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The Journal of Thoracic and Cardiovascular Surgery, Vol 94, 192-199, Copyright © 1987 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
PR Vouhe, F Baillot-Vernant, F Trinquet, D Sidi, B de Geeter, W Khoury, F Leca and JY Neveux
The surgical management of anomalous left coronary artery from the
pulmonary artery in infants and small children remains controversial,
because the ideal surgical procedure and the optimal time for operation are
yet to be determined. From 1977 to 1985, 22 patients less than 4 years of
age (mean age 18.2 months) underwent direct aortic reimplantation of the
anomalous left coronary artery. There were five operative deaths (23%,
confidence limits 13%-36%). The determinant risk factor of early mortality
was the severity of preoperative left ventricular dysfunction (p = 0.05),
not age at operation (p = 0.64) or preoperative clinical status (p = 0.36).
There were not late deaths (mean follow-up 38 months). All survivors but
one were symptom free. The reimplanted anomalous left coronary artery was
patent in each reevaluated case (9/17). Left ventricular function improved
significantly in all survivors. Moderate to severe preoperative mitral
incompetence lessened in all patients but one, without mitral valve repair.
When technically feasible, direct aortic reimplantation of the anomalous
left coronary artery is an attractive procedure because it offers a high
rate of patency and avoids the potential drawbacks of procedures involving
autogenous venous or arterial tissue. Optimal intraoperative myocardial
preservation and institution of temporary left ventricular assistance at
the end of the operation may decrease the operative risk. Left ventricular
function nearly always recovers after successful revascularization, and
resection of left ventricular myocardium is rarely indicated, if ever.
Mitral incompetence almost always lessens, and the mitral valve should not
be repaired at initial operation; however, residual mitral incompetence may
necessitate reoperation in a few cases. In infants with moderate left
ventricular damage (usually asymptomatic with medical therapy), surgical
treatment should be delayed until 18 to 24 months of age so that it can be
performed with a low operative risk. Infants with severely impaired left
ventricular function and persistent congestive heart failure should
probably undergo operation as soon as the diagnosis has been made.
ARTICLES
Anomalous left coronary artery from the pulmonary artery in infants. Which operation? When?
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