HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Chan, R. K. M. Articles by Buxton, B. F. Search for Related Content PubMed Articles by Chan, R. K. M. Articles by Buxton, B. F.

J Thorac Cardiovasc Surg 1996;111:902-903
© 1996 Mosby, Inc.

LETTERS TO THE EDITOR

Anomalous origin of the left coronary artery from the pulmonary artery: Is reconstruction of a double coronary artery system always necessary?

Department of Cardiology^a

Reply to the Editor:

Dr. Sivasubramanian and colleagues rightly highlight the importance of collateral blood flow, especially from noncoronary vessels, in adult patients with an anomalous left main coronary artery arising from the pulmonary artery. It is probably this feature that allows these patients to survive beyond childhood. We believe that it is important to assess the adequacy of these collaterals objectively before embarking on reconstructive surgery. This can be done indirectly by assessing left ventricular size and function and myocardial perfusion during functional testing. Despite brisk noncoronary collateral blood flow, as observed during attempts at cardiopulmonary bypass during the operation, the patient described in our report ¹ had evidence of myocardial ischemia before the operation. This was demonstrated by symptoms of fatigue and exertional dyspnea, left ventricular dilatation, reduced functional capacity, and the presence of reversible perfusion abnormality in the anterior wall.

The time scale for the development of myocardial ischemia as a result of inadequate collateral flow in patients with this coronary anomaly is unknown. In fact, it is uncertain whether these changes will eventually develop in all patients living beyond childhood. However, in view of reported cases of sudden death, ² occasionally not preceded by any ischemic symptoms, corrective surgery is usually recommended at diagnosis, even in symptom-free patients with no objective evidence of ischemia, such as the patient described by Dr. Sivasubramanian and colleagues.

Ligation of the left main coronary artery from its origin at the pulmonary artery without additional revascularization eradicates the coronary artery steal phenomenon ³ by ablating the coronary–pulmonary arterial shunt. We are concerned that this technique may not be adequate in improving myocardial blood flow to alleviate ischemia in some patients, especially those with clinical or objective evidence of myocardial ischemia. There have been case reports of late-onset sudden death in adult patients who underwent simple ligation of the left main coronary artery alone. ⁴ It will be interesting to follow-up carefully Dr. Sivasubramanian's patient to see whether simple ligation of the left main coronary artery from its anomalous origin will prevent any deterioration in left ventricular performance and arrhythmic events.

The fear of developing "the equivalent of left main trunk disease" later in life when obstructive disease develops in the conduit used to reconstruct a double coronary artery system is based on the theoretical assumption that regressed coronary and noncoronary collaterals will not regenerate. Given the widely published long-term patency of the left internal mammary artery when used as a conduit in patients with atheromatous coronary artery disease, ^{5 , 6} its use in patients with this coronary anomaly is also likely to result in lasting benefits.

References

1. Chan RKM, Hare DL, Buxton BF. Anomalous left main coronary artery arising from the pulmonary artery in an adult: treatment by internal mammary artery grafting. J THORAC CARDIOVASC SURG 1995;109:393-4.[Free Full Text]
   
2. Wesselhoeft H, Fawcett JS, Johnson AL. Anomalous origin of the left coronary artery from the pulmonary artery: its clinical spectrum, pathology and pathophysiology based on a review of 140 cases with seven further cases. Circulation 1968;38:403-25.[Abstract/Free Full Text]
   
3. Wright NL, Baue AE, Baum S, Zinnser HF. Coronary artery steal due to anomalous left coronary artery originating from the pulmonary artery. J THORAC CARDIOVASC SURG 1969;59:461-7.[Medline]
   
4. Wilson CL, Dlabal PW, McGuire SA. Surgical treatment of anomalous left coronary artery from pulmonary artery: followup in teenagers and adults. Am Heart J 1979;98:440-6.[Medline]
   
5. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal mammary artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1-6.[Abstract]
   
6. Dion R, Etienne PY, Verhelst R, et al. Bilateral mammary grafting: clinical, functional and angiographic assessment in 400 consecutive patients. Eur J Cardiothorac Surg 1993;7:287-94.[Abstract]
   

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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Chan, R. K. M. Articles by Buxton, B. F. Search for Related Content PubMed Articles by Chan, R. K. M. Articles by Buxton, B. F.