Aortic Reimplantation Research Articles

Anomalous Left Coronary Artery, Ventricular Septal Defect, and Double Aortic Arch

Anomalous origin of the left coronary artery from the pulmonary artery generally occurs in isolation. We report an infant diagnosed with double aortic arch and ventricular septal defect who was found to have an anomalous origin of the left coronary artery from the pulmonary artery at surgery. Successful ventricular septal defect repair, division of the arch, and aortic reimplantation of the left coronary artery was performed. This article describes a combination of lesions previously not described, highlights the altered presentation when multiple lesions coexist, discusses the propensity to miss the anomalous coronary, and reviews the literature that demonstrates the consequences of overlooking this defect.

Anomalous coronary artery origin from the pulmonary artery: correlation between surgical timing and left ventricular function recovery

Background This study investigates the correlation between surgical timing and 15-year longitudinal left ventricular and mitral valve function, after repair of anomalous coronary artery origin from the pulmonary artery. Methods Between 1987 and 2002, 31 patients (median age, 7.1 months) underwent repair for anomalous origin of the left (n = 28), right (n = 2), or both (n = 1) coronary arteries from the pulmonary artery. Repair was accomplished by subclavian interposition in 5 patients, intrapulmonary tunnel in 12, and direct aortic reimplantation in 14. Primary mitral valve repair was never associated with coronary revascularization. Total follow-up was 186.4 patient-years (mean, 77.2 months). Results Fifteen-year actuarial survival was 92.9% ± 4.9% for coronary transfer, 40.0% ± 21.9% for subclavian interposition, and 89.9% ± 7.5% for intrapulmonary tunnel ( p = 0.019). Five patients required further intervention for supravalvular pulmonary stenosis (n = 3), baffle leak (n = 1), and mitral valve replacement (n = 1). Coronary transfer allowed best freedom from long-term reoperation (92.3% ± 7.4%). Left ventricular shortening fraction increased from 17.3% ± 6.3% before operation to 34.1% ± 4.6% at last follow-up ( p < 0.01). Regression analysis demonstrated a linear relationship between age at repair and shortening fraction recovery ( r 2 = 0.573, p < 0.01). Patients younger than 6 months of age showed worse preoperative shortening fraction (15.9% ± 5.2%) and best longitudinal shortening fraction recovery (36.4% ± 5.1%; p < 0.001). Major improvement in mitral valve function was observed within 1 year from surgery in 90.4% of survivors. Conclusions Repair of anomalous coronary artery origin from the pulmonary artery in younger symptomatic infants offers the best potential for recovery of left ventricular function, despite a worse initial presentation. Coronary transfer is associated with superior long-term survival and freedom from reoperation. Most patients with patent two-coronary repair will recover normal mitral valve function; therefore, simultaneous mitral valve surgery seems unwarranted.

Anatomic repair of anomalous left coronary artery from the pulmonary artery by aortic reimplantation: early survival, patterns of ventricular recovery and late outcome

Background To determine the early and late outcomes of patients presenting with anomalous left coronary artery from the pulmonary artery who had repair by aortic reimplantation. Methods From January 1952 to July 2000, 67 patients presented with anomalous coronary artery from the pulmonary artery. Forty-seven patients who had repairs performed by aortic reimplantation are the subject of this study. The median age at repair was 7.7 months. Before repair, 10 infants (21%) presented in extremis requiring ventilatory and inotropic support, and 38 infants (80%) presented in heart failure. Autologous pericardial hood coronary arterioplasty was used in 4 patients, and concomitant mitral valve repair was used in 1 patient. Results Hospital survival was 92%. Five children required postoperative extracorporeal membrane oxygenation for a median of 4 days (range, 2 to 8 days). Patients who had extracorporeal membrane oxygenation were significantly more likely to have presented in critical condition (40% vs 3% if no extracorporeal membrane oxygenation; p = 0.006) or with ventricular arrhythmias (67% vs 7%; p = 0.027), to have presented with significantly lower preoperative repair median ejection fraction (10%, n = 5 vs 40%, n = 38; p = 0.01) or to have presented with more severe left ventricular dilatation ( p = 0.03). Within a 15-year or less follow-up (mean, 4.7 years) there were no late deaths. Kaplan-Meier survival was 91% at 5 years, and freedom from reoperation was 93% at 10 years. At late follow-up, echocardiography demonstrated significant improvements in mean ejection fraction (64% ± 9% vs 33% ± 21% preoperatively, p < 0.0001); moderate mitral regurgitation (9% vs 38% preoperatively, p < 0.02); and wall motion abnormalities (15% vs 81% preoperatively, p < 0.002). The ratio of measured left ventricular end-diastolic dimension to the 95th percentile of normal declined from 1.4 ± 0.3 to 1.0 ± 0.1 ( p < 0.0006). Children who had extracorporeal membrane oxygenation had normal ejection fractions and ventricular dimensions at follow-up (n = 3). Repeated measures of mixed linear regression analysis demonstrated that normalization of ejection fraction and left ventricular function occurred within 1 year of repair. Improvements in mitral regurgitation lagged behind normalization of ejection fraction and left ventricular dilatation. Conclusions Anatomic repair of anomalous left coronary artery from the pulmonary artery by aortic reimplantation yields excellent early survival and late functional outcomes even in critically ill infants.

Surgical intervention for anomalous origin of the left coronary artery from the pulmonary artery: The Tokyo experience

Background: Few studies after surgical repair of the anomalous origin of the left coronary artery have reported the importance of the mitral annuloplasty or the long-term results. Methods: Between January 1982 and March 2000, 29 patients with anomalous origin underwent surgical intervention at our institution (direct aortic reimplantation in 19 and Takeuchi procedure in 10). Age at the time of operation ranged from 2 months to 24 years (median, 29.3 months), and 9 patients were infants. Twenty-four patients had varying degrees of mitral incompetence. Simultaneous mitral annuloplasty at the anterolateral commissure was performed in all 24 patients with incompetence. Results: There were 2 hospital deaths among the infants, and no late deaths. Mean follow-up was 100 ± 57 months, and the actuarial survival was 93.1% at 10 years (70% confidence limits, 87-99). Cardiothoracic ratio at discharge was not decreasing significantly (P =.35); however, this value 5 years after the operation showed the significant decrease (P =.003) versus preoperative value. Preoperative mitral incompetence decreased in all but one of the operative survivors with mitral annuloplasty at the last follow-up. The left ventricular fractional shortening z-score was not normalized at discharge but was normalized in the late period. Conclusion: These data demonstrate that impaired left ventricular function normalized in the long term (even if it was below normal immediately after operation) after 2-coronary repair. We recommend that the simultaneous mitral annuloplasty should be performed at the time of operation for patients who have mitral incompetence with anomalous origin of the left coronary artery. (J Thorac Cardiovasc Surg 2001;121:792-7)

Infant partial left ventriculectomy for failure to wean from cardiopulmonary bypass

Following aortic reimplantation of anomalous left coronary artery from the pulmonary artery in a 6-month-old infant, the heart failed to wean after prolonged supportive cardiopulmonary bypass and maximal inotropic support. We performed partial left ventriculectomy (Batista procedure) that halved left atrial pressure and enabled discontinuation of bypass. Postoperative recovery was then uneventful.

Anomalous origin of the left coronary artery from the pulmonary trunk. Clinical features and midterm results after surgical treatment.

To report the authors' experience with the anomalous origin of the left coronary artery (AOLCA) from the pulmonary trunk, emphasizing preoperative data, surgical aspects and midterm results of the follow-up. Retrospective analysis of 11 patients operated upon at the Royal Brompton Hospital from October, 84 to April, 97. Nine infants had heart failure (HF) and two other children presented with dyspnea and chest pain. All had ECG changes. The echocardio-gram identified the anomalous origin of the coronary artery in 7 (64%) patients and hemodynamic studies were performed in 7 patients. All infants were operated upon between the 2nd and 10th month of life. Six patients were treated with aortic reimplantation of the left coronary artery, whereas five were operated upon according to the Takeuchi technique. All patients are alive, with clear improvement of the ECG changes and ventricular function, as evaluated by echocardiography. Two patients operated upon according to the Takeuchi technique required additional surgery due to severe supravalvular pulmonary stenosis. AOLCA is a rare disease. Most patients show early signs of severe HF associated with ECG findings. Surgical therapy must be instituted early in the disease, preferentially through aortic implantation of the anomalous coronary artery, with a high possibility of success. Shortly after surgery, clinical and ECG improvement, as well as normalization of left ventricular function, should be expected.

Individual anatomy demands various techniques in correction of an anomalous origin of the left coronary artery in the pulmonary artery.

Anomalous origin of the left coronary artery (ALCA) from the pulmonary artery is a rare cardiac anomaly. It can result in decreased myocardial perfusion and impaired left-ventricular function, which can lead to congestive heart failure or even myocardial infarction. Reconstructive surgery of the left coronary artery is the desirable measure in the management of this anomaly. Since July 1992, five patients with ALCA from the pulmonary artery were treated surgically. Age at operation ranged from 3 months to 11 years. Three patients had congestive heart failure and one was in cardiogenic shock. Operative techniques included "tunnel type" surgery in three cases and aortic reimplantation in two. Two operative variations performed successfully in this series are described. There were no postoperative deaths. At the latest follow-up (mean 14 months), all anastomoses were patent and showed antegrade flow. For those patients with ALCA from the pulmonary artery, direct reimplantation of the ALCA to the aorta is the most physiologically appropriate reconstructive solution, and offers good early and late results. Intrapulmonary tunnel from aortopulmonary window to coronary artery is recommended for children in whom aortic reimplantation is not anatomically feasible.

Improvement in left ventricular dysfunction after aortic reimplantation in 11 consecutive paediatric patients with anomalous origin of the left coronary artery from the pulmonary artery

To study the potential for recovery of left ventricular function in patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) after aortic reimplantation, serial two-dimensional echocardiographic examinations were performed before and up to 9 months after operation in 11 consecutive paediatric patients (group 1: six infants; group 2: five children above the age of 1 year). End-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), ejection fraction (EF), myocardial volume (MV), ratio of myocardial volume/end-diastolic volume (MVI), and regional wall motion of the left ventricle (LV) were studied. Pre-operatively, mean LVEDV was 339% of normal in group 1 and 289% in group 2 (P < 0.001); mean LVMV was about twice the normal value in both groups (P < 0.001); LVMVI was 0.79 +/- 0.23 in group 1 and 0.83 +/- 0.3 in group 2; LVEF was 28 +/- 10% in group 1 and 46 +/- 18% in group 2; regional wall motion was normal in two group 2 patients, the other showed uniform reduction in segmental shortening fraction. Postoperatively, mean LVEDV tended to become normal after 2 weeks in group 1 and after 3 months in group 2. In both groups mean LVEF reached the normal range after 3 months; LVMV as well as LVMVI normalized after 9 months. Three months after the operation, all infants had a nearly normal pattern of regional wall motion, while in three group 2 children a residual reduced shortening fraction could be observed in anterior or lateral segments.(ABSTRACT TRUNCATED AT 250 WORDS)

Anomalous origin of the left coronary artery from the pulmonary artery: Early results with direct aortic reimplantation

Between January 1991 and June 1993, eleven children with anomalous origin of the left coronary artery from the pulmonary artery underwent direct aortic reimplantation of the left coronary artery at the German Heart Institute Berlin. The patients’ ages ranged from 2.5 months to 10.5 years; six were infants. Three infants were intubated and their lungs ventilated before the operation, and one was resuscitated 2 days before the operation. The electrocardiograms of eight patients indicated deep Q waves. All but three of these patients had insufficient collaterals between the right and left coronary arteries. The entire group exhibited reduced left ventricular ejection fraction (minimum 15%) including mitral valve incompetence, which was moderate in six patients and severe in three. All six infants underwent emergency operations, and the remaining children, who were older, underwent elective operations involving moderate hypothermic perfusion and cold crystalloid cardioplegia. Aortic crossclamping time ranged from 22 to 79 minutes (mean 54 minutes). A two–coronary artery system was established in all patients by direct reimplantation of the anomalous left coronary artery into the ascending aorta. Three patients who also exhibited severe mitral valve incompetence underwent modified Kay mitral valve annuloplasty. A delayed sternal closure procedure (closure performed 1 to 10 days after the operation) was used on eight patients. A 10-month-old patient was successfully treated after the operation with a centrifugal left heart assist device and a 9-year-old patient received extracorporeal membrane oxygenation because of severe heart failure. No postoperative deaths occurred. Left ventricular end-diastolic volume decreased dramatically after the operation and returned to near normal values 1 to 9 months postoperatively. At the same time, the preoperatively depressed left ventricular ejection fraction returned to normal and mitral valve incompetence decreased or vanished in eight patients. Color Doppler echocardiograms (eleven patients) and coronary angiograms (three patients) indicated that the reimplanted left coronary artery was patent in all eleven patients during the follow-up period. Reimplantation of the left coronary artery into the ascending aorta is an effective method of establishing a two–coronary artery system in children with anomalous origin of the left coronary artery from the pulmonary artery. Mitral valve annuloplasty is recommended for patients who also have severe mitral valve incompetence. Prolonged assisted circulation must be used in cases of severe postoperative heart failure. (J T HORAC CARDIOVASC SURG 1994;108:354-62)

Anomalous left coronary artery from the pulmonary artery: Results of isolated aortic reimplantation

Thirty-one consecutive children with anomalous left coronary artery underwent direct aortic reimplantation of the anomalous artery without an associated procedure. There were five deaths (16%; 70% confidence limits, 9% to 26%), three in the hospital and two early (within 3 months). The severity of preoperative left ventricular dysfunction was the only incremental risk factor for mortality: 31% mortality rate among patients with left ventricular shortening fraction of less than 0.20 versus 0% among patients with a left ventricular shortening fraction of 0.20 or more ( p = 0.03). There were no late deaths up to 6 years, a survival rate of 84% ± 7%. Late results were studied in 23 survivors having a follow-up of longer than 12 months. Ninety-six percent were free of symptoms; left ventricular function recovered to normal in all patients; moderate to severe mitral regurgitation decreased to minimal or no regurgitation in most patients ( 5 / 7 ); and the reimplanted anomalous left coronary artery was patent in each patient. Based on this study, we reached five conclusions. (1) Direct aortic reimplantation is technically feasible in most patients with anomalous left coronary artery and yields a high rate of late patency. (2) Left ventricular resection is unnecessary. (3) The mitral valve should not be interfered with at the initial operation, but mitral regurgitation may persist in a few patients and necessitate later operation. (4) In patients with moderate left ventricular dysfunction, the operative risk is low and early operation indicated. (5) In patients with severe left ventricular dysfunction, the operative risk is high; heart transplantation may be suggested, but our current approach favors an immediate corrective procedure.

Isolation of the right subclavian artery

Loss of continuity between subclavian artery and aorta with persistent connection to the homolateral pulmonary artery through a ductus arteriosus is an uncommon malformation, involving generally the left subclavian artery and associated with intracardiac or aortic arch anomalies. We report a case of right subclavian isolation with a left-sided aortic arch, presenting as a single anomaly and surgically corrected by aortic reimplantation.

Bronchial revascularization in double-lung transplantation: A series of 8 patients

Donor airway ischemia is the main cause for defective tracheal or bronchial healing after double-lung transplantation. Anatomical studiesa and bronchial arteriograms have shown that the right intercostal bronchial artery is constant (95% of instances) and provides an important blood supply to the distal trachea, the carina, and the right bronchial tree as well as to the left side through a subcarinal and periadventitial anastomostic network. To maintain this important bilateral branchial circulation, it is of capital importance not to mobilize the arteries individually and to avoid large dissections around the carina. Both bronchi can thus be revascularized by indirect aortic reimplantation using a bypass graft to a single aortic patch that includes the origin of the right intercostal bronchial artery. Furthermore, the origin of other vessels (a common trunk and left arteries) can be found within a short distance of the right intercostal bronchial artery and possibly be contained within the same aortic patch. From a series of 56 lung transplantations, 8 patients underwent restoration of the bronchial vascularization using a recipient saphenous vein graft between the donor bronchial arteries and the anterior aspect of the recipient's ascending aorta. A lower tracheal anastomosis was performed. Bronchial arterial blood supply was evaluated both by endoscopy and by arteriography at about the 15th postoperative day. The bronchial circulation was visualized at this time in five of seven arteriographies, and this was associated with excellent tracheal healing in all 8 patients.

Anomalous origin of the left coronary artery from the pulmonary artery: repair by aortic reimplantation

From 1980 to 1990, 12 patients (mean age 2.5 years, range 5 months to 9 years) with anomalous origin of the left coronary artery from the pulmonary artery were treated surgically. Five infants were operated upon in the first year of life because of persistent symptoms of congestive heart failure. In all cases, a two-coronary system was constructed by direct aortic reimplantation of the anomalous vessel with no deaths early or late over a follow-up period of up to 10 years. The technique of reimplantation was facilitated by transection of the main pulmonary artery. One patient with severe mitral regurgitation underwent, in addition, a mitral annuloplasty. A pulmonary valvotomy was performed in another patient with associated pulmonary stenosis. Three patients are receiving medication. The reimplanted anomalous left coronary artery was patent in each reevaluated patient (10/12). Left ventricular function improved considerably in all cases. Patients with symptoms should undergo repair soon after diagnosis. Direct aortic reimplantation should be technically feasible in even the smallest infant. Operative mortality is related to preoperative conditions and severity of ischemic damage of the myocardium.

Aortic Reimplantation of the Superior Mesenteric Artery for Atherosclerotic Lesions of the Visceral Arteries: Sixty Cases

We report the results of a series of patients who had isolated or associated reimplantation of the superior mesenteric artery directly into the infrarenal aorta. Between 1967 and 1988, a total of 91 revascularizations for atheromatous lesions of the visceral arteries were performed in 89 patients. The superior mesenteric artery was reconstructed in 87 instances, 60 of which were direct or indirect reimplantations into the juxtarenal aorta. The procedure was isolated in 51 cases, and associated with the revascularization of another visceral artery in nine cases. These 60 patients were divided into three groups: Group A--seven patients undergoing emergency operation for acute intestinal ischemia; Group B--30 patients operated upon for chronic intestinal angina; and Group C--22 asymptomatic patients who underwent prophylactic revascularization. Two patients died in the immediate postoperative period (3.5%). Although most of the 29 late deaths were due to vascular disorders, only one was secondary to intestinal infarction. Twenty-one patients followed had good functional results; six patients had relapse of abdominal pain. Three of these underwent repeat revascularization of the superior mesenteric artery 12 days, 18 months, and 22 months, postoperatively. Follow-up ranged from six months to 18 years. Two patients were lost to follow-up. Overall actuarial survival at five years was 69.60 +/- 15%. In our experience, isolated reimplantation of the superior mesenteric artery on the anterior aspect of the infrarenal aorta is a simple and reliable technique which affords good long-term results.

Evolution of the Management of Anomalous Left Coronary Artery: A New Surgical Approach

Twelve patients with anomalous left coronary artery (LCA) from the pulmonary artery were treated surgically. Mean age was 13 months and mean weight, 7.7 kg. One of the following techniques was used in 8 patients: suture obliteration of the coronary orifice, ligation of the anomalous LCA and grafting of the internal mammary artery to the distal LCA, aortic reimplantation of the anomalous LCA, creation of an aortopulmonary window, and direct anastomosis to the right subclavian artery. In 4 patients, a new technique to establish a two-coronary artery system involved tube extension of the anomalous LCA with pulmonary artery wall and then anastomosis to the right subclavian artery using cardiopulmonary by-pass without aortic cross-clamping. There were two hospital deaths (17%) and one late death. The condition of the 9 long-term survivors was improved at late follow-up. Postoperative assessment showed smaller Q wave on the electrocardiogram, reduced cardiac size, and good left ventricular function. All patients in whom the repair was done using the new technique were free from postoperative cardiac complications, had shortened hospital stays, and were alive with a patent two-coronary artery system at late follow-up. We believe this approach is a safer method for establishing a two-coronary artery system in infants and small children with an anomalous LCA arising from the pulmonary artery.

Anomalous left coronary artery arising from the pulmonary artery: A series of 27 infants undergoing operation in the first years of life

Between 1977 and 1987, 27 infants (aged 3 to 54 months) underwent surgical treatment for correction of an anomalous left coronary artery arising from the pulmonary artery (ALCAPA). All had a direct aortic reimplantation. The overall operative mortality was 18.5% (five deaths). The follow-up period was from 2 months to 8 years (mean, 38 months). No late deaths occurred. During the 10 years, modifications of the surgical procedure and myocardial preservation were introduced (is, complete resection of the pulmonary trunk made anastomosis easier; since 1982, cardioplegia in both coronary systems has been used, and left atrial-to-aortic assistance was introduced). The latter was carried out when surgical repair was associated with acute cardiac failure and a high left atrial filling pressure at the end of cardiopulmonary bypass. In view of the results during the latter part of this series, it is felt that surgery should not be restricted in younger patients (<12 months). If medical treatment is unsuccessful, surgery aims to avoid irreversible left ventricular dysfunction and development of severe endocardial fibroelastosis.

先天性心疾患 Ａｏｒｔｉｃ ｉｍｐｌａｎｔａｔｉｏｎを施行したＢＷＧ症候群の検討 僧帽弁形成術の同時施行例を含めて

先天性心疾患 Ａｏｒｔｉｃ ｉｍｐｌａｎｔａｔｉｏｎを施行したＢＷＧ症候群の検討 僧帽弁形成術の同時施行例を含めて

Anomalous left coronary artery from the pulmonary artery in infants: Which operation? When?

The surgical management of anomalous left coronary artery from the pulmonary artery in infants and small children remains controversial, because the ideal surgical procedure and the optimal time for operation are yet to be determined. From 1977 to 1985, 22 patients less than 4 years of age (mean age 18.2 months) underwent direct aortic reimplantation of the anomalous left coronary artery. There were five operative deaths (23%, confidence limits 13%-36%). The determinant risk factor of early mortality was the severity of preoperative left ventricular dysfunction (p = 0.05), not age at operation (p = 0.64) or preoperative clinical status (p = 0.36). There were not late deaths (mean follow-up 38 months). All survivors but one were symptom free. The reimplanted anomalous left coronary artery was patent in each reevaluated case (9/17). Left ventricular function improved significantly in all survivors. Moderate to severe preoperative mitral incompetence lessened in all patients but one, without mitral valve repair. When technically feasible, direct aortic reimplantation of the anomalous left coronary artery is an attractive procedure because it offers a high rate of patency and avoids the potential drawbacks of procedures involving autogenous venous or arterial tissue. Optimal intraoperative myocardial preservation and institution of temporary left ventricular assistance at the end of the operation may decrease the operative risk. Left ventricular function nearly always recovers after successful revascularization, and resection of left ventricular myocardium is rarely indicated, if ever. Mitral incompetence almost always lessens, and the mitral valve should not be repaired at initial operation; however, residual mitral incompetence may necessitate reoperation in a few cases. In infants with moderate left ventricular damage (usually asymptomatic with medical therapy), surgical treatment should be delayed until 18 to 24 months of age so that it can be performed with a low operative risk. Infants with severely impaired left ventricular function and persistent congestive heart failure should probably undergo operation as soon as the diagnosis has been made.

Technical considerations in the surgical management of renovascular hypertension in children

Fifteen children with severe renovascular hypertension have been treated at the Mott Children's Hospital in the University of Michigan Medical Center between July 1974 and December 1980. The average age was 10.4 yr. Stenoses were of both intimal and medial fibrodysplastic types. Four patients had significant bilateral disease. Three patients had coexistent renal artery aneurysmal disease, and three others had midabdominal aortic coarctations. The most important diagnostic studies included assays of plasma renin activity and selective renal arteriography. Primary operations (11 unilateral, 4 bilateral) included 14 aortorenal by passes (13 vein grafts, 1 hypogastric artery graft), 1 vein patch angioplasty, 1 primary anastomosis, 1 aortic reimplantation, 1 partial nephrectomy (segmentectomy), and 1 arterial dilation. Four secondary operations were performed. Critical factors in pediatric reconstructive renovascular surgery include: (1) exposure through a generous transverse anterior abdominal incision, (2) systemic anticoagulation with sodium heparin, (3) end-to-end graft-to-renal artery anastomoses, (4) generous spatulation of vessels and grafts at anastomoses, (5) use of microvascular clamps, (6) use of silicon lubricants on dilators, and (7) extreme gentleness in handling all tissues. Eleven children experienced complete remission of hypertension. Four children were improved. Excellent results were attributable to carefully planned and executed reconstructive procedures.