Analysis of left ventricular wall movement before and after reimplantation of anomalous left coronary artery in infancy

Anomalous origin of the left coronary artery from the pulmonary artery: collective review of surgical therapy

Anomalous origin of the left coronary artery from the pulmonary artery is an extremely rare but potentially fatal congenital coronary anomaly. Prompt surgical reestablishment of a two-coronary system on diagnosis yields excellent results and allows progressive and nearly total myocardial recovery. Follow-up of all patients is required to assess the adequacy of repair and to exclude ongoing or recurrent myocardial insult.

Anomalous origin of the left coronary artery from the pulmonary artery: Successful surgical strategy without assist devices

The objective of this review was to analyze a surgical strategy for children with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) where aortic implantation was successful without the use of extracorporeal membrane oxygenation (ECMO) or left ventricular assist device (LVAD). From 1989 through 1999, 16 consecutive children underwent aortic implantation for ALCAPA. Median age was 0.45 years. Surgical strategy included bicaval venous cannulation, LV vent, moderate systemic hypothermia (28 degrees C), antegrade cardioplegia with pulmonary artery (PA) occlusion, PA transection, aortic implantation with a large "button" of PA, PA reconstruction with pericardium, intraoperative transesophageal echocardiography, and inotropic support with dopamine, dobutamine, and milrinone. All patients survived. No patient was placed on ECMO or LVAD. Mean cardiopulmonary bypass (CPB) time was 152 +/- 41 minutes. Mean aortic cross-clamp time was 46 +/- 13 minutes. Mean time from cross-clamp removal to CPB off ("weaning" time) was 58 +/- 20 minutes. One patient had delayed sternal closure. Only 2 patients required more than 10 &mgr;g/kg/minute of dopamine and dobutamine. Mean hospital stay was 29 +/- 25 days. One patient required outpatient inotropic support for 5 months. Although ECMO or LVAD may be necessary for some ALCAPA patients, we describe a surgical strategy of aortic implantation that was successful without the use of assist devices. Copyright 2000 by W.B. Saunders Company

Long-term follow-up after two coronary repair of anomalous left coronary artery from the pulmonary artery

A retrospective analysis of ten patients with anomalous left coronary artery arising from the pulmonary artery operated between 1979 and 1990 was undertaken. All presented with evidence of left ventricular dysfunction and "ischemic" mitral regurgitation. Surgical repair consisted of an aortopulmonary tunnel (Takeuchi) procedure in eight and direct left coronary artery reimplantation in two. Two patients required postoperative support with a left ventricular assist device. There were no operative or late deaths (CL 0% to 17%) for a follow-up of over 670 patient months. All patients are in New York Heart Association Class I or II, though two patients are still receiving anticongestive medications. One patient has required further surgery for pulmonary artery stenosis, and another has had a mitral valve replacement because of severe mitral regurgitation. One additional patient has moderate-to-severe residual mitral regurgitation and two have a trivial left coronary to main pulmonary artery fistula. All have a patent, nonstenotic left coronary artery and much improved left ventricular function and perfusion as assessed by echocardiography, thallium scan, gated blood pool scan, and angiography. There have been no documented arrhythmias, clinically or on Holter monitoring. The ECGs have shown resolution or improvement of the initial changes of ischemia/infarction in all patients. Chest X-rays have shown normalization of cardiothoracic ratio in eight of ten patients. Excellent early and late results can be achieved following timely surgical repair. Marked improvement in left ventricular function has been observed in patients with poor preoperative left ventricular function, even in the presence of extensive ischemia/infarction.