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J Thorac Cardiovasc Surg 2001;122:636
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Reply

Department Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku,
Tokyo 162-8666, Japan

Reply to the Editor:

We read with interest the letter from Alexi-Meskishvili and Hetzer regarding our article on surgical intervention for anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). ¹

We have treated 31 patients (direct coronary transfer in 21 and Takeuchi procedure in 10) through the end of April 2001. Overall mortality was 6.5% (2/31 patients).

Three options for mitral incompetence associated with ALCAPA can be summarized as follows: (1) Mitral annuloplasty should be performed in patients who have varying degrees of incompetence, as we ¹ recommended; (2) mitral valve surgery should be performed in patients with severe incompetence, as Alexi-Meskishvili and colleagues ² and Schwartz, Jonas, and Colan ³ recommended; and (3) the mitral valve should be subjected to no intervention at the initial operation, as Vouhé, ⁴ Cochrane, ⁵ and their associates advocated. The major concern is the degree of mitral incompetence in the late period. As we mentioned in the "Discussion" of our article, the option of leaving the mitral valve alone (concept 3) is not convincing from the published results. ^4,5 That the degree of mitral incompetence remained unchanged postoperatively in 38% of patients ³ does not seem to us to support concept 2. However, Alexi-Meskishvili and Hetzer showed good results using concept 2. It may be difficult to conclude which concept is better (1 or 2) from our data and Alexi-Meskishvili's data, because although the duration of follow-up and extent of improvement are almost equivalent, the number of patients differs. As experiences with each surgical concept are accumulated and as follow-up periods lengthen, criteria for mitral valve repair in ALCAPA (eg, related to the patient's age) may be determined in the future. At present, we are going to use concept 1 as our consistent surgical policy. We believe that mitral annuloplasty for even moderate or mild mitral incompetence is beneficial in an acute phase after 2-coronary repair.

Although direct aortic reimplantation (direct coronary transfer) is the procedure of choice, the Takeuchi operation is still an effective alternative. The primary advantage of the Takeuchi procedure is coronary rerouting in situ, particularly when the left coronary artery has no redundancy and has a very fragile arterial wall. We do not think every anomalous left coronary artery should be reimplanted directly to the aorta. Unlike the situation after the arterial switch operation, tension might be placed on the left coronary artery to reach the aorta after direct coronary transfer when the anomalous orifice is located far from the aorta.

We agree that a higher survival can be achieved with a chance of long-term recovery by using a left ventricular assist device. We are going to use such devices aggeressively in patients with severe left ventricular dysfunction.

12/8/118046

doi:10.1067/mtc.2001.118046

References

1. Isomatsu Y, Imai Y, Shin'oka T, Aoki M, Iwata Y. Surgical intervention for anomalous origin of the left coronary artery from the pulmonary artery: the Tokyo experience. J Thorac Cardiovasc Surg. 2001;121:792-7.[Abstract/Free Full Text]
   
2. Alexi-Meskishvili V, Hetzer R, Weng Y, Lange PE, Jin Z, Berger F, et al. Anomalous origin of the left coronary artery from the pulmonary artery: early results with direct aortic reimplantation. J Thorac Cardiovasc Surg. 1994;108:354-62.[Abstract/Free Full Text]
   
3. Schwartz ML, Jonas RA, Colan SD. Anomalous origin of left coronary artery from pulmonary artery: recovery of left ventricular function after dual coronary repair. J Am Coll Cardiol. 1997;30:547-53.[Abstract]
   
4. Vouhé PR, Baillot-Vernant F, Trinquet F, Sidi D, de Geeter B, Khoury W, et al. Anomalous left coronary artery from the pulmonary artery in infants: Which operation and when? J Thorac Cardiovasc Surg. 1987;94:192-9.[Abstract]
   
5. Cochrane AD, Coleman DM, Davis AM, Brizard CP, Wolfe R, Karl TR. Excellent long-term functional outcome after an operation for anomalous left coronary artery from the pulmonary artery. J Thorac Cardiovasc Surg. 1999;117:332-42.[Abstract/Free Full Text]
   

This Article Full Text (PDF) 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 Author home page(s): Yasuharu Imai Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Isomatsu, Y. Articles by Shin'oka, T. Search for Related Content PubMed Articles by Isomatsu, Y. Articles by Shin'oka, T.