# Reimplantation of an Anomalous Coronary Artery Arising from the Pulmonary Artery

Authors: Andrea Quarti; Alessandro D'Alfonso; Massimo Colaneri; Alessandra Baldinelli; Maria Grazia Bettuzzi; Marco Pozzi
Journal: Case Reports in Medicine
 (2009)

---

## Abstract

A case  of anomalous origin of the left coronary artery from the pulmonary artery in a patient with the origin of the coronary opposite to the aorta is reported. Between many surgical options we conclude to reestablish a double coronary system reconnecting the coronary through a conduit created with a pulmonary wall baffle and an autologous pericardial patch.


---

## Body

## 1. Introduction

Anomalous origin of the left coronary artery arising from the pulmonary artery (ALCAPA) is a rare  congenital anomaly. The anatomic characteristics of the relation between the ALCAPA and the aorta are the major
issue for the choice of the repairing technique.


## 2. Case Report

A 20-day-old boy was referred to our institution with signs of heart failure and low ejection fraction associated with mild-to-moderate mitral regurgitation (MR). At a physical examination, a systolic murmur was noted at the left sternal border. The chest X-ray showed an enlargement of the heart with  pulmonary plethora.An echocardiographic examination showed a dilated right coronary artery with retrograde flow through the left coronary  artery into the main pulmonary artery. A diagnosis of ALCAPA was made. At examination, a mild-to-moderate MR was also founded, related to ventricular dysfunction (EF 25%) with a central jet, thetering of the mitral leaflets and fibrosis of the anterior papillary muscles.  The patient didn’t require
preoperative inotrops and was under intravenous infusion of furosemide.The operation was performed through a median sternotomy on cardiopulmonary bypass using bicaval cannulation and moderate hypotermia. Myocardial protection was achieved by antegrade cardioplegia through the aortic root after cross-clamping the aorta and snaring of both the branches of the pulmonary artery to ensure efficient delivery of cardioplegia. We didn’t attempt to repair the mitral valve at the time of coronary relocation.Over the last 14 years we have used the reimplantation technique in all the cases. In our patient the left
coronary artery arised opposite to the aorta from the nonfacing sinus (Figure1) precluding the direct relocation. We explanted the coronary artery with a pulmonary artery wall baffle and reconstructed a conduit using the baffle and an autologous pericardial patch (Figure 2). The conduit obtained was then anastomosed on the aorta, and the pulmonary artery was finally reconstructed with autologous pericardial patch  (Figure 2). The patient was easily weaned from cardiopulmonary bypass on  a moderate amount of inotropic support. The patient was extubated on the third postoperative day and the daily echocardiographic examination depicted a slight but progressive improvement in the ejection fraction. One week after the procedure the EF  was 50% while the MR was mild.Figure 1
Coronary anatomy.Figure 2
Creation and relocation of the conduit.The patient was discharged from the hospital 13 days after the operation. At the last follow-up (6 months)
consisting of an echocardiography, the left ventricle was well functioning while the MR is still mild despite the
reduction of the ventricular volume.


## 3. Comment

Anomalous origin of the left coronary artery from the pulmonary artery is a rare condition leading to high mortality in the first year of life [1]. The most popular  surgical correction is the
direct relocation, firstly described by Neches et al. [2]. The major issue in applying this technique is the coronary anatomy and in particular the distance between the anomalous origin of the left coronary and the aorta.  Takeuchi et al. [3] described a
technique which creates a tunnel inside the pulmonary artery between the
coronary ostia and a surgically created aorto-pulmonary window. Potential
complications of this technique include: supra-valvular pulmonary stenosis,
coronary-PA fistula, aortic regurgitation, and reoperations or catheter
interventions which are necessary in almost 30% of patients after the procedure [4].Isolated ALCAPA ligation has also
been described, but this is the only technique leading to a reduced long-term
survival. This technique also precludes the normalization of LV
ejection fraction or volume [5, 6]. No
differences in long-term survival have been demonstrated between the other
techniques leading to a two-coronary system [5–7].Our policy is to reimplant directly
the ALCAPA on the aorta, but in our patient the distance between the coronary
origin in the nonfacing sinus of the pulmonary artery and the aorta precluded
a direct reimplantation. In order to avoid the complications described with the
Takeuchi technique we constructed an external conduit with the use of
autologous pericardium and reconnected the coronary artery through this
extension conduit to the aorta. The conduit hence obtained was then relocated
on the aorta (Figure2).Mitral valve repair was not
considered because in our previous experiences [8] we noticed
the improvement
in mitral valve function after the operation probably due to the decrease of
annular size with the reduction in left ventricular dimensions and the improvement
in papillary muscles perfusion.This technique is a very simple and fast solution to those
anatomical conditions precluding the direct relocation of the coronary artery
to the aorta. However,
although the early follow-up is very encouraging; the follow-up is too short to
exclude the possibility of medium- to long-term complication.



---

*Source: 835459-2009-03-25.xml*