Surgical Outcomes for Children with Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery

A Meta-Analysis of Mitral Surgery in Patients Undergoing Surgery for Anomalous Left Coronary Artery: When to Perform Repair?

The present study is the first meta-analysis comparing long-term outcomes in patients undergoing correction for anomalous left coronary artery (ALCAPA) regarding concomitant mitral valve surgery. A systematic literature review was conducted to identify all relevant studies with comparative data on mitral valve surgery performed during surgery for ALCAPA correction. Predefined primary end points included mortality and mitral valve (re)operation. Echocardiographic outcomes were assessed when available (including severity of mitral regurgitation). Fifty-three relevant retrospective studies with comparative data for ALCAPA patients with concomitant mitral valve surgery were identified from the existing literature. The study population included 3,851 patients, of whom 55% were girls. The mean age at surgery was 6 months [0-99 months]. The mean follow-up after surgery was 22.7 years [6.3-37.2]. Among patients with available echocardiographic data at the time of ALCAPA correction, 283 had no mitral regurgitation (13%), 642 had mild mitral regurgitation (30%), 756 had moderate mitral regurgitation (36%), and 437 had severe mitral regurgitation (21%). A subgroup of patients who underwent mitral valve surgery (yMVS; n = 753; 19.5% of the total population) was identified. A total of 228 patients died during follow-up (5.9%), with no differences among patients who underwent vs those who did not undergo mitral valve concomitant surgery at baseline (p = ns). Among the 1,536 patients with available follow-up echocardiographic data, 519 had no mitral regurgitation (34%), 663 had mild mitral regurgitation (43%), 268 had moderate mitral regurgitation (17%), and 86 had severe mitral regurgitation (6%). Overall, during follow-up, 91 patients underwent mitral valve surgery (first MVS for 20 pts and reintervention for 71 pts, representing a 10% reintervention rate). In regression analysis, we found no association between the mean age at first surgery and the need for reoperation (p = 0.458). Mitral valve surgery is performed in about 20% of patients undergoing ALCAPA correction. Indications for MVS vary among centers, although the severity of MV regurgitation was the most common criterion (more than 50% of the yMVS group). Of yMVS patients, approximately 10% underwent a second MVS during follow-up, regardless of age at first surgery. Overall, long-term mortality in these patients is over 5%, with no evident impact related to concomitant MV surgery.

Anatomical Variants of the Origin of the Coronary Arteries: A Systematic Review and Meta-Analysis of Prevalence

PURPOSE

The most common anomaly is an anomalous left coronary artery originating from the pulmonary artery. These variants can be different and depend on the location as well as how they present themselves in their anatomical distribution and their symptomatological relationship. For these reasons, this review aims to identify the variants of the coronary artery and how they are associated with different clinical conditions.

METHODS

The databases Medline, Scopus, Web of Science, Google Scholar, CINAHL, and LILACS were researched until January 2024. Two authors independently performed the search, study selection, and data extraction. Methodological quality was evaluated using an assurance tool for anatomical studies (AQUA). Pooled prevalence was estimated using a random effects model.

RESULTS

A total of 39 studies met the established selection criteria. In this study, 21 articles with a total of 578,868 subjects were included in the meta-analysis. The coronary artery origin variant was 1% (CI = 0.8-1.2%). For this third sample, the funnel plot graph showed an important asymmetry, with a p-value of 0.162, which is directly associated with this asymmetry.

CONCLUSIONS

It is recommended that patients whose diagnosis was made incidentally and in the absence of symptoms undergo periodic controls to prevent future complications, including death. Finally, we believe that further studies could improve the anatomical, embryological, and physiological understanding of this variant in the heart.

Past, Present, and Future of Surgical Treatment of Anomalous Left Coronary Artery from the Pulmonary Artery

In recent years, with advancements in surgical techniques and the widespread utilization of extracorporeal cardiac assist devices such as extracorporeal membrane oxygenation (ECMO), the treatment outcomes for ALCAPA (Anomalous left coronary artery from the pulmonary artery) have demonstrated significant improvements. However, the surgical indications and methods of ALCAPA, especially the surgical methods of ALCAPA with intramural coronary artery, and whether to treat MR at the same time are still controversial. The long-term prognosis remain discouraging simultaneously, with significant variations in outcomes across different centers. The present review specifically addresses these aforementioned concerns. This article reviews the pathophysiology and classification, diagnosis, indications, surgical strategy and prognosis of ALCAPA. We believe that this review will provide some reference for future researchers and provide new ideas for reducing the adverse prognosis of children with congenital heart disease in future.

Effectiveness and Safety of Mitral Valve Plasty in Patients with an Anomalous Origin of the Coronary Artery from the Pulmonary Artery

The study aimed to determine the effectiveness and safety of anomalous coronary artery from pulmonary artery (ACAPA) patients with moderate or severe mitral valve regurgitation (MVR) receiving mitral valve plasty (MVP) concurrently. Consecutive ACAPA patients undergoing surgery between 2015 and 2021 were retrospectively included. Patients were divided into three groups: moderate MVR without MVP (non-MVP (moderate) N = 14), moderate MVR with MVP (MVP (moderate) N = 13), and severe MVR with MVP (MVP (severe) N = 13). The primary safety endpoint was in-hospital surgery-related complications. The primary effectiveness outcome was left ventricular ejection function (LVEF) and left ventricular end-diastolic diameter (LVEDD) z-score at 2- and 24-month follow-ups. Multivariable linear regression models were used to obtain the β coefficient. The median age of the included patients was 7.5 years (IQR 1.4-26.5). The in-hospital surgery-related complication rates were 7.1%, 15.4%, and 7.7% in non-MVP (moderate), MVP (moderate), and MVP (severe) groups, separately. At the 2-month follow-up, the non-MVP (moderate) group had a better LVEF and LVEDD z-score compared with the MVP (moderate) group (LVEF β = 9.22, 95%CI 1.09 to 17.35; LVEDD z-score β = -2.49, 95%CI -4.53 to -0.45). At the 24-month follow-up, the LVEF of all patients and the LVEDD z-score of 90% of patients in the three groups returned to normal. For ACAPA patients with moderate MVR, MVP was not necessary, especially for pediatric patients (age < 3 years) and patients with secondary MVR. Further studies for ACAPA patients with severe MVR are still needed.