Surgical Reimplantation Research Articles

Cardiac Arrest with “Pseudo-Brugada” ECG Pattern in the Setting of a Coronary Artery Anomaly

A 36-year-old Hispanic man with no prior cardiac history presented with chest pain and then ventricular fibrillation requiring defibrillation after a physical altercation. His ECG on presentation to the emergency room was suggestive of Brugada syndrome, which later normalized. Cardiac catheterization revealed anomalous origin of right coronary artery from the left coronary cusp (coursing between the pulmonary artery and the aorta) for which he underwent surgical reimplantation, and subsequent pharmacological challenge test did not provoke reappearance of a Brugada ECG pattern. A review of literature on Brugada syndrome and anomalous origin of the coronary arteries is presented.

Long-Term Outcome of Surgically Repaired Unilateral Anomalous Pulmonary Artery Origin

The long-term outcome after surgical reimplantation of a unilateral congenitally anomalous pulmonary artery (UCAPA) origin is inadequately described. We performed a single-center retrospective review of patients with pulmonary artery (PA) sling or anomalous origin of 1 PA from the ascending aorta who underwent surgical repair from 1980 to 2006. Baseline data were available for 20 patients with PA sling and 29 patients with anomalous origin of 1 PA from the ascending aorta. Follow-up data for 38 patients, representing 190 cumulative patient-years, were available. Of 28 (74%) patients who developed pulmonary artery stenosis (PAS), 17 (45%) patients underwent a first intervention for PAS, and 9 (24%) patients underwent a second intervention. Median time from surgical repair to diagnosis of PAS was 0.4 years (95% confidence interval [CI] 0, 0.9). Median time from diagnosis of PAS to first intervention was 2.7 years (95% CI 0.07, 5.4). In the 29 patients initially repaired at our center, no first intervention occurred later than 2.8 postoperative years. Median time from first to second intervention was 2 years (95% CI 0, 4.8). Percutaneous intervention for postoperative PAS resulted in acute hemodynamic and anatomic improvement with modest risk profile. On multivariate analysis, recent surgical repair (after 1993) was a risk factor for PAS (p = 0.03, hazard ratio [HR] 1.9), and operative first intervention (vs. percutaneous) was a risk factor for second intervention (p = 0.05, HR 11.2). After reimplantation of a UCAPA origin, PAS is frequent and occurs early postoperatively. Close follow-up after repair is necessary.

Reimplantation of anomalous right coronary artery from left main coronary artery: a surgical option

Anomalous right coronary artery (ARCA) from left sinus of Valsalva could present in several forms either being intramural or extramural, and most occurring with separate ostium from left coronary system. ARCA originating from the left main coronary artery (LMCA) is very rare and treatments proposed for this type of anomaly are pulmonary artery translocation or coronary artery bypass grafting (CABG) of the right coronary system. There has not been any report in the literature of successful reimplantation of ARCA from LMCA, to the best of our knowledge, as another surgical option for this anomaly. We are reporting a case of successful surgical reimplantation of an ARCA from LMCA.

Effectiveness and Cost Analyses of Different Methods of Antirefluxiv Operations in Vur 3

Purpose In order to the cure rates and cost-effectiveness of different antirefluxiv surgeries in children with VUR (vesicorenal reflux) Grade 3. Material and Methods We reviewed retrospectively the medical records of 401 patients (514 renal units (RU) who got admitted to our institution for treatment of primary VUR 3 between 1993 and 2009. Three different therapeutic options (Group 1: intravesical; Group 2: extravesical; Group 3: endoscopic) were offered to parents. The average costs of different surgeries and re-interventions. were calculated according to the hospital stay with operation theatre (OR), ultrasound (US) and standard laboratory examinations (LA). Results Intravesical re-implantation (group 1) were performed in 98 children (n=152 RU). There was no re- intervention necessary. In group 2 132 children (n= 136 RU) underwent an extravesical surgery. In 4% a second intervention was necessary and of these six patients treated, one subsequently required surgery.In group 3 171 patients (n= 226 RU) underwent endoscopic injection (Deflux ® ). After the first injection 157 RU (69%) were cured, 9 RU required a second, 2 RU a third injection and 58 RU required surgical reimplantation. Mean cost/patient in group 1, 2 and 3 were 16,293€, 10,365€ and 5,659 €, respectively. Mean total (surgery + redo surgery) cost/patient in group 1, 2 and 3 after one year were 16.471€, 19.633 € and 17.925€, respectively. Conclusions For each child with VUR grade 3 open ureteral reimplantation (intra- or extravesical) conveys a higher initial success rate than endoscopic correction. The long-term cost-effectiveness is higher in group 1 than in group 3, where initially surgery costs less.

Reimplantación coclear en el mismo oído: hallazgos, peculiaridades de la técnica quirúrgica y complicaciones

IntroductionCochlear implants are, for many reasons, expirable electronic devices and occasionally may have to be replaced. The surgical cochlear reimplantation technique is not substantially different from the initial implantation but does have some peculiarities. These peculiarities are analyzed in this paper not only from the point of view of surgical technique but also with respect to the complications involved and the functional auditive outcome obtained. ObjectivesAn accurate description of the surgical findings, peculiarities of the surgical technique and complications found during the process of cochlear reimplantation. An evaluation of the audiometric functional outcome of the reimplantation. Material and methodA descriptive retrospective review of 34 reimplantations in the same ear, carried out at our department during the period between 1993 and 2008, in 27 patients in a tertiary hospital by the same team of seniors surgeons. The cochlear implants replaced were 2 Ineraid ® (Smith & Nephew Richards, TN), 23 Laura ® (Philips Hearing Implants), 8 nucleus 24K ® (Cochlear Corp., Englewood, CO), 1 Clarion r (Advanced Bionics, Sylmar, CA). ResultsThe rate of reimplantation in the same ear was 18.5% per patient. The most frequent reason in our series was internal failure of the device (14 cases). Other causes were substitution for a technological update (7 cases), misplacement of electrodes (8 cases), necrosis/infection of the skin flap with exposure of the implant (3 cases) and external injuries (2 cases). The most important surgical findings were partial mastoidectomy reossification, absence of ossification in the posterior tympanostomy and the permeability of the basal turn of the cochlea when it housed the electrodes. A complete reintroduction of the electrodes was achieved in 25 patients and a partial one in 2 patients. The rate of complications generated was similar in reimplantation and in virgin ear implantation, except for when the original implant was an Ineraid device. ConclusionsThe surgical technique of reimplantation and multireimplantation technique has characteristic peculiarities at each step, but in general terms, its complexity is similar to that of implantation in virgin ears and the rate of complications is also similar. The introduction of the new electrodes is simple and complete in the immense majority of cases, given that the cochlea remains permeable, as long as it houses the electrodes; otherwise it tends to become reossified. The functional auditory outcome of the new implant is in relation with its capacities. If they are equal to those of the initial implant then the auditory outcome will be similar and if they are better, then so will the outcome be, with the exception of ears with long periods of auditive deprivation.

Cochlear reimplantation in the same ear: Findings, peculiarities of the surgical technique and complications

IntroductionCochlear implants are, for many reasons, expirable electronic devices and may occasionally have to be replaced. The surgical cochlear reimplantation technique is not substantially different from the initial implantation but does have some peculiarities. These distinctive features are analysed in this paper not only from the point of view of surgical technique but also with respect to the complications involved and the functional auditory outcome obtained. ObjectivesAn accurate description of the surgical findings, peculiarities of the surgical technique and complications found during the process of cochlear reimplantation. An evaluation of the audiometric functional outcome of the reimplantation. Materials and methodA descriptive retrospective review of 34 reimplantations in the same ear, carried out at our department during the period between 1993 and 2008, in 27 patients in a tertiary hospital by the same team of senior surgeons. The cochlear implants replaced were 2 Ineraid® (Smith & Nephew Richards, TN), 23 Laura® (Philips Hearing Implants), 8 nucleus 24K® (Cochlear Corp., Englewood, CO) and 1 Clarion® (Advanced Bionics, Sylmar, CA). ResultsThe rate of reimplantation in the same ear was 18.5% per patient. The most frequent reason in our series was internal failure of the device (14 cases). Other causes were substitution for a technological update (7 cases), misplacement of electrodes (8 cases), necrosis/infection of the skin flap with exposure of the implant (3 cases) and external injuries (2 cases). The most important surgical findings were partial mastoidectomy reossification, absence of ossification in the posterior tympanostomy and the permeability of the basal turn of the cochlea when it housed the electrodes. Complete reintroduction of the electrodes was achieved in 25 patients and partial reintroduction in 2 patients. The rate of complications generated was similar in reimplantation and in virgin ear implantation, except for when the original implant was an Ineraid® device. ConclusionsThe surgical technique for reimplantation and multireimplantation has characteristic peculiarities at each step. However, in general terms, its complexity is similar to that of implantation in virgin ears and the rate of complications is also similar. The introduction of the new electrodes is simple and complete in the immense majority of cases, given that the cochlea remains permeable, as long as it houses the electrodes; otherwise it tends to become reossified. The functional auditory outcome of the new implant is in relation with its capacities. If these are equal to those of the initial implant, then the auditory outcome will be similar; if they are better, then so will the outcome be. One exception is ears with long periods of auditory deprivation.

Management of Benign Ureteral Strictures in the Endoscopic Era

During the past decade, endoscopic management has emerged as the first-line treatment of benign ureteral strictures. We reviewed our experience with the management of benign ureteral strictures to determine the success rate of endoscopic surgery in a contemporary series and assessed the viability of surgical reimplantation in the modern era. We identified 75 patients with a diagnosis of ureteral stricture between 2000 and 2005 via electronic medical records search and excluded those with completely obliterated, external compressive, malignant, or ureteroenteric strictures, ureteropelvic junction obstruction, and those with follow-up less than 2 months. Thirty-four patients who were treated endoscopically (balloon dilation and/or holmium laser endoureterotomy) were identified. Mean stricture length in each patient was 1.6 +/- 1 cm (range 0.5-4 cm), and the mean number of procedures per patient was 1.7 +/- 0.8. Endoscopic success was achieved in 29 (85%), while 5 (15%) patients experienced endoscopic management failure and ultimately needed ureteral reimplantation. When comparing the endoscopically treated and reimplant groups, there was no significant difference in mean stricture length (1.38 +/- 1.13 vs 2 +/- 1.1 cm, P = 0.14), yet mean number of procedures performed (1.41 +/- 0.85 vs 3.6 +/- 1.5; P = 0.002) reached statistical significance. There were no clinical or radiographic signs of obstruction in 100% of patients who received endoscopic therapy only and 100% of patients who needed open surgical management at a mean follow-up of 25.2 +/- 19.3 and 7.7 +/- 3.2 months, respectively. Endoscopic surgery is clearly a successful primary treatment modality in the management of benign ureteral strictures with minimal morbidity. In the modern era of endoscopic surgery, however, ureteral reimplantation remains a viable option in treating the small subset of patients with benign ureteral strictures for whom endoscopic management fails.

Autologous Adipocyte Graft in Endoscopic Treatment of Vesico-Renal Reflux in Children: A Preliminary Study

No bulking agent is ideal for endoscopically treating vesico-renal reflux in children. Many teams have tried to find a safe and efficient material, ideally an autologous material. We describe here a protocol for the use of autologous viable fat in the treatment of primary vesico-renal reflux in children aged from 3 to 15 years. Fat harvesting was done from the medial side of the thigh by manual aspiration. Samples were centrifuged to purify the graft from blood and lipid. Lastly fat was injected beneath the pathologic ureter by a conventional endoscopic technique. A voiding cystourethrography (VCUG) closed the procedure. Follow-up included renal ultrasonography the day after surgery, and one and three months later. A VCUG was performed systematically at three months and, in cases of acute pyelonephritis, during the survey.Sixty-four children with 94 refluxing units were treated by autologous fat injection with a follow-up from 6 to 40 months. At the end of the procedure, we systematically obtained a very good increase in height of the pathologic meatus and VCUG was normal in all cases. None presented with an obstruction during the follow-up period. Two children presented with an acute pyelonephritis before the third month. At three months, VCUG was not realized in 14 cases (22%) because the parents refused the procedure. One of those children presented with an acute pyelonephritis five months after endoscopic treatment. VCUG was normal for 17 of 50 children (34%), and showed a real improvement for 19 other children (38%). Three children had a surgical reimplantation because of the persistence of an unchanged high-grade vesico-renal reflux; histological examination found viable adipocytes on sections of the distal pathologic ureter. Clinically, 11 children (17%) presented with an acute pyelonephritis after treatment at a mean follow-up time of 10 months.These preliminary findings led us to modify the technique in order to improve our results. Our first concern is feasibility and safety of this technique, regardless of the use of other synthetic bulking agents the innocuousness of which is uncertain.

Endoscopic Treatment with Deflux® for Refluxing Duplex Systems

The aim of this study was to review the experience of a single institution with the endoscopic Deflux (Q-Med Scandinavia, Uppsala, Sweden) procedure and assess its effectiveness in the treatment of refluxing duplex systems. A retrospective review of all patients that underwent endoscopic Deflux treatment for vesicoureteral reflux (VUR) in duplex systems between June 2003 and July 2007 was performed. Data collection included: age, gender, side of refluxing ureter, preoperative radiologic grade of VUR on a voiding cystourethrogram (VCUG), presence of VUR on a radionuclide VCUG 3 months postprocedure, volume of Deflux injected, number of Deflux injections performed per patient, and number of patients that underwent reimplantation surgery. Sixteen patients with duplex systems, two being bilateral, for a total of 18 duplex ureteral systems, underwent the Deflux procedure. Grades of reflux were as follows: grade II: 4 ureters; grade III: 8 ureters; grade IV: 4 ureters; and grade V: 2 ureters. Deflux injection volume ranged from 0.28 to 1.5 cc (mean, 0.84). Fourteen ureteral systems required one injection, three required two injections, and one required three injections. The overall success rate of the procedure after a maximum of three injections was 94%. One patient with preoperative unilateral grade V reflux had persistent high-grade reflux after two injections and opted to proceed with surgical reimplantation. The mean follow-up was 24 months (mean, 6-48). We conclude that the Deflux procedure is a safe, effective minimally invasive treatment alternative for patients with refluxing duplex systems.

Ureteral stents and retrograde studies: a primer for the gynecologist

To review basic techniques and recent advances in endourology for the practicing gynecologist. New ureteral stent designs are available to improve comfort and reduce some of the complications of indwelling ureteral stents. A large prospective study failed to show a significant benefit of prophylactic ureteral catheterization prior to major gynecological surgery to reduce the risk of ureteral injury. There is a shift in the management of some iatrogenic ureteric injuries from surgical reimplantation to more conservative endoscopic management by interventional radiologists and urologists. The indications, techniques, and complications of advanced endourology techniques including the use of indwelling ureteral stents and retrograde pyelography are reviewed. Indwelling ureteral stents are used to establish and maintain patency of the ureters for many indications, including specific gynecological indications such as iatrogenic ureteral injury, ureteric fistula, extrinsic compression from tumor, and prophylactically to prevent ureteric injury. Retrograde pyelography is a very useful technique to image the renal collecting system with particular utility in patients with contraindications to intravenous contrast and to investigate suspected iatrogenic ureteral injuries.

Reimplantation of an Inverted Maxillary Premolar: Case Report of a Multidiscplinary Treatment Approach

Inversion of premolars is an extremely rare condition, which usually requires extraction. This case report describes the inversion of an impacted maxillary second premolar in an 11-year-old male, and the multidisciplinary treatment approach for bringing the tooth into a normal position within the arch. In order to provide sufficient space for surgical reimplantation of the tooth, the mesially-drifted neighbouring maxillary first molar was first endodontically treated, followed by orthodontic distalization of the tooth. The inverted tooth was removed surgically and reimplanted without the use of splints for stabilization. After a 12-month follow-up period, the tooth maintained its vitality without any root resorption. Reimplantation of impacted inverted premolars can be a viable treatment alternative to extraction.

Unusual case of recurrent renal artery stenosis: lessons to learn

Department of Interventional Cardiology and Vascular Medicine, Massachusetts General Hospital, Boston, Massachusetts, USACASE PRESENTATIONA 39 year old male chef with previous right aorto-renalartery surgical reimplantation at age 8 for reportedcongenital renal artery stenosis presented to an outsidehospital with gastroenteritis including symptoms ofabdominal pain, nausea, diarrhea and vomiting. Pastmedical history apart from previous surgery for congenitalrenal artery stenosis was unremarkable. He was an activetobacco user of one pack per day for the previous20 years. There was no family history of prematurecoronary disease. Examination revealed a blood pressureof 210/100 mmHg, heart rate of 88 beats per minute andrespiratory rate of 16 per minute. Blood pressurerecordings were equal in both upper limbs. The radial,brachial, femoral and distal lower limb pulses weresymmetrical and of normal volume. No bruits wereaudible over the carotid, subclavian or femoral arteries.The remainders of the cardiac, respiratory and abdominalexaminations were unremarkable apart from a surgicalscar as a result of previous renal artery surgery.Medications included nifedipine 90mg and enalapril20mg had been started one month earlier for worseninghypertension. Laboratory profile on admission is shown in(Table 1).

Anomalous Left Coronary Artery from the Pulmonary Artery in a Preterm Infant: Presentation after Ligation of Ductus Arteriosus

Surgical or medical closure of a patent ductus arteriosus (PDA) is a very common practice in premature infants in the neonatal intensive care unit, but often the coronary arteries are not delineated prior to closure. In this report, a 32-week gestational age premature infant who underwent surgical ligation of a PDA developed new-onset left ventricular systolic dysfunction. A repeat echocardiogram noted an anomalous left coronary artery from the pulmonary artery. Successful left coronary artery reimplantation with rapid normalization of left ventricular systolic function occurred. As previously not reported, ligation of a PDA in a premature infant can unmask anomalous left coronary artery from the pulmonary artery. Surgical left coronary artery reimplantation is the mainstay of therapy and should be performed to establish normal coronary blood flow, even in a premature, low birth weight infant.

Restoration of hand function in a rat model of repair of brachial plexus injury

The incurability of spinal cord injury and subcortical strokes is due to the inability of nerve fibres to regenerate. One of the clearest clinical situations where failure of regeneration leads to a permanent functional deficit is avulsion of the brachial plexus. In current practice, surgical re-implantation of avulsed spinal roots provides a degree of motor recovery, but the patients neither recover sensation nor the use of the hand. In the present rat study, we show that transplantation of cultured adult olfactory ensheathing cells restores the sensory input needed for a complex, goal-directed fore-paw function and re-establishes synaptic transmission to the spinal grey matter and cuneate nucleus by providing a bridge for regeneration of severed dorsal root fibres into the spinal cord. Success in a first application of human olfactory ensheathing cells in clinical brachial plexus injury would open the way to the wider field of brain and spinal cord injuries.

Combined percutaneous revascularization and cell therapy after failed repair of anomalous origin of left coronary artery from pulmonary artery

This report shows the course of an infant with an abnormal left coronary artery origin arising from the pulmonary artery who underwent failed surgical reimplantation. Treatment entailed combined stent revascularization followed by intracoronary infusion of bone marrow-derived mononuclear cells. The patient was admitted with an acute coronary syndrome and low cardiac output; he was endotracheally intubated under respiratory assistance. Fourteen months after intracoronary infusion of autologous bone marrow-derived mononuclear cells, the infant remains symptom-free with significant recovery of the left ventricular function. These findings suggest that the combination of percutaneous revascularization and cell therapy should be considered in those infants or children in whom salvage therapy for ischemic heart disease is required.

Helicopter Transfers – Need for Implication Assessment

On reading this article, we noted some similarities with our recent audit. We have received 37 helicopter transfers over the last 24 months. Our hospital built a helicopter pad to receive plastic surgical re-implantation patients; the orthopaedic department noticed it on a return to work after a weekend. We do not have neurosurgery on site but are otherwise well served by all specialties. Other local hospitals are not similarly blessed with such helicopter pads. The majority of transfers have been orthopaedic at 14 cases and plastic surgery at 2 cases. Unfortunately, four head injury cases might have been more fortuitously taken to a local neurosurgical centre which was flown over in one instance. One child was sent to a local paediatric hospital after initial assessment in the accident and emergency department. Twenty-eight cases were from out of the area and an equivalent of 15 trauma lists have been used for these outlying patient displacing our local patients with their more routine trauma. Thirteen cases were discharged directly from the casualty, one or two being bewildered by the transfer (anxiety provoking?) and some wondered how they would get home. We acknowledge that we have far fewer cases, but wonder if Swindon has received appropriate funding and staffing for this extra work. We have not.

A review of 15-year experience with anomalous origin of the left coronary artery

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare condition presenting in infancy with acute myocardial ischaemia. A retrospective study was undertaken to assess the presenting features and long-term outcome of all cases of ALCAPA presenting to our institution over a 15-year period. All the cases were located using the hospital discharge system and charts were reviewed. The mean age at diagnosis was 4.5 months (2 weeks to 16 months). The predominant presenting symptoms were irritability, pallor, and tachypnoea. The predominant electrocardiogram findings were Q waves and ST segment changes in the anterolateral chest leads. One died from the 11 patients in our series. The outcome for surgical re-implantation in infants with a diagnosis of ALCAPA is very good however, early diagnosis is crucial to survival. Although once successfully repaired, patients in general were free of symptoms, ventricular dysfunction was usually present, requiring long-term follow-up.

Nuestra experiencia en el empleo de diferentes materiales inyectables en el tratamiento endoscópico del reflujo vesicoureteral

Vesicoureteral reflux (VUR) is the most common urologic anomaly in childhood, affecting 1% of the pediatric population. Endoscopic treatment of VUR is accepted as the first therapeutic option and various injectable materials have been used since its implantation. We present our experience in the endoscopic treatment of VUR with various substances which we have been employing since we started performing the procedure.We have performed a retrospective descriptive study including 445 patients that underwent endoscopic treatment for vesicoureteral reflux in our centre between 1988 and 2004. We treated a total of 568 ureters, and we analyze results depending on the material employed, grade of reflux and associated pathology.Among 569 ureters with vesicoureteral reflux undergoing treatment 457 were single VUR (79%), 76 (15%) were part of a double renal system, 24 (4%) were associated with neurogenic bladder, and 12 (2%) were secondary VUR after antireflux open surgery. We use three types of materials, with predominance of polytetrafluorethylene in 257 ureters, followed by hyaluronic acid dextranomer in 159, and finally polydimethylsiloxane in 153. In the cases of single VUR global cure rate was 88% (381 ureters), with significant improvement of the grade of reflux in 7% (51 ureters), and 5.5% of the cases (25 patients) requiring a Cohen type reimplantation. We observed a lower success rate and greater need of repeated injections in grade IV and V refluxes. In VUR associated with duplication results are worse, with less successes and greater need of procedures for its resolution. We cured 59 ureters (77%) out of 76 treated, 13 (19%) improved, and 4% required Cohen type reimplantation. In cases of VUR associated with neurogenic bladder 20 ureters were cured (83%). There was significant improvement in two ureters (8%); there were two failures (8%), requiring Cohen type reimplantation to avoid progressive deterioration of the kidney. In the cases of VUR after open surgical reimplantation all 12 ureters treated were cured (100%). Among 8 single ureters, reflux was solved with 1 procedure in 6 and 1 required 2 procedures. The total number of cured ureters has been 496 (87%), and 51 (9%) have improved. 22 ureters underwent surgery (4%). 68% of the cases were cured ofter 1 injection, 16.5% after 2, and 1 & after 3. There have been 5 complications (0.8%): 1 case of hemorrhagic cystitis which resolved spontaneously in two days, and 4 pyelonephritis which received the appropriate antibiotic therapy following antibiogram. We did not have any case of recurrent lower urinary tract infections. Follow-up has range it from 1.5 to 15 years.It seems that both polydimethylsiloxane and hyaluronic acid dextranomer are good and safe materials, and do not have the risk of distant migration of polytetrafluorethylene.

A hazardous finding of a rare anomalous left main coronary artery in a patient with a secundum atrial septal defect

A 23-year-old male referred for evaluation of a "choking" sensation with exertion and a murmur. A transthoracic echocardiogram demonstrated right atrial and ventricular dilatation, right ventricular volume overload, and a large secundum atrial septal defect (ASD) with left to right shunt and a calculated pulmonary-to-systemic blood flow ratio (Qp/Qs) estimated at 2.3 to 1. Cardiac catheterization also demonstrated evidence of the ASD with Qp/Qs of 4.6 to 1 with a significant step-up in oxygen saturation at the right atrial level. Additionally, an anomalous left main coronary artery (ALMCA) origin from the anterior right coronary cusp was suspected. Using 64-slice multidetector computed tomography coronary angiography (CCTA) the left main coronary artery was seen to arise from the right coronary cusp then traverse between the pulmonary trunk and the proximal ascending aorta before bifurcating into the left anterior descending and circumflex arteries that followed their normal courses distally. Based on the high risk nature of associated sudden death from an anomalous left main coronary artery (ALMCA) coursing between the aorta and the pulmonary trunk, the patient underwent surgical re-implantation of the ALMCA to the left coronary cusp and repair of the ASD. This case highlights a rare finding of a hazardous ALMCA in a patient with a secundum ASD and the utility of CCTA in evaluating the course of coronary anomalies along with other cardiac pathology.

Anomalous Right Coronary Artery from the Pulmonary Artery: Noninvasive Diagnosis and Serial Evaluation

Isolated anomalous origin of the right coronary artery from the main pulmonary artery (ARCAPA) is a rare congenital cardiac malformation. We reviewed the current literature and found only 31 patients with ARCAPA. We report the first case that was diagnosed and followed on a noninvasive basis with cardiovascular magnetic resonance after surgical re-implantation. This report of a patient with ARCAPA showed resolving coronary artery sizes secondary to decreased pulmonary steal. Cardiovascular magnetic resonance is an accurate and reliable imaging modality that allows serial noninvasive follow up in patients with coronary artery anomalies.