Implantation Of Left Coronary Artery Research Articles

Long term results of surgical management of anomalous origin of the left coronary artery from pulmonary artery (ALCAPA) and mitral incompetence

Establishment of two coronary systems is not the end point of challenge in management of anomalous origin of the left coronary artery from pulmonary artery (ALCAPA). To touch or not touch the mitral valve if there is severe mitral regurgitation is still a point of big challenge, another point is the timing and criteria for mechanical support (ECMO). Forty-seven cases with a median age of 1.29 years (28 days to 8 years) underwent ALCAPA repair from January 1985 to July 2012. Seven cases (14.89%) had associated lesions. Ligation of anomalous left coronary artery was performed in four cases (8.51%), Takeuchi’s repair was done for three cases (6.38%) and 40 cases (85.1%) underwent direct aortic implantation of left coronary artery. Preoperative echo showed moderate to severe left ventricular dysfunction with severe mitral regurgitation in 15 cases (31.91%). Mortality rate was 17.02% (eight cases). Four cases (8.51%) needed ECMO support in operating room and two patients needed ECMO support in intensive care unit. Mitral valve repair was adopted in three cases (6.38) and mitral valve replacement was performed in one case (2.12%). Early postoperative echo showed moderate to severe mitral regurge with severe LV dysfunction in eight cases (17.02%) which improved in the first year of follow up. One case (2.12%) returned back with left coronary artery origin stenosis after Takeuchi’s repair. Early diagnosis and repair of ALCAPA improve outcome of surgery. Aortic implantation of left coronary artery is the best technique of ALCAPA repair and can be done easily. In severe mitral regurgitation, it is better not to touch the mitral valve as repair is very technically demanding especially in small babies without expected good results and consumes a lot of cross clamp time with subsequent bad impact on surgical outcome. Mechanical support should be decided according to the degree of LV dysfunction and severity of mitral valve regurgitation.

Renal allograft function not impacted by extensive aortic dissection.

A 63-year-old hypertensive male underwent renal transplantation from his nephew in 2005. In 2007, he was diagnosed with aortic dissection—Stanford type A and B with aortic aneurysm. He had resection of the aortic aneurysm and replacement of the ascending aorta with a hemi-arch graft with left coronary artery implantation. In January 2010, he presented with chest pain, fever and malaise. Blood pressure was 107/73 mmHg and pulse 96/min and the femoral, anterior tibial, posterior tibial and dorsalis pedis artery pulses were palpable bilaterally. Computed tomography (CT) chest scan showed left pleural effusion. Diagnostic pleural tap was bloody and positive for Mycobacterium tuberculosis by polymerase chain reaction. Blood urea was 21 mg/dL, creatinine 1.2 mg/dL, haemoglobin 10.7 g/dL, WBC 11 800 mm3, platelet count 173 000 mm3, total protein 6.3 g/dL, albumin 2.9 mg/dL, electrolytes normal and troponin-I 0.031 ng/mL. Maintenance immunosuppressives used were prednisone 5 mg OD, mycophenolate mofetil 500 mg BD and rapamycin 1 mg OD. Other medications used were isoniazid 300 mg OD, pyrazinamide 750 mg BD, rifampicin 450 mg OD, levofloxacin 500 mg OD and vitamin B6 20 mg OD. CT angiogram showed normal ascending aorta with previous aortic repair. Dissection originated distal to left subclavian artery with dense contrast-filled false lumen and poorly filled true lumen. The dissection had a spiral course extending up to proximal segments of the iliac arteries (Figure 1). The abdominal aortic segment was not dilated. The origin of the artery for the transplant kidney and visceral arteries was the true lumen. The false lumen extended up to the left common iliac artery (Figure 2). This patient, with an unusual presentation of aortic dissection, and probably with a leaking aneurysm due to an infective pathology caused by Mycobacterium tuberculosis, had good allograft function as the transplant renal artery originated from the true lumen of the right common iliac artery maintaining adequate perfusion. He continues to have a good graft function 4 months later. Fig. 1 Dissection extending up to iliac arteries. Fig. 2 Transplant kidney and the vascular supply. Conflict of interest statement. None declared.