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J Thorac Cardiovasc Surg 1994;108:1147
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Anomalous origin of the left coronary artery from the pulmonary artery

Cardiac and Thoracic Surgery
Henry Ford Hospital
Detroit, MI 48202-2689

To the Editor:

In a recent article in this JOURNAL, Tashiro and colleagues ¹ reported their use of a new technique to restore a dual coronary system for repair of anomalous origin of the left coronary artery from the pulmonary artery in two adult patients The repair entails transection and reanastomosis of the pulmonary trunk, as well as creation of a new left main coronary artery with anastomosis to the aorta, and mandates aortic crossclamping and cardioplegic arrest. Although we agree that teleologic supposition would favor restoration of a two coronary system in this setting, we nonetheless submit that this technique, although innovative, may be unnecessarily complex. We believe comparable results can be effected by conventional revascularization techniques.

A 66-year-old man was admitted to an outside hospital with the recent onset of exertional dyspnea. Workup at that institution revealed evidence of a sinus arrhythmia for which the patient underwent insertion of a permanent transvenous VVI pacemaker. Over the subsequent 2 years, the patient continued to have worsening dyspnea and was transferred to our institution after requiring hospitalization for an exacerbation of congestive heart failure. Cardiac catheterization demonstrated an anomalous origin of the left coronary artery from the pulmonary artery with collateral flow from a massively dilated right coronary artery. At operation, the proximal 3 cm of the right coronary artery was severely calcified and the left anterior descending artery measured approximately 8 mm in its midportion. Repair included two-layer closure of a 12 mm fistulous opening from within the pulmonary artery and bypass grafting of the midportion of the left anterior descending artery with the pedicled left internal thoracic artery. This repair was easily accomplished in a moderately hypothermic fibrillating heart vented through the open pulmonary artery, with a brief period of local occlusion for the arterial anastomosis. The postoperative course was uneventful and the patient remains well 16 months later.

The technique proposed by the authors may, indeed, be advantageous in infants and small children, in whom size constraints may preclude effective internal thoracic artery grafting. However, for the rare patient in whom this anomaly becomes manifest in adult life, closure of the fistula with arterial grafting of the left anterior descending artery would seem to be considerably less complicated. As described here, we purposely wanted the aorta unclamped while closing the fistula to ensure complete obliteration and to avoid maldistribution of antegrade infusion of cardioplegic solution into the aortic root. Alternatively, cardioplegic solution could have been given retrograde or after fistula closure. Regardless of the myocardial protective strategy, we maintained the advantage of a two coronary system without need for prosthetic material or concern over the longevity of saphenous vein bypass grafting.

References

1. Tashiro T, Todo K, Haruta Y, Yasunaga H, Nagata M, Nakamura M. Anomalous origin of the left coronary artery from the pulmonary artery: new operative technique. J THORAC CARDIOVASC SURG 1993;106:718-22.[Abstract]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Gaetano Paone Norman A. Silverman Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Paone, G. Articles by Silverman, N. A. Search for Related Content PubMed PubMed Citation Articles by Paone, G. Articles by Silverman, N. A.