Takeuchi Procedure Research Articles

Análise da técnica de takeuchi usada para o tratamento da origem anômala da artéria coronária esquerda do tronco pulmonar

Evaluation of a case series of anomalous origin of the left coronary artery from the pulmonary artery corrected with the Takeuchi procedure, analyzing their immediate and late surgical outcomes as well as the related morbidity. To report a case series of anomalous origin of the left coronary artery from the pulmonary artery corrected with the Takeuchi procedure. The analysis was based on data collected from the medical records of 12 patients undergoing surgical correction between 1981 and 2003. The mean age of the patients was 5.9 +/- 1.7 months. The predominant manifestation was heart failure, especially in the infants. The baseline electrocardiogram showed a Q wave in DI and aVL and signs of myocardial ischemia in ten cases. Echocardiogram with a pattern of dilated cardiomyopathy and mitral regurgitation was found in six patients. The mean age at surgical correction was 31.8 +/- 14.3 months. The immediate surgical mortality was 16% (two patients), from cardiac dysfunction. In the outpatient follow-up we observed that the symptoms, ischemic electrocardiographic changes, cardiac function and mitral regurgitation improved. Three cases progressed with supravalvar pulmonary stenosis during follow-up. This heart disease should be suspected in every infant presenting with heart failure. Surgical correction with the Takeuchi procedure has proven efficient, with a low mortality rate. Cardiac function returns to normal and mitral regurgitation improves after surgical correction.

Aortopulmonary Window and Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery: Long-Term Result After Takeuchi-Type Repair

We describe the case of a 2-month-old infant with the rare association of aortopulmonary window and anomalous origin of the right coronary artery from the pulmonary artery. The diagnosis was made by angiography and surgical repair was carried on employing the Takeuchi procedure. The angiographic control obtained 5 years after the operation showed an optimal surgical result. The latest echocardiographic follow-up, 24 years after the repair, has been fully satisfactory.

Repair of Anomalous Origin of Left Coronary Artery from the Pulmonary Artery

Patients with anomalous origin of the left coronary artery from the pulmonary artery often have mitral valve regurgitation. Although establishing dual coronary circulation is the procedure of choice, there remains controversy as to how the mitral valve is handled. Between April 1999 and August 2005, 8 patients underwent surgical correction at our institution. There were 4 males and 4 females, aged from 9 months to 13 years (mean, 6.4 years). Six patients underwent direct aortic reimplantation and 2 had a Takeuchi procedure. Simultaneous mitral annuloplasty was performed in 7 patients with moderate or severe mitral regurgitation. There were no deaths or postoperative complications. Follow-up ranged from 4 to 80 months (mean, 34 +/- 26 months). Left ventricular function improved significantly from a preoperative fractional shortening of 0.21 +/- 0.09 to 0.35 +/- 0.06. Mitral regurgitation decreased on follow-up in the 7 patients who had mitral annuloplasty. We recommend performing mitral annuloplasty at the time of operation in patients with moderate or severe mitral regurgitation and anomalous origin of the left coronary artery from the pulmonary artery.

Results of surgical correction in patients with anomalous origin of the coronary artery from the pulmonary artery

To evaluate effectiveness of surgical correction in patients with anomalous origin of the coronary artery from the pulmonary artery. Between April 1999 and August 2005, 12 patients with anomalous origin of the coronary artery from the pulmonary artery underwent surgical correction. There were 8 patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), and 4 patients with anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA). Eight patients underwent direct aortic reimplantation, and 4 patients underwent a Takeuchi procedure (intrapulmonary artery baffle with an autologous pericardial patch). Simultaneous mitral annuloplasty was performed in 7 patients of ALCAPA with moderate and severe mitral regurgitation. One patient of ARCAPA was associated with an atrial septal defect (ASD) which was closed with an amplatzer septal occluder through right atrium under transesophageal echocardiography (TEE) without CPB. There were neither early and late deaths nor postoperative complications. Follow-up of all patients ranged from 7 to 83 months (mean, 32 +/- 24 months). The left ventricular function after operation improved from a preoperative fractional shortening (FS) of 0.21 +/- 0.09 to 0.35 +/- 0.06 (P = 0.006) for patients with ALCAPA. Preoperative mitral regurgitation decreased in 7 patients of ALCAPA after mitral annuloplasty at the follow-up. All patients were doing well and their exercise tolerance improved to normal. They were free from symptoms. Reestablishment of a two-coronary system is necessary for patients with anomalous origin of the coronary artery from the pulmonary artery. The left ventricular function improved after 2-coronary repair. We recommend that the simultaneous mitral annuloplasty should be performed at the time of operation for patients who have moderate and severe mitral regurgitation with ALCAPA. Surgical correction of ARCAPA and ARCAPA show good early and mid-term results, long-term results need to be followed up.

Invited commentary

Michielon and associates from Ospedale Pediatrico Bambino Gesu, Rome, Italy, have presented their experience with surgical repair of anomalous coronary artery from the pulmonary artery using three different techniques from 1987–2002. Five had subclavian-to-coronary artery grafts, 12 had an intrapulmonary artery tunnel, and 14 had direct reimplantation. In general, this is a nicely researched and written manuscript that is largely confirmatory of a number of extant papers dealing with this subject [1Dodge-Khatami A. Mavroudis C. Backer C.L. Anomalous origin of the left coronary artery from the pulmonary artery: collective review of surgical therapy.Ann Thorac Surg. 2002; 74: 946-955Google Scholar]. The conclusions are simple and in accordance with numerous previous reports. However, the authors include two interesting components that are not commonly found in the other literature reports. The first is that the authors present a comparison of three different techniques from the same institution that is very useful. The second is that the authors have analyzed their data to determine the left ventricular recovery time as it relates to age at operation. This is important information. The comparison of these three techniques brings to light the superiority of the aortic implantation method, which as the authors conclude, can be used in the great majority of cases. Coronary mobilization techniques, stemming from the arterial switch operation experience, have allowed for this significant trend. Through their long-term followup the authors also document the problems that are associated with the Takeuchi intrapulmonary tunnel technique; namely that tunnel stenosis and supravalvar pulmonary artery stenosis occur in a high percentage of patients. Even so, the authors “still consider the modified Takeuchi procedure a valid alternative in case of leftward location of the coronary ostium, especially when extensive collaterals surround the pulmonary sinuses.” The problem of extensive collaterals on the surface of the pulmonary artery in this disease has not been discussed to any great degree in literature reports. In our practice we take great care to ligate and divide these vessels and to assure hemostasis before the coronary button dissection. Failure to do this in one of our patients required repeat cardiopulmonary bypass to control the bleeding. We do not believe that extensive surface pulmonary artery collaterals should mitigate against the coronary reimplantation technique as long as careful hemostasis is achieved. This leads to a further conclusion that the Takeuchi operation should only be used rarely and only in the most unusual cases. We have used the Takeuchi operation only once, early in our series [2Backer C.L. Stout M.J. Zales V.R. Muster A.J. Weigel T.J. Idriss F.S. Mavroudis C. Anomalous origin of the left coronary artery a twenty-year review of surgical management.J Thorac Cardiovasc Surg. 1992; 103: 1049-1058Google Scholar] because of intellectual curiosity and not because of inability to transfer the artery to the aorta. This patient has supravalvar pulmonary stenosis, which we are following. Other than this patient, we have been able to transfer the anomalous coronary artery in all of our patients in the modern era [3Backer C.L. Hillman N.D. Dodge-Khatami A. Mavroudis C. Anomalous origin of the left main coronary from the pulmonary artery successful surgical strategy without assist devices.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2000; 3: 165-172Abstract Full Text PDF Google Scholar]. The authors have analyzed their data in a comprehensive manner to compare the three techniques. It comes as no surprise that (1) an earlier operation (less than 6 months) is better for long-term recovery, (2) that mitral insufficiency regresses in most cases, and (3) that coronary artery transfer yields superior long-term survival and freedom from reoperation. Nevertheless, their analysis, although confirmatory, is well executed and is welcomed as a very important contribution.

A reoperation of Adult-Type Bland-White-Garland syndrome

We present a 25-year-old female patient with Bland-White-Garland syndrome (anomalous origin of the left coronary artery from the pulmonary artery) who underwent mitral valve replacement (MVR) and coronary artery bypass grafting. She had previously undergone MVR and had been treated by the Takeuchi procedure for mitral valve regurgitation and a coronary artery anomaly, respectively, at 17 years of age. She was hospitalized with shortness of breath within 7 years of surgical intervention. Swan-Ganz catheterization revealed mild pulmonary hypertension and elevated mean pulmonary wedge pressure. Echocardiography revealed marked severe calcification of the bio valve and moderate mitral valve regurgitation. Coronary angiography revealed retrograde collateral blood flow from the right coronary artery to the left coronary artery, but intrapulmonary tunnel was not visualized by pulmonary arteriography. We performed MVR with a mechanical valve and coronary artery bypass grafting between the left internal thoracic artery and the left anterior descending artery. The postoperative course was unremarkable, and no complaints were reported during follow-up at the outpatient clinic.

Creation of a dual-coronary system for anomalous origin of the left coronary artery from the pulmonary artery utilizing the trapdoor flap method.

Results of the repair of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) have improved. Direct implantation of the anomalous coronary artery into the ascending aorta establishes a dual-coronary system and is the goal of current surgical approaches. We report the development of our surgical technique for ALCAPA. Between September 1993 and December 2000, 13 patients underwent surgery for ALCAPA. There were four males and nine females. Ages ranged from 1 month to 25 years (median=3.9) and weight ranged from 2.6 to 102kg (median=16.8). One patient had previously undergone an operative procedure at an outside institution. Direct implantation of the anomalous coronary artery into the ascending aorta was feasible in 12 of 13 patients. In situ transfer was performed in one patient with an intramural coronary artery. The first case in the series required an intrapulmonary baffle reconstruction (Takeuchi procedure) because the coronary artery arose remotely from the ascending aorta from the left-anterior sinus of the PA. For coronary transfer, a trapdoor flap was created on the ascending aorta for the implantation of the coronary button and the sinus defect in the main PA was augmented with a pericardial patch. The left ventricular (LV) shortening fraction was improved from a median value of 27% (range 12-36%) preoperatively to 33% (range 24-45%) in the immediate postoperative period (P=0.004). The LV end-diastolic dimension decreased from a median value of 36 mm (range 22-70 mm) preoperatively to 29 mm (range 19-56 mm) in the immediate postoperative period (P=0.004). There has been no mortality or reoperation during a median follow-up of 36 months. Using a standard technique, direct implantation of the anomalous coronary artery into the ascending aorta was achieved in all cases but one. At intermediate follow-up, LV function had improved by echocardiography. No postoperative mechanical circulatory support was required in any of these patients. This operative technique is reproducible and is applicable to the majority of patients with ALCAPA.

Surgical Repair of Anomalous Origin of the Coronary Artery from the Pulmonary Artery in Children

Objective: To evaluate surgical management of children with coronary artery anomalies, including patients with rare abnormalities (left anterior descending artery or right coronary artery originating from the pulmonary artery). Methods: A retrospective review of eight patients (aged 2 months-10 yr; median 3.5 yr), treated for coronary artery anomalies between 1989 and 1999. Coronary vessels were reimplanted to the aorta in four children, while the remaining four were subjected to the Takeuchi procedure. Results: All children survived. None required mechanical circulatory support. In six patients significant mitral valve insufficiency developed, nevertheless, no intraoperative mitral valvuloplasty was performed. Follow-up was 2 months-10 yr. All patients developed normally and are currently in NYHA class I. Echocardiography revealed normal FS and EF values within 1–17 months postoperatively. Conclusions: In children with coronary artery anomalies, the best results are achieved with an early diagnosis and aggressive management. In our opinion coronary vessel reimplantation and the Takeuchi procedure yields comparable results.

Repair of anomalous left main coronary artery arising from the pulmonary artery in infants: long-term impact on the mitral valve

Background. Infants presenting with anomalous left coronary artery off the pulmonary artery (ALCAPA) are generally in heart failure and often have significant mitral valve regurgitation (MR). Although establishing a dual coronary circulation is the procedure of choice, there remains controversy as to how the mitral valve is handled.Methods. We reviewed our experience with this lesion at St. Louis Children’s Hospital. Over the past 15 years, 17 infants under 18 months of age have undergone repair, with all but one being treated with reimplantation of the left coronary artery into the aorta; the other underwent the Takeuchi procedure (intrapulmonary artery baffle) and was excluded from this evaluation. The average age and weight at operation were 0.5 ± 0.3 years and 6.1 ± 1.9 kg, respectively. All presented with varying degrees of heart failure and 9 patients also had either moderate or severe MR.Results. There was one early and no late deaths after reimplantation of the left coronary artery. The left ventricular function postrepair improved from a preoperative shortening fraction of 0.19 ± 0.09 to 0.34 ± 0.08 (p < 0.01). Moderate or severe MR was present in 2 patients postoperatively, and both developed significant obstruction in the left coronary artery postoperatively as well. Both underwent mitral valve repair and revascularization of the left coronary artery.Conclusions. Excellent results can be obtained in the treatment of this very high-risk group of patients. Mitral valve repair is not generally necessary at the time of the initial operation. However, should MR recur or persist late, it may herald the presence of a coexistent, significant coronary stenosis. Cardiac catheterization should be performed to assess the patency of the left coronary artery before performing mitral valve surgery.

Surgical repair of anomalous origin of the coronary artery from the pulmonary artery in children

Objective: To evaluate surgical management of children with coronary artery anomalies, including patients with rare abnormalities (left anterior descending artery or right coronary artery originating from the pulmonary artery).Methods: A retrospective review of eight patients (aged 2 months–10 yr; median 3.5 yr), treated for coronary artery anomalies between 1989 and 1999. Coronary vessels were reimplanted to the aorta in four children, while the remaining four were subjected to the Takeuchi procedure.Results: All children survived. None required mechanical circulatory support. In six patients significant mitral valve insufficiency developed, nevertheless, no intraoperative mitral valvuloplasty was performed. Follow-up was 2 months–10 yr. All patients developed normally and are currently in NYHA class I. Echocardiography revealed normal FS and EF values within 1–17 months postoperatively.Conclusions: In children with coronary artery anomalies, the best results are achieved with an early diagnosis and aggressive management. In our opinion coronary vessel reimplantation and the Takeuchi procedure yields comparable results.

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)

Balloon dilation for postoperative pulmonary stenosis following surgical creation of an intrapulmonary coronary arterial tunnel

AbstractBalloon dilation was performed in four patients with postoperative pulmonary stenosis who had undergone surgical creation of a coronary arterial tunnel in the pulmonary trunk. Two patients had complete transposition in whom the arterial switch operation had been performed using the modified Aubert method. The other two patients had anomalous origin of the left coronary artery from the pulmonary trunk treated with the Takeuchi procedure. Balloon dilation was performed at 11 locations. The pressure gradient decreased from 48 ± 22 to 24 ± 14mmHg (p&lt;0.01), and the diameter of the narrowest segment increased from 5.3 ± 2.5 to 7.5 ± 2.8mm (p&lt;0.01), respectively. Of the 11 procedures, 8 (73%) were judged successful with use of the criterion of success as a greater than 50% decrease in pressure gradient, and/or a greater than 50% increase in diameter. The inflated balloon must have compressed the coronary arterial tunnel in the pulmonary trunk, but there was no apparent myocardial damage in any patient, although transient and mild ST-T changes appeared on electrocardiographic monitoring during the procedure in 2 patients. Rupture of the wall of the pulmonary trunk occurred in two patients, one of whom required elective surgical intervention. These data suggest that balloon dilation should be performed with caution for management of postoperative pulmonary arterial stenosis in patients with a surgically created intrapulmonary coronary arterial tunnel, since tearing the wall of the pulmonary trunk may occur.

Noninvasive imaging of intraarterial baffles in infants and children.

Baffles within the lumen of the pulmonary artery are created in (1) the Aubert procedure, a variation of the arterial switch favored by some surgeons when two major coronary ostia arise close to one another or when one coronary artery has an intramural course, and (2) the Takeuchi procedure, a technique applied to patients with anomalous origin of the left coronary from the pulmonary artery. In both operations, coronary artery transplantation is avoided; instead, an aorticopulmonary window is created and aortic blood is redirected by an intrapulmonary artery baffle into the coronary circulation. We imaged five patients with Aubert and 10 patients with Takeuchi procedures by use of ultrasound to assess the sequelae of such intraarterial baffles. All five Aubert patients were < 3 weeks old; the ages of the 10 Takeuchi patients ranged from 2 to 86 months. Two patients died early after surgery; the remaining 13 patients were observed for 3 to 83 months (median 46 months). In all 15 patients, the baffle geometry was visualized and the aorticopulmonary window was identified. In the six who had serial imaging, none developed aorticopulmonary window stenosis. In no patient was any peribaffle shunting detected. Supravalvar narrowing, caused by the baffle partially obstructing the neopulmonary artery, was observed in two of five Aubert patients; in only one of these has reoperation been performed. In one of the 10 Takeuchi patients supravalvar narrowing of the pulmonary artery (related to repair of coexistent tetralogy of Fallot) has developed and the patient has since undergone reoperation.

Left coronary artery-to-pulmonary artery communication (a late postoperative complication after the Takeuchi procedure for repair of anomalous origin of left coronary artery from the pulmonary artery) detected by color Doppler flow mapping

Left coronary artery-to-pulmonary artery communication (a late postoperative complication after the Takeuchi procedure for repair of anomalous origin of left coronary artery from the pulmonary artery) detected by color Doppler flow mapping

Anomalous origin of left coronary artery from pulmonary artery: Ligation versus establishment of a two coronary artery system

Between 1959 and 1985, 24 patients (mean age 38 months, range 15 days to 13 years) with anomalous origin of the left coronary artery from the pulmonary artery as an isolated lesion were treated surgically at Children's Hospital, Boston. In 11 cases a left coronary-to-aortic tunnel was created with a pulmonary artery baffle (Takeuchi) with no deaths either early or late over a mean follow-up period of 18 1/2 months. Late complications of this procedure include moderate aortic regurgitation (one), supravalvular pulmonary stenosis (two-one required a second operation), obstructed baffle (one-asymptomatic). In 11 cases of coronary ligation or ostial closure there was a 27% early mortality and a 25% late mortality over a mean follow-up period of 10 1/2 years. Late complications include residual shunt (three-two required a second operation), severe mitral regurgitation (one), and recurrence of angina (one). Two patients had other procedures. Both early and late deaths occurred in the group who had congestive heart failure and who had simple ligation. Five infants who had profoundly depressed ventricular function and moderate to severe mitral regurgitation, together with widespread Q waves on electrocardiogram, showed a dramatic improvement in ventricular function after the Takeuchi procedure. The Takeuchi procedure is a simple and effective means of establishing a two coronary artery system in the child with anomalous origin of the left coronary artery from the pulmonary artery. This procedure is particularly recommended over coronary ligation in patients in congestive heart failure.