Portal de Periódicos da CAPES

“Spiral-Cuff” Technique for Repair of Anomalous Left Coronary Artery From the Pulmonary Artery

2008; Elsevier BV; Volume: 86; Issue: 2 Linguagem: Inglês

10.1016/j.athoracsur.2008.02.005

1552-6259

Yukio Ando, Hideaki Kado, Munetaka Masuda, Toshihide Nakano, Kazuhiro Hinokiyama, Akira Shiose, Masaki Kajimoto,

Cardiovascular Issues in Pregnancy

We describe a new technique for coronary transfer in the repair of anomalous origin of the left coronary artery from the pulmonary artery. The left coronary artery is elongated with the native pulmonary artery wall to form a spiral-shaped coronary cuff to construct an unstretched new left coronary artery system from the ascending aorta. A postoperative angiographic scan showed good flow of the left coronary artery without any kinking or narrowing. This technique is considered useful when an anomalous coronary artery arises a long way from the ascending aorta. We describe a new technique for coronary transfer in the repair of anomalous origin of the left coronary artery from the pulmonary artery. The left coronary artery is elongated with the native pulmonary artery wall to form a spiral-shaped coronary cuff to construct an unstretched new left coronary artery system from the ascending aorta. A postoperative angiographic scan showed good flow of the left coronary artery without any kinking or narrowing. This technique is considered useful when an anomalous coronary artery arises a long way from the ascending aorta. Currently the direct implantation of an anomalous coronary artery into the ascending aorta is widely seen as the best method for repair of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). However, this procedure may be difficult when the anomalous left coronary artery (LCA) arises a long way from the ascending aorta. We describe a new technique of coronary elongation that makes coronary transfer easier in such cases without concerns of coronary stenosis and pulmonary tract obstruction.TechniqueFrom 1983 to 2006, a total of 16 patients underwent surgery for ALCAPA at Fukuoka Children's Hospital or Yokohama City University Hospital. In this series, 6 patients (1 male, 5 females; ages 2 months to 7 years [median age, 2.2 years] body weights, 4.0 to 23.0 kg [median body weight, 11.1 kg]) underwent a new procedure for coronary elongation called the “spiral-cuff” technique. Two infants presented with heart failure and demonstrated severely impaired left ventricular function; one of the infants was in shock status at the time of admission and required respirator and catecholamine support. Four patients presented without evidence of heart failure. All patients underwent cardiac catheterization, except for the patient on a respirator for whom diagnosis was made by echocardiography. The origin of the anomalous LCA was from the nonfacing pulmonary sinus in 3 patients and from the right hand pulmonary sinus (sinus 1 of the pulmonary artery) in 3 patients. Mitral regurgitation was present in 3 patients (severe in 2, moderate in 1).All patients were operated on through a median sternotomy. After establishing cardiopulmonary bypass in the usual manner, an aortic cross clamp was placed and both branch pulmonary arteries were snared. Crystalloid cardioplegia (Kyushu University solution) was administered simultaneously in both great arteries. The pulmonary trunk was transected above the level of the anomalously originated LCA. After careful mobilization of the LCA, the coronary orifice was excised with a ring-shaped pulmonary artery wall of 5-mm width (Fig 1A). This was then incised at the right side of the coronary origin. The inferior end of the pulmonary artery wall was sewn with a 6-0 or 7-0 absorbable suture starting at the bottom of the coronary origin to form a spiral-shaped coronary cuff (Fig 1B). The coronary cuff was then anastomosed to the aorta with absorbable sutures. The two ends of the transected pulmonary artery were sutured directly, and the defect in the pulmonary sinus was filled with an autologous pericardial patch (Fig 1C). In 3 patients who had more than moderate mitral regurgitation, we found ischemic damage of the papillary muscle and prolapse of the anterior mitral leaflet. Thus, mitral annuloplasty and implantation of artificial chordae were performed in 2 patients, whereas the patient on the respirator required mitral valve replacement.Postoperative courses were uneventful in all the patients, except for the patient with mitral valve replacement who required extracorporeal circulatory support for 2 days. There were no hospital or late deaths. The follow-up periods ranged from 3 months to 10 years (median, 2.6 years). No coronary events occurred in any patients. Postoperative echocardiogram demonstrated improved left ventricular wall motion, and mitral regurgitation was less than mild in all patients. Postoperative angiography was performed in 4 patients and demonstrated good flows of the LCA without any kinking or narrowing (Fig 2). No pulmonary artery obstructions were evident.Fig 2Postoperative angiographies of (Left) the anterior view and (Right) the lateral view show wide and smooth coronary pathways without any kinking or narrowing.View Large Image Figure ViewerDownload (PPT)CommentAlthough direct implantation of an anomalous LCA into the ascending aorta is considered the best method for repair of ALCAPA, the distance between the ostium of the anomalous LCA and the ascending aorta is a crucial factor for this procedure. Coronary transfer can be performed without difficulty when the anomalous LCA arises from the posterior aspect of the pulmonary trunk, but this may not be possible when it arises from the left or anterior aspect. In such situations, other surgical techniques are required to facilitate tension-free coronary transfer. Historically, bypass graft procedures have been performed; however, distal anastomotic stenosis has been frequently observed because of the technical difficulties involved in anastomosis in the small coronary arteries [1Kesler K.A. Pennington D.G. Nouri S. 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: 25-29PubMed Google Scholar]. Takeuchi and colleagues [2Takeuchi S. Imamura H. Katsumoto K. et al.New surgical method for repair of anomalous left coronary artery from pulmonary artery.J Thorac Cardiovasc Surg. 1979; 78: 7-11PubMed Google Scholar] reported an intrapulmonary tunnel patch procedure; however, baffle and pulmonary artery obstructions are major late complications in this procedure. Others have described methods involving the construction of a tubular extension of the coronary artery with pulmonary arterial wall flap, trap door technique, or a combination of both [3Sese A. Imoto Y. New technique in the transfer of an anomalously originated left coronary artery to the aorta.Ann Thorac Surg. 1992; 53: 527-529Abstract Full Text PDF PubMed Scopus (44) Google Scholar, 4Turley K. Szarnicki R.J. Flachsbart K.D. Richter R.C. Popper R.W. 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: 84-89PubMed Scopus (105) Google Scholar, 5Ando M. Mee R.B. Duncan B.W. Drummond-Webb J.J. Seshadri S.G. Igor Mesia C.I. 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: 576-581Crossref PubMed Scopus (33) Google Scholar]. However, reconstruction of a uniform coronary pathway using these methods is a technically demanding issue.In our technique, the pulmonary artery wall is excised in a ring-shaped fashion and sewn up to form a spiral-shaped cuff. Therefore, the reconstructed cuff size as a new coronary orifice can be larger than that possible with other techniques. As well, this procedure provides a satisfactory elongated and wide coronary pathway. Therefore, the most suitable site of implantation can be chosen without the fear of possibility of kinking or overstretching of the reimplanted coronary artery. Because the pulmonary artery wall is used in systemic circulation, aneurysmal dilatation of the newly constructed coronary artery might occur in the future, similar to the arterial switch operation [6Hutter P.A. Thomeer B.J. Jansen P. et al.Fate of the aortic root after arterial switch operation.Eur J Cardiothorac Surg. 2001; 20: 82-88Crossref PubMed Scopus (74) Google Scholar] and the Ross procedure [7David T.E. Omran A. Ivanov J. et al.Dilation of the pulmonary autograft after the Ross procedure.J Thorac Cardiovasc Surg. 2000; 119: 210-220Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar]. Careful follow-up is mandatory. Fortunately, in the patients presented here, we have not seen any aneurysmal change of the coronary system.In conclusion, our technique is a useful adjunct for transfer of an anomalous LCA to the aorta, especially when the anomalous LCA arises a long way from the ascending aorta. Currently the direct implantation of an anomalous coronary artery into the ascending aorta is widely seen as the best method for repair of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). However, this procedure may be difficult when the anomalous left coronary artery (LCA) arises a long way from the ascending aorta. We describe a new technique of coronary elongation that makes coronary transfer easier in such cases without concerns of coronary stenosis and pulmonary tract obstruction. TechniqueFrom 1983 to 2006, a total of 16 patients underwent surgery for ALCAPA at Fukuoka Children's Hospital or Yokohama City University Hospital. In this series, 6 patients (1 male, 5 females; ages 2 months to 7 years [median age, 2.2 years] body weights, 4.0 to 23.0 kg [median body weight, 11.1 kg]) underwent a new procedure for coronary elongation called the “spiral-cuff” technique. Two infants presented with heart failure and demonstrated severely impaired left ventricular function; one of the infants was in shock status at the time of admission and required respirator and catecholamine support. Four patients presented without evidence of heart failure. All patients underwent cardiac catheterization, except for the patient on a respirator for whom diagnosis was made by echocardiography. The origin of the anomalous LCA was from the nonfacing pulmonary sinus in 3 patients and from the right hand pulmonary sinus (sinus 1 of the pulmonary artery) in 3 patients. Mitral regurgitation was present in 3 patients (severe in 2, moderate in 1).All patients were operated on through a median sternotomy. After establishing cardiopulmonary bypass in the usual manner, an aortic cross clamp was placed and both branch pulmonary arteries were snared. Crystalloid cardioplegia (Kyushu University solution) was administered simultaneously in both great arteries. The pulmonary trunk was transected above the level of the anomalously originated LCA. After careful mobilization of the LCA, the coronary orifice was excised with a ring-shaped pulmonary artery wall of 5-mm width (Fig 1A). This was then incised at the right side of the coronary origin. The inferior end of the pulmonary artery wall was sewn with a 6-0 or 7-0 absorbable suture starting at the bottom of the coronary origin to form a spiral-shaped coronary cuff (Fig 1B). The coronary cuff was then anastomosed to the aorta with absorbable sutures. The two ends of the transected pulmonary artery were sutured directly, and the defect in the pulmonary sinus was filled with an autologous pericardial patch (Fig 1C). In 3 patients who had more than moderate mitral regurgitation, we found ischemic damage of the papillary muscle and prolapse of the anterior mitral leaflet. Thus, mitral annuloplasty and implantation of artificial chordae were performed in 2 patients, whereas the patient on the respirator required mitral valve replacement.Postoperative courses were uneventful in all the patients, except for the patient with mitral valve replacement who required extracorporeal circulatory support for 2 days. There were no hospital or late deaths. The follow-up periods ranged from 3 months to 10 years (median, 2.6 years). No coronary events occurred in any patients. Postoperative echocardiogram demonstrated improved left ventricular wall motion, and mitral regurgitation was less than mild in all patients. Postoperative angiography was performed in 4 patients and demonstrated good flows of the LCA without any kinking or narrowing (Fig 2). No pulmonary artery obstructions were evident. From 1983 to 2006, a total of 16 patients underwent surgery for ALCAPA at Fukuoka Children's Hospital or Yokohama City University Hospital. In this series, 6 patients (1 male, 5 females; ages 2 months to 7 years [median age, 2.2 years] body weights, 4.0 to 23.0 kg [median body weight, 11.1 kg]) underwent a new procedure for coronary elongation called the “spiral-cuff” technique. Two infants presented with heart failure and demonstrated severely impaired left ventricular function; one of the infants was in shock status at the time of admission and required respirator and catecholamine support. Four patients presented without evidence of heart failure. All patients underwent cardiac catheterization, except for the patient on a respirator for whom diagnosis was made by echocardiography. The origin of the anomalous LCA was from the nonfacing pulmonary sinus in 3 patients and from the right hand pulmonary sinus (sinus 1 of the pulmonary artery) in 3 patients. Mitral regurgitation was present in 3 patients (severe in 2, moderate in 1). All patients were operated on through a median sternotomy. After establishing cardiopulmonary bypass in the usual manner, an aortic cross clamp was placed and both branch pulmonary arteries were snared. Crystalloid cardioplegia (Kyushu University solution) was administered simultaneously in both great arteries. The pulmonary trunk was transected above the level of the anomalously originated LCA. After careful mobilization of the LCA, the coronary orifice was excised with a ring-shaped pulmonary artery wall of 5-mm width (Fig 1A). This was then incised at the right side of the coronary origin. The inferior end of the pulmonary artery wall was sewn with a 6-0 or 7-0 absorbable suture starting at the bottom of the coronary origin to form a spiral-shaped coronary cuff (Fig 1B). The coronary cuff was then anastomosed to the aorta with absorbable sutures. The two ends of the transected pulmonary artery were sutured directly, and the defect in the pulmonary sinus was filled with an autologous pericardial patch (Fig 1C). In 3 patients who had more than moderate mitral regurgitation, we found ischemic damage of the papillary muscle and prolapse of the anterior mitral leaflet. Thus, mitral annuloplasty and implantation of artificial chordae were performed in 2 patients, whereas the patient on the respirator required mitral valve replacement. Postoperative courses were uneventful in all the patients, except for the patient with mitral valve replacement who required extracorporeal circulatory support for 2 days. There were no hospital or late deaths. The follow-up periods ranged from 3 months to 10 years (median, 2.6 years). No coronary events occurred in any patients. Postoperative echocardiogram demonstrated improved left ventricular wall motion, and mitral regurgitation was less than mild in all patients. Postoperative angiography was performed in 4 patients and demonstrated good flows of the LCA without any kinking or narrowing (Fig 2). No pulmonary artery obstructions were evident. CommentAlthough direct implantation of an anomalous LCA into the ascending aorta is considered the best method for repair of ALCAPA, the distance between the ostium of the anomalous LCA and the ascending aorta is a crucial factor for this procedure. Coronary transfer can be performed without difficulty when the anomalous LCA arises from the posterior aspect of the pulmonary trunk, but this may not be possible when it arises from the left or anterior aspect. In such situations, other surgical techniques are required to facilitate tension-free coronary transfer. Historically, bypass graft procedures have been performed; however, distal anastomotic stenosis has been frequently observed because of the technical difficulties involved in anastomosis in the small coronary arteries [1Kesler K.A. Pennington D.G. Nouri S. 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: 25-29PubMed Google Scholar]. Takeuchi and colleagues [2Takeuchi S. Imamura H. Katsumoto K. et al.New surgical method for repair of anomalous left coronary artery from pulmonary artery.J Thorac Cardiovasc Surg. 1979; 78: 7-11PubMed Google Scholar] reported an intrapulmonary tunnel patch procedure; however, baffle and pulmonary artery obstructions are major late complications in this procedure. Others have described methods involving the construction of a tubular extension of the coronary artery with pulmonary arterial wall flap, trap door technique, or a combination of both [3Sese A. Imoto Y. New technique in the transfer of an anomalously originated left coronary artery to the aorta.Ann Thorac Surg. 1992; 53: 527-529Abstract Full Text PDF PubMed Scopus (44) Google Scholar, 4Turley K. Szarnicki R.J. Flachsbart K.D. Richter R.C. Popper R.W. 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: 84-89PubMed Scopus (105) Google Scholar, 5Ando M. Mee R.B. Duncan B.W. Drummond-Webb J.J. Seshadri S.G. Igor Mesia C.I. 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: 576-581Crossref PubMed Scopus (33) Google Scholar]. However, reconstruction of a uniform coronary pathway using these methods is a technically demanding issue.In our technique, the pulmonary artery wall is excised in a ring-shaped fashion and sewn up to form a spiral-shaped cuff. Therefore, the reconstructed cuff size as a new coronary orifice can be larger than that possible with other techniques. As well, this procedure provides a satisfactory elongated and wide coronary pathway. Therefore, the most suitable site of implantation can be chosen without the fear of possibility of kinking or overstretching of the reimplanted coronary artery. Because the pulmonary artery wall is used in systemic circulation, aneurysmal dilatation of the newly constructed coronary artery might occur in the future, similar to the arterial switch operation [6Hutter P.A. Thomeer B.J. Jansen P. et al.Fate of the aortic root after arterial switch operation.Eur J Cardiothorac Surg. 2001; 20: 82-88Crossref PubMed Scopus (74) Google Scholar] and the Ross procedure [7David T.E. Omran A. Ivanov J. et al.Dilation of the pulmonary autograft after the Ross procedure.J Thorac Cardiovasc Surg. 2000; 119: 210-220Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar]. Careful follow-up is mandatory. Fortunately, in the patients presented here, we have not seen any aneurysmal change of the coronary system.In conclusion, our technique is a useful adjunct for transfer of an anomalous LCA to the aorta, especially when the anomalous LCA arises a long way from the ascending aorta. Although direct implantation of an anomalous LCA into the ascending aorta is considered the best method for repair of ALCAPA, the distance between the ostium of the anomalous LCA and the ascending aorta is a crucial factor for this procedure. Coronary transfer can be performed without difficulty when the anomalous LCA arises from the posterior aspect of the pulmonary trunk, but this may not be possible when it arises from the left or anterior aspect. In such situations, other surgical techniques are required to facilitate tension-free coronary transfer. Historically, bypass graft procedures have been performed; however, distal anastomotic stenosis has been frequently observed because of the technical difficulties involved in anastomosis in the small coronary arteries [1Kesler K.A. Pennington D.G. Nouri S. 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: 25-29PubMed Google Scholar]. Takeuchi and colleagues [2Takeuchi S. Imamura H. Katsumoto K. et al.New surgical method for repair of anomalous left coronary artery from pulmonary artery.J Thorac Cardiovasc Surg. 1979; 78: 7-11PubMed Google Scholar] reported an intrapulmonary tunnel patch procedure; however, baffle and pulmonary artery obstructions are major late complications in this procedure. Others have described methods involving the construction of a tubular extension of the coronary artery with pulmonary arterial wall flap, trap door technique, or a combination of both [3Sese A. Imoto Y. New technique in the transfer of an anomalously originated left coronary artery to the aorta.Ann Thorac Surg. 1992; 53: 527-529Abstract Full Text PDF PubMed Scopus (44) Google Scholar, 4Turley K. Szarnicki R.J. Flachsbart K.D. Richter R.C. Popper R.W. 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: 84-89PubMed Scopus (105) Google Scholar, 5Ando M. Mee R.B. Duncan B.W. Drummond-Webb J.J. Seshadri S.G. Igor Mesia C.I. 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: 576-581Crossref PubMed Scopus (33) Google Scholar]. However, reconstruction of a uniform coronary pathway using these methods is a technically demanding issue. In our technique, the pulmonary artery wall is excised in a ring-shaped fashion and sewn up to form a spiral-shaped cuff. Therefore, the reconstructed cuff size as a new coronary orifice can be larger than that possible with other techniques. As well, this procedure provides a satisfactory elongated and wide coronary pathway. Therefore, the most suitable site of implantation can be chosen without the fear of possibility of kinking or overstretching of the reimplanted coronary artery. Because the pulmonary artery wall is used in systemic circulation, aneurysmal dilatation of the newly constructed coronary artery might occur in the future, similar to the arterial switch operation [6Hutter P.A. Thomeer B.J. Jansen P. et al.Fate of the aortic root after arterial switch operation.Eur J Cardiothorac Surg. 2001; 20: 82-88Crossref PubMed Scopus (74) Google Scholar] and the Ross procedure [7David T.E. Omran A. Ivanov J. et al.Dilation of the pulmonary autograft after the Ross procedure.J Thorac Cardiovasc Surg. 2000; 119: 210-220Abstract Full Text Full Text PDF PubMed Scopus (289) Google Scholar]. Careful follow-up is mandatory. Fortunately, in the patients presented here, we have not seen any aneurysmal change of the coronary system. In conclusion, our technique is a useful adjunct for transfer of an anomalous LCA to the aorta, especially when the anomalous LCA arises a long way from the ascending aorta.