bypass with moderate dose of inotropic support. The sternal wound was closed at the operative conclusion. Figure 2: View largeDownload slide The superior pulmonary artery flap technique for the repair of an anomalous origin of the left main coronary artery from the pulmonary artery arising from the non-facing pulmonary sinus. (A) An anomalous origin of the LCA from the left anterior pulmonary sinus. (B) The orifice of the LCA was excised with sinus tissue and long superior pulmonary flap. (C) Anterior and posterior edges of extension flap were sewn together, creating long autogenous coronary extension tube. The reconstructed coronary artery was implanted into the created hole in the ascending aorta. (D) The pulmonary artery continuity was restored, and pulmonary artery wall defect was patched with treated autologous pericardium. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; PDA: patent ductus arteriosus; RCA: right coronary artery. Figure 2: View largeDownload slide The superior pulmonary artery flap technique for the repair of an anomalous origin of the left main coronary artery from the pulmonary artery arising from the non-facing pulmonary sinus. (A) An anomalous origin of the LCA from the left anterior pulmonary sinus. (B) The orifice of the LCA was excised with sinus tissue and long superior pulmonary flap. (C) Anterior and posterior edges of extension flap were sewn together, creating long autogenous coronary extension tube. The reconstructed coronary artery was implanted into the created hole in the ascending aorta. (D) The pulmonary artery continuity was restored, and pulmonary artery wall defect was patched with treated autologous pericardium. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; PDA: patent ductus arteriosus; RCA: right coronary artery. RESULTS The patient did well and was subsequently discharged home on Day 24 after the surgery. Coronary patency and myocardial recovery were observed using serial transthoracic echocardiography. Good flow in both coronary arteries was documented (Fig. 3). On the latest scan at 18 weeks postoperatively, her left ventricular function was normalized (ejection fraction of 0.53 with trivial mitral regurgitation; Table 1). Table 1: Preoperative and postoperative echocardiographic parameters Parameters  Preoperative echocardiography  Postoperative echocardiography   Day 4  Day 18  Day 129  LVFS  0.16  0.12  0.14  0.27  LVEF  0.34  0.27  0.33  0.53  MR  Moderate to severe  Moderate  Trivial  Trivial  Parameters  Preoperative echocardiography  Postoperative echocardiography   Day 4  Day 18  Day 129  LVFS  0.16  0.12  0.14  0.27  LVEF  0.34  0.27  0.33  0.53  MR  Moderate to severe  Moderate  Trivial  Trivial  LVEF: left ventricular ejection fraction; LVFS: left ventricular fractional shortening; MR: mitral regurgitation. Table 1: Preoperative and postoperative echocardiographic parameters Parameters  Preoperative echocardiography  Postoperative echocardiography   Day 4  Day 18  Day 129  LVFS  0.16  0.12  0.14  0.27  LVEF  0.34  0.27  0.33  0.53  MR  Moderate to severe  Moderate  Trivial  Trivial  Parameters  Preoperative echocardiography  Postoperative echocardiography   Day 4  Day 18  Day 129  LVFS  0.16  0.12  0.14  0.27  LVEF  0.34  0.27  0.33  0.53  MR  Moderate to severe  Moderate  Trivial  Trivial  LVEF: left ventricular ejection fraction; LVFS: left ventricular fractional shortening; MR: mitral regurgitation. Figure 3: View largeDownload slide Postoperative transthoracic echocardiography. (A) The implanted LCA was widely patent. (B) The RCA. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; RCA: right coronary artery; RVOT: right ventricular outflow tract. Figure 3: View largeDownload slide Postoperative transthoracic echocardiography. (A) The implanted LCA was widely patent. (B) The RCA. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; RCA: right coronary artery; RVOT: right ventricular outflow tract. DISCUSSION The goal of the ALCAPA repair is to establish a 2-coronary system with the least risk of early or late obstruction. In the non-facing coronary take off, ostium to aortic root separation gap precludes direct implantation without excessive tension. Several techniques of extra-anatomical bypass have been described, but the outcome is generally not satisfactory [2, 3] except for left internal mammary grafting. However, this operation is often technically challenging for sick infants. Although experience with the Takeuchi operation has been promising, particularly for the early outcome, late sequelae requiring reoperation, such as significant pulmonary obstruction, coronary obstruction, ischaemic mitral insufficiency and baffle leak, have been reported [4]. Procedure of choice for aortic implantation of the remote-origin anomalous left coronary artery is to elongate it with cuff of adjacent autogenous pulmonary arterial with or without other tissue [5–11]. A long-term patency and growth potential are expected. All these techniques have their own limitations. For the technique involving the elongation of left coronary using transverse strip of pulmonary artery wall combined with an aortic flap [5, 6, 8], unnecessary aortic wall defect has to be created and addressed. If pericardium was used instead [10, 11], it has no growth potential and might be a substrate of suboptimal patency. In addition, 2 rolls of suture are required for composite tube creation. Turley et al. [7] elegantly described a method of long coronary augmentation tube reconstruction with 2 lateral pulmonary artery flaps. This procedure also required 2 rolls of suture, and it is suitable only for coronary arising from the main pulmonary artery. Wu et al. [9] proposed an interesting technique extending remote coronary using posterior transverse pulmonary artery sleeve that was rolled and sewn with a single-suture line creating tube graft in continuity with coronary origin. For coronary button crossing cusp commissure, it has to be taken down and reattached to the repaired pulmonary trunk [11]. Such a procedure might lead to late pulmonary insufficiency. To form an autologous tube of 3 mm in diameter for an infant, a significant portion of pulmonary artery or sinus has to be excised and subsequently replaced with pericardial patch of no growth capacity. Direct repair without patch material could be performed with the cost of pulmonary artery shortening and hazardous tension on transferred coronary artery. Hence, circumferential or even large transverse defect on the pulmonary trunk should be avoided. In the unusual case of deeply seated ostium similar to that in our patient, a transverse pulmonary sinus flap could not provide adequate length and size of extension tube even with commissure take down. Our superior pulmonary artery flap technique, which extends to the left of pulmonary artery bifurcation, allows creation of longer extension flap for tension-free aortic implantation even above the sinotubular junction (with less chance to injure the aortic valve even without additional aortotomy for visualization). The size of the pulmonary sinus is not an issue, and the pulmonary valve commissure is well preserved. The longitudinal pericardial patching could preserve length and growth of the pulmonary artery. Although our superior pulmonary artery flap technique has some theoretical advantages and early results have been very promising in this group of patients, there remains the need for follow-up on the condition of the reconstructed coronary tube and repaired pulmonary trunk. This will in turn allow for a more thorough evaluation of the benefits of our suggested technique relative to those proposed in earlier studies. This technique is recommended for all ALCAPA patients with remote location of the left coronary origin, especially for deeply seated coronary ostium in non-facing sinus. ACKNOWLEDGEMENTS We gratefully acknowledge the contributions of Kritvikrom Durongpisitkul, Paweena Chungsomprasong and Supaluck Kanjanauthai who provided imaging and cared for the study patient; Thaworn Subtaweesin who served as senior advisor and Patompong Ungprasert who performed language editing. Conflict of interest: none declared. REFERENCES 1 Wesselhoeft H, Fawcett JS, Johnson AL. Anomalous origin of the left coronary artery from the pulmonary trunk. Its clinical spectrum, pathology, and pathophysiology, based on a review of 140 cases with seven further cases. Circulation  1968; 38: 403– 25. Google Scholar CrossRef Search ADS PubMed  2 el-Said GM, Ruzyllo W, Williams RL, Mullins CE, Hallman GL, Cooley DA et al.  . Early and late result of saphenous vein graft for anomalous origin of left coronary artery from pulmonary artery. Circulation  1973; 48: III2– 6. Google Scholar CrossRef Search ADS PubMed  3 Kesler KA, Pennington DG, Nouri S, Boegner E, Kanter KR, Harvey L et al.  . Left subclavian-left coronary artery anastomosis for anomalous origin of the left coronary artery. Long-term follow-up. J Thorac Cardiovasc Surg  1989; 98: 25– 9. Google Scholar PubMed  4 Ginde S, Earing MG, Bartz PJ, Cava JR, Tweddell JS. Late complications after Takeuchi repair of anomalous left coronary artery from the pulmonary artery: case series and review of literature. Pediatr Cardiol  2012; 33: 1115– 23. Google Scholar CrossRef Search ADS PubMed  5 Sese A, Imoto Y. New technique in the transfer of an anomalously originated left coronary artery to the aorta. Ann Thorac Surg  1992; 53: 527– 9. Google Scholar CrossRef Search ADS PubMed  6 Katsumata T, Westaby S. Anomalous left coronary artery from the pulmonary artery: a simple method for aortic implantation with autogenous arterial tissue. Ann Thorac Surg  1999; 68: 1090– 1. Google Scholar CrossRef Search ADS PubMed  7 Turley K, Szarnicki RJ, Flachsbart KD, Richter RC, Popper RW, Tarnoff H. Aortic implantation is possible in all cases of anomalous origin of the left coronary artery from the pulmonary artery. Ann Thorac Surg  1995; 60: 84– 9. Google Scholar CrossRef Search ADS PubMed  8 Amanullah MM, Hamilton JR, Hasan A. Anomalous left coronary artery from the pulmonary artery: creating an autogenous arterial conduit for aortic implantation. Eur J Cardiothorac Surg  2001; 20: 853– 5. Google Scholar CrossRef Search ADS PubMed  9 Wu Q, Xu Z. An alternative procedure for correction of anomalous origin of left coronary artery from the pulmonary artery. Ann Thorac Surg  2007; 84: 2132– 3. Google Scholar CrossRef Search ADS PubMed  10 Sodian R, Rassoullian D, Beiras-Fernandez A, Loeff M, Schmitz C, Reichart B et al.  . ALCAPA with the ectopic orifice at the non-facing sinus: successful anatomic repair by creation of an autologous extrapulmonary tunnel. Tex Heart Inst J  2008; 35: 32– 5. Google Scholar PubMed  11 Ma K, Wang L, Hua Z, Yang K, Hu S, Yan J et al.  . Outcomes of coronary transfer for anomalous origin of the left coronary artery from the pulmonary artery. Eur J Cardiothorac Surg  2015; 47: 659– 64. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Superior pulmonary arterial flap for the repair of the left coronary artery from the non-facing pulmonary sinus

Loading next page...
 
/lp/ou_press/superior-pulmonary-arterial-flap-for-the-repair-of-the-left-coronary-0oR9rp4r4O
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1569-9293
eISSN
1569-9285
D.O.I.
10.1093/icvts/ivy013
Publisher site
See Article on Publisher Site

Abstract

Abstract OBJECTIVES The anomalous left coronary artery arising from the non-facing pulmonary sinus origin is uncommon but poses a great challenge as its distance precludes direct aortic implantation. We describe an innovative technique for aortic implantation of this anomaly in a 2-month-old infant. METHODS Using a longitudinal pulmonary arterial flap, coronary tube extension was constructed without pulmonary commissure disturbance. RESULTS Myocardial recovery after 2-coronary artery system restoration was excellent. CONCLUSIONS With this approach, coronary transfer using autologous tissue with growth potential is possible. Anomalous origin of the left main coronary artery from the pulmonary artery, Aortic implantation, Non-facing pulmonary sinus INTRODUCTION Anomalous origin of the left main coronary artery from the pulmonary artery (ALCAPA) is a rare but potentially lethal congenital heart defect. Approximately 65% of children with ALCAPA die within the first year of life due to left-sided myocardial failure, ischaemic mitral insufficiency or sudden cardiac death [1]. Diagnosis of ALCAPA, regardless of clinical status, is an indication for timely surgical correction. Various surgical techniques aiming at 2-coronary system restoration have been reported for different anatomical locations of the ectopic coronary ostium. The anomalous left coronary artery usually arises from the left posterior (facing) pulmonary sinus of Valsalva. The non-facing pulmonary sinus origin is uncommon but poses a great challenge as its distance precludes direct aortic implantation. Alternative techniques for this entity have their own advantages and limitations. In this report, we describe an alternative surgical technique, superior pulmonary arterial flap left main coronary extension for aortic implantation. MATERIALS AND METHODS A 2-month-old female infant with a body weight of 4.7 kg presented with congestive heart failure for 3 days. Transthoracic echocardiography was performed (Fig. 1), and it revealed an abnormal origin of the left coronary artery arising from the non-facing pulmonary sinus with left ventricular dilatation (ejection fraction of 0.34) and moderate-to-severe mitral valve regurgitation. ALCAPA was diagnosed, and a cardiac surgeon was consulted for urgent surgical correction. Figure 1: View largeDownload slide Preoperative transthoracic echocardiography. (A) The LCA arises from the non-facing pulmonary sinus. (B) The RCA arises from the right aortic sinus. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; RCA: right coronary artery; RVOT: right ventricular outflow tract. Figure 1: View largeDownload slide Preoperative transthoracic echocardiography. (A) The LCA arises from the non-facing pulmonary sinus. (B) The RCA arises from the right aortic sinus. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; RCA: right coronary artery; RVOT: right ventricular outflow tract. The operation was performed through a median sternotomy. A piece of pericardium was harvested and soaked in glutaraldehyde solution. Using the ascending aortic cannulation and right atrial drainage, the hypothermic cardiopulmonary bypass was commenced, and both pulmonary arteries were occluded soon after. The ductus arteriosus was ligated and divided. The left heart was vented through the right superior pulmonary vein. After aortic cross-clamping, cold blood cardioplegia was infused to the aortic root and the main pulmonary artery. Transverse pulmonary arteriotomy was performed on the right side of the main pulmonary artery. The origin of the left coronary artery at the base of the anterior pulmonary sinus was carefully inspected and confirmed (Fig. 2A). The left coronary orifice, along with the sinus and left anterior pulmonary artery wall, was excised superiorly towards the left pulmonary artery creating a good length extension sleeve of coronary ostium (Fig. 2B). The pulmonary artery was transected for exposure. Both edges of the flap were sewn together to form tubular extension of the left coronary artery, which was implanted to the created circular defect on the posterior aortic wall just above the empty left sinus using fine continuous sutures (Fig. 2C). The pulmonary artery continuity was restored over the reconstructed left coronary artery. The pulmonary trunk defect was patched with a piece of treated pericardium beginning from the sinus (Fig. 2D). Completion of the repair was performed under beating heart condition after the aortic clamp removal. The mitral insufficiency was left untouched, in the light of improvement after coronary transfer. The patient came off the bypass with moderate dose of inotropic support. The sternal wound was closed at the operative conclusion. Figure 2: View largeDownload slide The superior pulmonary artery flap technique for the repair of an anomalous origin of the left main coronary artery from the pulmonary artery arising from the non-facing pulmonary sinus. (A) An anomalous origin of the LCA from the left anterior pulmonary sinus. (B) The orifice of the LCA was excised with sinus tissue and long superior pulmonary flap. (C) Anterior and posterior edges of extension flap were sewn together, creating long autogenous coronary extension tube. The reconstructed coronary artery was implanted into the created hole in the ascending aorta. (D) The pulmonary artery continuity was restored, and pulmonary artery wall defect was patched with treated autologous pericardium. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; PDA: patent ductus arteriosus; RCA: right coronary artery. Figure 2: View largeDownload slide The superior pulmonary artery flap technique for the repair of an anomalous origin of the left main coronary artery from the pulmonary artery arising from the non-facing pulmonary sinus. (A) An anomalous origin of the LCA from the left anterior pulmonary sinus. (B) The orifice of the LCA was excised with sinus tissue and long superior pulmonary flap. (C) Anterior and posterior edges of extension flap were sewn together, creating long autogenous coronary extension tube. The reconstructed coronary artery was implanted into the created hole in the ascending aorta. (D) The pulmonary artery continuity was restored, and pulmonary artery wall defect was patched with treated autologous pericardium. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; PDA: patent ductus arteriosus; RCA: right coronary artery. RESULTS The patient did well and was subsequently discharged home on Day 24 after the surgery. Coronary patency and myocardial recovery were observed using serial transthoracic echocardiography. Good flow in both coronary arteries was documented (Fig. 3). On the latest scan at 18 weeks postoperatively, her left ventricular function was normalized (ejection fraction of 0.53 with trivial mitral regurgitation; Table 1). Table 1: Preoperative and postoperative echocardiographic parameters Parameters  Preoperative echocardiography  Postoperative echocardiography   Day 4  Day 18  Day 129  LVFS  0.16  0.12  0.14  0.27  LVEF  0.34  0.27  0.33  0.53  MR  Moderate to severe  Moderate  Trivial  Trivial  Parameters  Preoperative echocardiography  Postoperative echocardiography   Day 4  Day 18  Day 129  LVFS  0.16  0.12  0.14  0.27  LVEF  0.34  0.27  0.33  0.53  MR  Moderate to severe  Moderate  Trivial  Trivial  LVEF: left ventricular ejection fraction; LVFS: left ventricular fractional shortening; MR: mitral regurgitation. Table 1: Preoperative and postoperative echocardiographic parameters Parameters  Preoperative echocardiography  Postoperative echocardiography   Day 4  Day 18  Day 129  LVFS  0.16  0.12  0.14  0.27  LVEF  0.34  0.27  0.33  0.53  MR  Moderate to severe  Moderate  Trivial  Trivial  Parameters  Preoperative echocardiography  Postoperative echocardiography   Day 4  Day 18  Day 129  LVFS  0.16  0.12  0.14  0.27  LVEF  0.34  0.27  0.33  0.53  MR  Moderate to severe  Moderate  Trivial  Trivial  LVEF: left ventricular ejection fraction; LVFS: left ventricular fractional shortening; MR: mitral regurgitation. Figure 3: View largeDownload slide Postoperative transthoracic echocardiography. (A) The implanted LCA was widely patent. (B) The RCA. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; RCA: right coronary artery; RVOT: right ventricular outflow tract. Figure 3: View largeDownload slide Postoperative transthoracic echocardiography. (A) The implanted LCA was widely patent. (B) The RCA. Ao: aorta; LCA: left coronary artery; PA: pulmonary artery; RCA: right coronary artery; RVOT: right ventricular outflow tract. DISCUSSION The goal of the ALCAPA repair is to establish a 2-coronary system with the least risk of early or late obstruction. In the non-facing coronary take off, ostium to aortic root separation gap precludes direct implantation without excessive tension. Several techniques of extra-anatomical bypass have been described, but the outcome is generally not satisfactory [2, 3] except for left internal mammary grafting. However, this operation is often technically challenging for sick infants. Although experience with the Takeuchi operation has been promising, particularly for the early outcome, late sequelae requiring reoperation, such as significant pulmonary obstruction, coronary obstruction, ischaemic mitral insufficiency and baffle leak, have been reported [4]. Procedure of choice for aortic implantation of the remote-origin anomalous left coronary artery is to elongate it with cuff of adjacent autogenous pulmonary arterial with or without other tissue [5–11]. A long-term patency and growth potential are expected. All these techniques have their own limitations. For the technique involving the elongation of left coronary using transverse strip of pulmonary artery wall combined with an aortic flap [5, 6, 8], unnecessary aortic wall defect has to be created and addressed. If pericardium was used instead [10, 11], it has no growth potential and might be a substrate of suboptimal patency. In addition, 2 rolls of suture are required for composite tube creation. Turley et al. [7] elegantly described a method of long coronary augmentation tube reconstruction with 2 lateral pulmonary artery flaps. This procedure also required 2 rolls of suture, and it is suitable only for coronary arising from the main pulmonary artery. Wu et al. [9] proposed an interesting technique extending remote coronary using posterior transverse pulmonary artery sleeve that was rolled and sewn with a single-suture line creating tube graft in continuity with coronary origin. For coronary button crossing cusp commissure, it has to be taken down and reattached to the repaired pulmonary trunk [11]. Such a procedure might lead to late pulmonary insufficiency. To form an autologous tube of 3 mm in diameter for an infant, a significant portion of pulmonary artery or sinus has to be excised and subsequently replaced with pericardial patch of no growth capacity. Direct repair without patch material could be performed with the cost of pulmonary artery shortening and hazardous tension on transferred coronary artery. Hence, circumferential or even large transverse defect on the pulmonary trunk should be avoided. In the unusual case of deeply seated ostium similar to that in our patient, a transverse pulmonary sinus flap could not provide adequate length and size of extension tube even with commissure take down. Our superior pulmonary artery flap technique, which extends to the left of pulmonary artery bifurcation, allows creation of longer extension flap for tension-free aortic implantation even above the sinotubular junction (with less chance to injure the aortic valve even without additional aortotomy for visualization). The size of the pulmonary sinus is not an issue, and the pulmonary valve commissure is well preserved. The longitudinal pericardial patching could preserve length and growth of the pulmonary artery. Although our superior pulmonary artery flap technique has some theoretical advantages and early results have been very promising in this group of patients, there remains the need for follow-up on the condition of the reconstructed coronary tube and repaired pulmonary trunk. This will in turn allow for a more thorough evaluation of the benefits of our suggested technique relative to those proposed in earlier studies. This technique is recommended for all ALCAPA patients with remote location of the left coronary origin, especially for deeply seated coronary ostium in non-facing sinus. ACKNOWLEDGEMENTS We gratefully acknowledge the contributions of Kritvikrom Durongpisitkul, Paweena Chungsomprasong and Supaluck Kanjanauthai who provided imaging and cared for the study patient; Thaworn Subtaweesin who served as senior advisor and Patompong Ungprasert who performed language editing. Conflict of interest: none declared. REFERENCES 1 Wesselhoeft H, Fawcett JS, Johnson AL. Anomalous origin of the left coronary artery from the pulmonary trunk. Its clinical spectrum, pathology, and pathophysiology, based on a review of 140 cases with seven further cases. Circulation  1968; 38: 403– 25. Google Scholar CrossRef Search ADS PubMed  2 el-Said GM, Ruzyllo W, Williams RL, Mullins CE, Hallman GL, Cooley DA et al.  . Early and late result of saphenous vein graft for anomalous origin of left coronary artery from pulmonary artery. Circulation  1973; 48: III2– 6. Google Scholar CrossRef Search ADS PubMed  3 Kesler KA, Pennington DG, Nouri S, Boegner E, Kanter KR, Harvey L et al.  . Left subclavian-left coronary artery anastomosis for anomalous origin of the left coronary artery. Long-term follow-up. J Thorac Cardiovasc Surg  1989; 98: 25– 9. Google Scholar PubMed  4 Ginde S, Earing MG, Bartz PJ, Cava JR, Tweddell JS. Late complications after Takeuchi repair of anomalous left coronary artery from the pulmonary artery: case series and review of literature. Pediatr Cardiol  2012; 33: 1115– 23. Google Scholar CrossRef Search ADS PubMed  5 Sese A, Imoto Y. New technique in the transfer of an anomalously originated left coronary artery to the aorta. Ann Thorac Surg  1992; 53: 527– 9. Google Scholar CrossRef Search ADS PubMed  6 Katsumata T, Westaby S. Anomalous left coronary artery from the pulmonary artery: a simple method for aortic implantation with autogenous arterial tissue. Ann Thorac Surg  1999; 68: 1090– 1. Google Scholar CrossRef Search ADS PubMed  7 Turley K, Szarnicki RJ, Flachsbart KD, Richter RC, Popper RW, Tarnoff H. Aortic implantation is possible in all cases of anomalous origin of the left coronary artery from the pulmonary artery. Ann Thorac Surg  1995; 60: 84– 9. Google Scholar CrossRef Search ADS PubMed  8 Amanullah MM, Hamilton JR, Hasan A. Anomalous left coronary artery from the pulmonary artery: creating an autogenous arterial conduit for aortic implantation. Eur J Cardiothorac Surg  2001; 20: 853– 5. Google Scholar CrossRef Search ADS PubMed  9 Wu Q, Xu Z. An alternative procedure for correction of anomalous origin of left coronary artery from the pulmonary artery. Ann Thorac Surg  2007; 84: 2132– 3. Google Scholar CrossRef Search ADS PubMed  10 Sodian R, Rassoullian D, Beiras-Fernandez A, Loeff M, Schmitz C, Reichart B et al.  . ALCAPA with the ectopic orifice at the non-facing sinus: successful anatomic repair by creation of an autologous extrapulmonary tunnel. Tex Heart Inst J  2008; 35: 32– 5. Google Scholar PubMed  11 Ma K, Wang L, Hua Z, Yang K, Hu S, Yan J et al.  . Outcomes of coronary transfer for anomalous origin of the left coronary artery from the pulmonary artery. Eur J Cardiothorac Surg  2015; 47: 659– 64. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Jan 29, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off