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.

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

Objective of this study is to summarize surgical outcomes of patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in a single center. The clinical data of 89 children undergoing surgical treatment in Beijing Children's Hospital from January 2007 to January 2022 were retrospectively analyzed. seven patients underwent ECMO support for acute left heart failure after operation, and 2 patients were discharged after weaning successfully. Eight patients died in the early postoperative period, all of them were infants, of which 5 patients underwent ECMO support, 2 patients died of cerebral hemorrhage, 2 patients died of multiple organ dysfunction, and 4 patients died of left heart failure. Three patients died late, 3 patients were lost to follow-up, and 78 patients (96.3%) completed long-term follow-up. A logistic regression model multivariate analysis showed that postoperative moderate or severe mitral regurgitation (MR) (OR 26.948 P = 0.024) and prolonged aortic cross-clamp time (OR 1.038 P = 0.050) were independent risk factors of early mortality. Compared with the Non-MVP group (20/36), the MVP group (patients with moderate or severe MR who underwent MVP at the same time) (16/36) had more significant improvement in early postoperative LEVEF [(50.68 ± 13.85)% vs (40.50 ± 13.58)% P = 0.033] and had a lower proportion of moderate or severe MR after operation (2/16 vs 11/20 P = 0.014). Children with ALCAPA can obtain a good prognosis by reconstructing the blood supply of both coronary arteries. Mitral valvuloplasty (MVP) is more helpful in improving the prognosis of children with moderate or severe MR and mitral valve structural disease. Reasonable placement of ECMO can help reduce the mortality of critically ill children after operation, but be alert to complications in the central system.

Anomalous left coronary artery from the pulmonary artery: Outcomes and management of mitral valve

Objective

Use of concomitant mitral valve repair remains controversial in the anomalous left coronary artery from the pulmonary artery (ALCAPA) with mitral regurgitation (MR). This study aimed to evaluate postoperative mitral valve function and explore the indication for concomitant mitral valve repair.

Materials and methods

The medical records of 111 patients with ALCAPA and MR who underwent ALCAPA surgery between April 2006 and November 2020 were reviewed. The patients were categorized into three groups for comparison, namely, group I consisted of 38 patients with trivial or mild MR who underwent ALCAPA repair only; group II consisted of 37 patients with moderate or severe MR who similarly had only surgery of the ALCAPA performed; and group III consisted of 36 patients who had concomitant mitral valve repair for moderate or severe MR.

Result

Overall mortality was 7.2% (8 of 111). The mortality of group II (16.2%, 6 of 37) was higher than those of groups I (5.3%, 2 of 38) and III (0%, 0 of 36) (p = 0.027). All three patients who underwent mitral valve reintervention were in group II. At the last follow-up, none of the patients had more than moderate MR in group I. The percentage of patients with improved MR grade was 79.4% (27 of 34) in group III and 51.4% (19 of 37) in group II (p = 0.001). The multivariate logistic regression revealed that concomitant mitral valve repair (adjusted odds ratio = 4.492, 95% CI: 1.909–12.794; p < 0.001) was the major factor influencing MR grade improvement.

Conclusion

The long-term outcomes after ALCAPA repair were favorable. For mild MR, ALCAPA repair only can be performed. For moderate and severe MR, we suggest concomitant mitral valve repair.

Anomalous origin of the left coronary artery from the pulmonary artery as a rare cause of mitral valve prolapse: a case report

BACKGROUND

 Mitral valve prolapse (MVP) is an etiologically heterogeneous disorder. Early diagnosis and prompt treatment of the underlying disease are of great significance. Herein, we present a rare case of MVP caused by anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).

CASE PRESENTATION

A 22-year-old female presented with a 16-year history of anterior mitral leaflet prolapse. However, she had never experienced any discomfort before. At a routine follow-up, a transthoracic echocardiogram showed anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation, and a retrograde blood flow from an extremely dilated left coronary artery (LCA). Further coronary angiography and coronary computed tomography angiography confirmed the diagnosis of ALCAPA. She subsequently underwent successful LCA reimplantation and concomitant mitral valve replacement. Intraoperatively, her mitral annulus was mildly dilated, anterior mitral valve leaflet appeared markedly thickened with rolled edges, and a chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened.

CONCLUSIONS

ALCAPA is a rare and potentially life-threatening congenital coronary artery anomaly that may cause mitral valve prolapse. Echocardiogram is an important screening tool for this disorder.

The salutary effect of peritoneal dialysis catheters on enhanced recovery among high-risk pediatric patients undergoing the left coronary transfer procedure: a cohort study

BACKGROUND

Evidence for peritoneal dialysis catheter (PDC) usage in pediatric patients undergoing surgery for deteriorating cardiac dysfunction is lacking. This investigation explored factors associated with PDC usage and its effectiveness in children with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).

METHODS

Eighty-four children undergoing left coronary artery transfer were retrospectively recruited. The primary endpoint was the postoperative ratio of the general ward/[intensive care unit (ICU)] length of stay. Univariable and multivariable analyses were fitted to assess factors related most strongly to PDC and the ratio of general ward/ICU length of stay.

RESULTS

Of the 84 patients, 17 (20.2%) underwent postoperative PDC placement. Patients with extreme cardiac dysfunction [left ventricular ejection fraction (LVEF) ≤25%] were much more likely to require a PDC (OR, 9.88; 95% CI, 2.13-45.76; P = 0.003). Moreover, univariate analysis indicated that concomitant mitral repair significantly decreased the likelihood of PDC placement (OR, 0.25; 95% CI, 0.07-0.85; P = 0.026). In those with cardiac dysfunction (LVEF ≤50%), PDC use was associated with a reduced ratio of ward/ICU length of stay (B, - 1.62; 95% CI, - 2.77- -0.46; P = 0.008), as was age ≤ 12 months (B, - 1.57; 95% CI, - 2.88- -0.26; P = 0.02). At the 1-year follow-up, cardiac improvement was significantly greater in patients with PDC usage than in those without it (P <  0.001), and the number of mitral recoveries was comparable between the groups (64.2% vs. 53.3%, P = 0.434).

CONCLUSION

In cohorts with ALCAPA, PDC placement following surgery may be necessary for patients with extreme cardiac compromise, while concomitant mitral repair can probably reduce their usage rate. PDC is beneficial in conferring an improvement in cardiac and mitral performance. Importantly, after patients are transferred from the ICU, recovery efficiency in the general ward can be enhanced by PDC placement, and hospital discharge can therefore be achieved early, especially for patients younger than 12 months or with LVEF ≤50%.

Anomalous left coronary artery from pulmonary artery repair: Outcomes from the European Congenital Heart Surgeons Association Database

INTRODUCTION

We sought to determine the surgical outcomes of patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) enrolled in the European Congenital Heart Surgeons Association (ECHSA) database.

MATERIALS AND METHODS

From 1999 to 2019, 907 patients with ALCAPA underwent surgical repair and were included in the current study. The primary outcome was in-hospital mortality. Secondary outcomes included frequency and results of concomitant mitral valve surgery and postoperative mechanical circulatory support (MCS).

RESULTS

The overall in-hospital mortality was 6% (54/907) and was significantly higher in neonates (p = .01), patients with lower body surface area (BSA) (p = .01), and those requiring postoperative MCS (p = .001). Associated mitral valve surgery was performed in 144 patients (15.9%) and was associated with longer cardiopulmonary bypass (CPB) and aortic cross-clamp times (AOX) (p ≤ .0001) but was not significantly related to an increase in in-hospital mortality. Postoperative MCS was required in 66 patients (7.3%). These patients were younger (p ≤ .001), had a lower BSA (p ≤ .001), and required a longer CPB (p ≤ .001) and AOX time (p ≤ .001).

CONCLUSIONS

ALCAPA repair can be achieved successfully, and with low surgical risk. Concomitant mitral valve procedures can be performed without increasing operative mortality. The use of MCS remains a valuable option, especially in younger patients.

Unexpected mechanism of mitral regurgitation in a patient post ALCAPA repair: Added value of three-dimensional echocardiography

Accurate assessment of etiology of mitral regurgitation (MR) is one of the key steps in the decision-making process and further clinical management of patients with severe MR. Our clinical case illustrates the added value of three-dimensional echocardiography (3DE) in assessment of mitral valve morphology and identification of an unexpected mechanism of MR which was not previously diagnosed using conventional echocardiography. 3DE helped to choose appropriate management strategy in this patient.

Pediatric Mitral Regurgitation: Standardized Repair-Oriented Strategy With Leaflet Plication

To introduce a standardized strategy and reproducible procedures of mitral repair for mitral regurgitation in the pediatric population with leaflet plication as a principal technique. Consecutive patients who had undergone mitral repair by our standardized repair-oriented strategy in our institution from January 2016 to December 2019 were included retrospectively. The standardized repair strategy included 3-step inspections and repair from the subvalvular to leaflet, and then to the annular level. The main surgical techniques included chordae detachment, papillary muscle splitting, leaflet plication, and posterior annuloplasty. The indication for leaflet plication was that the distance between 2 adjacent chordae tendineae was greater than 4 mm. A total of 113 patients were enrolled. During 22.6-month (range, 2-50 months) follow-up period, primary endpoint was documented in 15 (13.3%) patients, including 1 (0.9%) death, 0 transplantation, and 14 (12.4%) functional mitral failure. Freedom form primary endpoints at 6 months, 1 year, and 3 years was 94.7%, 94.7%, and 82.3%, respectively. Significant independent predictors of functional mitral valve failure were younger age (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.04-0.72; P = 0.037) and ischemic mitral regurgitation (MR) (HR, 24.34; 95% CI, 4.52-47.33; P < 0.001). Leaflet plication was significantly associated with well-functioned mitral valve (HR, 7.42; 95% CI, 2.35-30.54; P = 0.004). Compared with nonischemic MR group, ischemic MR group was noted with higher occurrence of primary endpoint events (11/28 vs 4/85, P < 0.001). The short- to mid-term outcomes of standardized mitral repair technique with leaflet plication were favorable, among which, however, repair for mitral regurgitation with ischemic lesions is comparatively challenging.