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J Thorac Cardiovasc Surg 1995;110:561-562
© 1995 Mosby, Inc.

BRIEF COMMUNICATIONS

REPAIR OF TETRALOGY OF FALLOT WITH ANOMALOUS ORIGIN OF LEFT ANTERIOR DESCENDING CORONARY ARTERY

San Francisco, Calif.

From the Division of Cardiothoracic Surgery, St. Vincent Hospital, Portland, Ore.

In tetralogy of Fallot the left anterior descending coronary artery (LAD) originates anomalously from the right coronary artery in approximately 5% of patients and crosses the right ventricular outflow tract (RVOT) at a variable distance from the pulmonary anulus. ^1,2 The surgical approach in this subset of tetralogy, as in the entire spectrum of this anomaly, primarily depends on the size of the pulmonary valve anulus and the anatomic features of the RVOT. In many patients successful repair can be accomplished by a transatrial-transpulmonary approach, which, as compared with the classic transventricular approach, may lessen development of right ventricular dysfunction over the long term. ^3,4 Generally, transannular patching is required when the pulmonary anulus is expected to be too small (Z value -5 or smaller) to lead to an acceptable postoperative right ventricular/left ventricular pressure ratio (maximum 0.65). ⁵

Various techniques for repair of tetralogy with anomalous origin of the LAD and small pulmonary anulus have been reported, all of which consist of RVOT reconstruction with either a patch or a conduit. ^2,6-8 An alternative technique of RVOT reconstruction in this subset of tetralogy is analogous to the one described by Barbero-Marcial and colleagues ⁹ for repair of truncus arteriosus without use of an extracardiac conduit. A longitudinal incision is made in the RVOT extending approximately 4 mm proximal to the LAD (Fig. 1). Two parallel longitudinal incisions in the main pulmonary artery are connected by a transverse incision so that a wide flap is created that is of sufficient length to reach the edge of the ventriculotomy (Fig. 2). The pulmonary artery flap is approximated to the superior edge of the ventriculotomy with 7-0 or 6-0 polyglyconate suture (Maxon; Davis & Geck, Inc., Danbury, Conn.). Subsequently, a hood of oval-shaped glutaraldehyde-treated pericardial patch or pulmonary homograft patch is circumferentially sutured to the edge of the ventriculotomy, both edges of the pulmonary artery flap, and the edge of the pulmonary arteriotomy (Fig. 3).

View larger version (31K): [in this window] [in a new window]   Fig. 1. Repair of tetralogy of Fallot with anomalous origin of LAD and small pulmonary anulus. Longitudinal incision is made in RVOT distal to LAD; if possible, large conal branch should be preserved. Two parallel longitudinal incisions in main pulmonary artery are connected distally, thus creating wide flap of pulmonary artery tissue.

View larger version (35K): [in this window] [in a new window]   Fig. 2. Pulmonary artery flap is sutured to superior edge of ventriculotomy.

View larger version (35K): [in this window] [in a new window]   Fig. 3. Oval-shaped glutaraldehyde-treated pericardial patch (or, alternatively, pulmonary homograft patch) is circumferentially sutured to edges of ventriculotomy, pulmonary artery flap, and pulmonary arteriotomy.

Potential advantages of the proposed technique (versus conventional patch or conduit reconstruction) are (1) lower probability of late RVOT or pulmonary stenosis, or both, because the posterior wall of the constructed pathway consists of autogenous tissue with preserved growth potential and (2) lower probability of compression or stretching of the LAD as compared with that when the conventional patch technique is used, especially when the patch is placed underneath the mobilized LAD. If the described technique is applied at neonatal age, use of a pulmonary homograft patch with a monocusp valve may be advantageous to preserve right ventricular compliance in the presence of increased pulmonary arteriolar resistance.

Although repair of tetralogy with anomalous origin of the LAD and small pulmonary anulus can be staged, long-term results of this approach may be less favorable than those with early (age 1 to 6 months) primary repair. Advantages of the latter approach (versus a staged approach) are as follows: (1) early relief of RVOT obstruction, which avoids secondary hypertrophy of the right ventricular infundibulum and muscle bundles and therefore necessitates less extensive muscle resection; (2) avoidance of biventricular volume overload (as a result of shunt physiologic conditions), which leads to better preservation of ventricular function; (3) preservation of pulmonary artery architecture; and (4) avoidance of detrimental developmental effects of prolonged cyanosis.

References

1. Dabizzi RP, Caprioli G, Aiazzi L, et al. Distribution and anomalies of coronary arteries in tetralogy of Fallot. Circulation 1980;61:95-102.[Abstract/Free Full Text]
   
2. Humes RA, Driscoll DJ, Danielson GK, Puga FJ. Tetralogy of Fallot with anomalous origin of left anterior descending coronary artery: surgical options. J THORAC CARDIOVASC SURG 1987;94:784-7.[Abstract]
   
3. Pacifico AD, Sand ME, Bargeron LM Jr, Colvin EC. Transatrial-transpulmonary repair of tetralogy of Fallot. J THORAC CARDIOVASC SURG 1987;93:919-24.[Abstract]
   
4. Dietl CA, Cazzaniga ME, Dubner SJ, Perez-Balino NA, Torres AR, Favaloro RG. Life-threatening arrhythmias and RV dysfunction after surgical repair of tetralogy of Fallot: comparison between transventricular and transatrial approaches. Circulation 1994;90(Suppl):II7-12.
   
5. Kirklin JW, Blackstone EH, Jonas RA, et al. Morphologic and surgical determinants of outcome after repair of tetralogy of Fallot and pulmonary stenosis: a two-institution study. J THORAC CARDIOVASC SURG 1992;103:706-23.[Abstract]
   
6. Meyer J, Chiariello L, Hallman GL, Cooley DA. Coronary artery anomalies in patients with tetralogy of Fallot. J THORAC CARDIOVASC SURG 1975;69:373-6.[Abstract]
   
7. Bonchek LI. A method of outflow tract reconstruction in tetralogy of Fallot with anomalous anterior descending coronary artery. Ann Thorac Surg 1976;21:451-3.[Abstract/Free Full Text]
   
8. Hurwitz RA, Smith W, King H, Girod DA, Caldwell RL. Tetralogy of Fallot with abnormal coronary artery: 1967 to 1977. J THORAC CARDIOVASC SURG 1980;80:129-34.[Abstract]
   
9. Barbero-Marcial M, Riso A, Atik E, Jatene A. A technique for correction of truncus arteriosus types I and II without extracardiac conduits. J THORAC CARDIOVASC SURG 1990;99:364-9.[Abstract]
   

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This Article Alert me when this article is cited Alert me if a correction is posted Citation Map 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): Jacques A. M. van Son Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by van Son, J. A. M. Search for Related Content PubMed PubMed Citation Articles by van Son, J. A. M.