Emergency ligation of anomalous left coronary artery arising from the pulmonary artery

doi:10.1016/S0003-4975(00)01179-6

The Annals of Thoracic Surgery

Volume 69, Issue 5, May 2000, Pages 1591-1592

https://doi.org/10.1016/S0003-4975(00)01179-6 Get rights and content

Abstract

We report two cases of successful emergency ligation of anomalous left coronary artery arising from the pulmonary artery (ALCAPA) in patients with previous cardiac arrest. Both patients had regained marginal cardiac output after cardiopulmonary resuscitation and had maximal doses of inotropic support. The ALCAPA ligation was then performed as a life-saving procedure in the absence of any kind of mechanical circulatory support.

Section snippets

Patient 1

In June 1979, a 5-month-old girl was admitted because of severe congestive heart failure with dilated cardiomyopathy. The diagnosis of ALCAPA was suspected with the electrocardiographic (ECG) changes and confirmed by cardiac catheterization in which large intercoronary vessels were visualized and left-to-right shunt was detected. One day after admission, the baby experienced worsening cardiac failure, severe low output state despite inotropic support, and arrested heart. In that scenario,

Comment

The pleural cavity was entered through a posterolateral thoracotomy. The lung was retracted and the pericardium was opened in a longitudinal fashion. The anomalous left coronary artery was identified and doubly ligated proximal to its origin. The chest was closed in the usual fashion.

In patient 1, after retracting the lung, the heart arrested and internal cardiac massage was instituted. The coronary artery was ligated in an arrested heart. Both patients markedly improved left ventricular

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There are more references available in the full text version of this article.

Cited by (32)

Management of anomalous origin of the left coronary artery from the pulmonary artery in an adult with ischemic cardiomyopathy and pulmonary hypertension
2014, Annals of Thoracic Surgery
Citation Excerpt :
Adult patients with ALCAPA are at risk for sudden death. Surgical ligation of the LMCA has been offered to such patients [5]. More recently, transcatheter embolization of the LMCA has been reported in a patient felt to be unsuitable for surgical reimplantation of the LMCA [6].
Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital anomaly that usually presents in infancy with cardiomyopathy and congestive heart failure. Surgical reimplantation of the anomalous left coronary artery is offered as definitive treatment in infancy. We describe the case of a 26-year-old man presenting with cardiomyopathy who was identified to have an anomalous left coronary artery from the pulmonary artery. Surgical reimplantation presented a high risk due to severe postcapillary pulmonary hypertension. Transcatheter occlusion of the proximal left main coronary artery was obtained. The patient was started subsequently on anticongestive therapy. Surgical coronary artery bypass was performed 3-months later after resolution of postcapillary pulmonary hypertension. The patient remains well at 1-year follow-up.
Successful percutaneous treatment of anomalous left coronary artery from pulmonary artery
2007, International Journal of Cardiology
Citation Excerpt :
Those patients with satisfactory collateralization may have a variable onset of symptoms. Large interconnections, as in our patient, can be associated with myocardial steal and consequent myocardial ischemia from left to right shunting and develop left ventricular dysfunction [3,5]. These patients also are at risk of sudden cardiac death [2,6].
Anomalous origin of the left main coronary artery from the pulmonary artery (ALCAPA) is an uncommon congenital condition seen in the adult population, with most patients developing symptoms in infancy.
We describe successful closure of an ALCAPA in an adult using a percutaneous transcatheter approach in a patient with evidence of anterior wall ischemia believed to be the consequence of myocardial steal.
A 30-year-old female was noted to have continuous flow in the right ventricular septum on transthoracic echocardiography, with subsequent imaging confirming the presence of an ALCAPA. Myocardial perfusion imaging confirmed anterior wall ischemia, and as a strategy to optimize coronary perfusion pressure, the patient underwent percutaneous ALCAPA closure using an Amplatzer™ vascular plug. The procedure was well tolerated, with no evidence of anterior ischemia or myocardial dysfunction. Follow up perfusion imaging demonstrated no residual anterior wall ischemia.
Transcatheter closure of an ALCAPA is a potentially safe and effective alternative treatment strategy in this patient population.
Anomalous origin of the left coronary artery from the right pulmonary artery complicating a case of coarctation of the aorta
2004, Journal of Cardiothoracic and Vascular Anesthesia
Anomalous coronary artery origin from the pulmonary artery: Correlation between surgical timing and left ventricular function recovery
2003, Annals of Thoracic Surgery
Citation Excerpt :
Currently, simple ligation of the anomalous coronary artery is not recommended because of the risk of sudden death associated with a single coronary artery system and reduced myocardial flow reserve, as demonstrated by impaired treadmill exercise tolerance. However, emergency ligation of the anomalous coronary artery in infancy has been recently reported as a lifesaving procedure for patients with compromised cardiac output presenting in centers where circulatory assist devices are not available [14]. The general consensus towards restitution of a dual coronary circulation is supported by the superb results of early and late survival, associated with apparently complete recovery of LV function at late follow-up [9].
This study investigates the correlation between surgical timing and 15-year longitudinal left ventricular and mitral valve function, after repair of anomalous coronary artery origin from the pulmonary artery.
Between 1987 and 2002, 31 patients (median age, 7.1 months) underwent repair for anomalous origin of the left (n = 28), right (n = 2), or both (n = 1) coronary arteries from the pulmonary artery. Repair was accomplished by subclavian interposition in 5 patients, intrapulmonary tunnel in 12, and direct aortic reimplantation in 14. Primary mitral valve repair was never associated with coronary revascularization. Total follow-up was 186.4 patient-years (mean, 77.2 months).
Fifteen-year actuarial survival was 92.9% ± 4.9% for coronary transfer, 40.0% ± 21.9% for subclavian interposition, and 89.9% ± 7.5% for intrapulmonary tunnel (p = 0.019). Five patients required further intervention for supravalvular pulmonary stenosis (n = 3), baffle leak (n = 1), and mitral valve replacement (n = 1). Coronary transfer allowed best freedom from long-term reoperation (92.3% ± 7.4%). Left ventricular shortening fraction increased from 17.3% ± 6.3% before operation to 34.1% ± 4.6% at last follow-up (p < 0.01). Regression analysis demonstrated a linear relationship between age at repair and shortening fraction recovery (r² = 0.573, p < 0.01). Patients younger than 6 months of age showed worse preoperative shortening fraction (15.9% ± 5.2%) and best longitudinal shortening fraction recovery (36.4% ± 5.1%; p < 0.001). Major improvement in mitral valve function was observed within 1 year from surgery in 90.4% of survivors.
Repair of anomalous coronary artery origin from the pulmonary artery in younger symptomatic infants offers the best potential for recovery of left ventricular function, despite a worse initial presentation. Coronary transfer is associated with superior long-term survival and freedom from reoperation. Most patients with patent two-coronary repair will recover normal mitral valve function; therefore, simultaneous mitral valve surgery seems unwarranted.
Transcatheter occlusion of an anomalous origin of left coronary artery from pulmonary artery in an adult as an alternative to surgery
2020, Cardiology in the Young
Utility of Konar-Multifunctional occluder in complex situations: Unconventional uses in rare situations
2023, Research Square

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Case reportsEmergency ligation of anomalous left coronary artery arising from the pulmonary artery

Abstract

Section snippets

Patient 1

Comment

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Case reports
Emergency ligation of anomalous left coronary artery arising from the pulmonary artery