Anomalous Origin of the Left Coronary Artery

In this anomaly, the left coronary artery usually arises from the main pulmonary artery, usually resulting in left ventricular and septal ischemia and development of extensive collaterals between the right and left coronary arteries. Surgical repair is performed at any age immediately following the establishment of the diagnosis. Early repair is performed to avoid congestive heart failure and myocardial fibrosis caused by inadequate myocardial perfusion accentuated by a steal phenomenon with retrograde flow from the left coronary into the main pulmonary artery. Surgery should always establish a two-coronary system.

Coronary Artery Surgery

Figure 18-1. Extensive collaterals have formed between the right and left coronary arteries and there is marked enlargement of the left anterior descending coronary artery.

[eft anterior descending coronary artery

18-1-1. Repair by Intrapulmonary Artery Tunnel (Takeuchi

Procedure)

ascending aorta main pulmonary artery branches of right coronary artery

Figure 18-1. Extensive collaterals have formed between the right and left coronary arteries and there is marked enlargement of the left anterior descending coronary artery.

Anomalous Coronary Artery

main pulmonary artery anomalous left coronary artery ceph

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Lateral Descending Artery

Figure 18-2. The main left coronary artery arises from the left lateral aspect of the main pulmonary artery.

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Figure 18-2. The main left coronary artery arises from the left lateral aspect of the main pulmonary artery.

Anomalous Coronary Artery Origin

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Figure 18-3. After the cardiopulmonary bypass is established and with aortic clamping, cardioplegia, and profound local cardiac cooling, a transverse incision is made in the proximal main pulmonary artery. The orifice of the left coronary artery is immediately above the pulmonary valve. An aortotomy is made to visualize the aortic valve.

caud orifice of left coronary artery pulmonary valve aortotomy

Figure 18-3. After the cardiopulmonary bypass is established and with aortic clamping, cardioplegia, and profound local cardiac cooling, a transverse incision is made in the proximal main pulmonary artery. The orifice of the left coronary artery is immediately above the pulmonary valve. An aortotomy is made to visualize the aortic valve.

punch aortotomy main pulmonary arteriotomy caud

Figure 18-4. Using a circular punch, adjacent openings are made in the proximal ascending aorta and proximal main pulmonary artery. Semilunar valves are visualized to avoid injury to these structures.

punch aortotomy main pulmonary arteriotomy caud

Figure 18-4. Using a circular punch, adjacent openings are made in the proximal ascending aorta and proximal main pulmonary artery. Semilunar valves are visualized to avoid injury to these structures.

Pulmonary Semilunar Valve

window adjacent aortotomy

Figure 18-5. The adjacent circular openings are stitched together to create an aorto-pulmonary (A-P) artery window.

window adjacent aortotomy

Figure 18-5. The adjacent circular openings are stitched together to create an aorto-pulmonary (A-P) artery window.

Pericardial Patch

pericardial patch tunnel ceph caud

Patching Coronary Artery Anomalies

Figure 18-6. A pericardial patch is stitched across the posterior wall of the main pulmonary artery immediately above the valve, creating a tunnel to connect the orifice of the left coronary artery to the iatrogenic A-P artery window. If indicated, the proximal main pulmonary artery is enlarged with a second pericardial patch placed in its anterior wall to avoid obstruction of the pulmonary artery by the posterior pericardial patch tunnel.

Figure 18-6. A pericardial patch is stitched across the posterior wall of the main pulmonary artery immediately above the valve, creating a tunnel to connect the orifice of the left coronary artery to the iatrogenic A-P artery window. If indicated, the proximal main pulmonary artery is enlarged with a second pericardial patch placed in its anterior wall to avoid obstruction of the pulmonary artery by the posterior pericardial patch tunnel.

Patching Coronary Artery Anomalies
Patching Coronary Artery Anomalies
Figure 18-7. In another child whose anomaly was not discovered until age 4 years, the apex of the left ventricle is extensively scarred due to longstanding ischemia.

fibrosis caud

Figure 18-9. The incision in the left ventricular apex is extended to normal-appearing myocardium.

ceph

u caud

Cardiac Fibrosis Will Die

Figure 18-8. After the coronary artery is repaired, the scarred aneurysm is incised. Myocardial fibrosis is seen.

fibrosis fibrosis caud ceph

u caud

Figure 18-8. After the coronary artery is repaired, the scarred aneurysm is incised. Myocardial fibrosis is seen.

Figure 18-9. The incision in the left ventricular apex is extended to normal-appearing myocardium.

Figure 18-10. The aneurysm and scarred myocardium are excluded during closure of the left ventricular apex by interrupted felted mattress sutures followed by an over-and-over running stitch.

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Figure 18-10. The aneurysm and scarred myocardium are excluded during closure of the left ventricular apex by interrupted felted mattress sutures followed by an over-and-over running stitch.

18-1-2. Repair by Direct Re-Implantation

Descending Aorta Pulmonary Artery

ascending aorta main pulmonary artery left anterior descending coronary artery main right coronary artery

Figure 18-11. In another patient, the left anterior descending coronary artery is markedly enlarged as is the main right coronary artery. Collateral vessels have developed from the right coronary across the surface of the right ventricle.

ascending aorta main pulmonary artery left anterior descending coronary artery main right coronary artery

Figure 18-11. In another patient, the left anterior descending coronary artery is markedly enlarged as is the main right coronary artery. Collateral vessels have developed from the right coronary across the surface of the right ventricle.

Figure 18-12. The main pulmonary artery is retracted to display the origin of the main left coronary artery from the pulmonary artery.

main pulmonary artery main left coronary artery

Figure 18-12. The main pulmonary artery is retracted to display the origin of the main left coronary artery from the pulmonary artery.

Picture Left Pulmonary Arter

orifice of left coronary artery pulmonary valve

Figure 18-13. A transverse opening in the proximal main pulmonary artery is made. The orifice of the anomalous left coronary artery is seen adjacent to normal pulmonary valve leaflets.

orifice of left coronary artery pulmonary valve

Figure 18-13. A transverse opening in the proximal main pulmonary artery is made. The orifice of the anomalous left coronary artery is seen adjacent to normal pulmonary valve leaflets.

Coronary Buttons

Figure 18-14. The anomalous left coronary artery is explanted from the main pulmonary artery with a button of surrounding tissue. A higher ascending aortotomy is made in order to identify the aortic valve leaflets.

aortotomy left coronary artery caud

Figure 18-14. The anomalous left coronary artery is explanted from the main pulmonary artery with a button of surrounding tissue. A higher ascending aortotomy is made in order to identify the aortic valve leaflets.

Aortic Valve Leaflets Coronary Artery

Figure 18-15. A pericardial autograft is stitched over the coronary explant site. A site for the implant of the left coronary artery is marked on the aortic root remote from the aortic valve leaflets.

pericardial patch

Figure 18-15. A pericardial autograft is stitched over the coronary explant site. A site for the implant of the left coronary artery is marked on the aortic root remote from the aortic valve leaflets.

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Figure 18-16. An oval opening is made in the medial aortic root avoiding damage to the valve leaflets. The left coronary artery will be shifted to the aortic root for a direct anastomosis.

implant site caud

Figure 18-16. An oval opening is made in the medial aortic root avoiding damage to the valve leaflets. The left coronary artery will be shifted to the aortic root for a direct anastomosis.

left coronary artery caud

Figure 18-17. The left coronary artery to aorta anastomosis is being constructed.

coronary anastomosis caud

Figure 18-17. The left coronary artery to aorta anastomosis is being constructed.

Left Main Pulmonary Artery

main pulmonary artery pericardial patch left coronary artery

Figure 18-18. The coronary to aorta anastomosis is complete. A pericardial patch is stitched over the explant site in the main pulmonary artery.

main pulmonary artery pericardial patch left coronary artery caud

Figure 18-18. The coronary to aorta anastomosis is complete. A pericardial patch is stitched over the explant site in the main pulmonary artery.

18-1-3. Coronary Artery Origin from Right Pulmonary Artery

ascending aorta right pulmonary artery anomalous left coronary artery ceph caud

Figure 18-19. In another baby, the anomalous left coronary artery arises from the caudad surface of the proximal right pulmonary artery.

Anomalous Coronary Artery

anomalous left coronary artery caud

Figure 18-20. After placing the child on bypass, the anomalous coronary vessel is inspected. It can be seen entering the epicardial surface of the heart, behind the ascending aorta.

anomalous left coronary artery caud

Figure 18-20. After placing the child on bypass, the anomalous coronary vessel is inspected. It can be seen entering the epicardial surface of the heart, behind the ascending aorta.

Figure 18-21. The anomalous coronary vessel is explanted from the right pulmonary artery with a button of surrounding tissue.

Coronary Buttons

coronary artery button

Figure 18-21. The anomalous coronary vessel is explanted from the right pulmonary artery with a button of surrounding tissue.

coronary artery button caud

ascending aorta coronary anastomosis

Figure 18-22. The button is anastomosed to the posterior ascending aorta, being careful not to twist the coronary during implantation.

ascending aorta coronary anastomosis caud

Figure 18-22. The button is anastomosed to the posterior ascending aorta, being careful not to twist the coronary during implantation.

Coronary Anastomosis

coronary anastomosis

Figure 18-23. The coronary anastomosis is complete.

Figure 18-23. The coronary anastomosis is complete.

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left coronary artery

Figure 18-24. The coronary implant site is viewed through an anterior opening in the ascending aorta. Probing it confirms patency.

left coronary artery

Figure 18-24. The coronary implant site is viewed through an anterior opening in the ascending aorta. Probing it confirms patency.

right pulmonary artery

Patching Coronary Artery Anomalies

right pulmonary artery pericardial patch caud

Figure 18-25. A pericardial patch is stitched over the explant site in the proximal right pulmonary artery.

pericardial patch caud

Figure 18-25. A pericardial patch is stitched over the explant site in the proximal right pulmonary artery.

Blood Pressure Health

Blood Pressure Health

Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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