Medicine
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Direct Re-implantation of Left Coronary Artery into the Aorta in Adults with Anomalous Origin of Left Coronary Artery from the Pulmonary Artery (ALCAPA)
Chapters
Summary April 24th, 2017
Surgical correction of ALCAPA is highly recommended, regardless of age or the degree of intercoronary collateralization. This protocol presents a technique for the direct re-implantation of adult-type ALCAPA into the aorta to re-establish the dual-coronary perfusion. Whenever feasible, direct re-implantation is preferred to other surgical correction techniques.
Transcript
The overall goal of this surgical procedure is to reconnect the anomalous left coronary artery from the pulmonary artery directly into the aorta. This method improves on the surgical correction of the ALCAPA, such as by relieving tension on the coronary anastomosis. But the main advantage of this technique is that it provides a great physiological restitution of the dual coronary perfusion.
Though this method can be applied to surgical correction of ALCAPA, it can also provide insight for other surgical procedures such as reimplantation of coronaries during aortic roots surgery. After preparing the patient for surgery and opening the sternum, incise the pericardium over the aorta to uncover the massively dilated and tortuous right coronary artery. Grab the pericardium and cut up to its reflection line over the ascending aorta.
Use electrocautery as needed. Then dissect the aorta circumferentially. Gently push the ascending aorta to the left using a lung retractor and grip the soft tissue behind the ascending aorta.
Separate the posterior wall of the ascending aorta from the surrounding tissue using electrocautery. Continue to dissect cautery behind the ascending aorta, being careful to avoid injury to the right pulmonary artery. Next, gently push aside the main pulmonary artery and separate the attached ascending aorta using electrocautery.
Then dissect the main pulmonary artery. First, push aside the ascending aorta with a clamped piece of gauze. Then with new gauze, dissect the posterior wall of the main pulmonary artery without injuring the adjacent main left coronary artery.
Now pass the dissector under the main pulmonary artery and gently open it to make a tunnel. Then grip an open loop in jaws of the dissector. Finally, grab the adventitia of the ascending aorta and pull the vessel loop held by the dissector to encircle the main pulmonary artery.
Continue by placing a left ventricular vent. After placing a pursestring on the right upper pulmonary vein, gently push the superior vena cava towards the left side and make a small cut in the middle of the pursestring. Then gently open the clamp.
Next, insert a vent through the right upper pulmonary vein and mitral valve into the left ventricle to unload the left heart. After securing the vent with ligature, gently dilate the opening in the pulmonary artery. And insert an antegrade cardioplegia cannula in the main pulmonary artery.
Now insert an antegrade cardioplegia cannula into the ascending aorta. Secure it with a braided polyester two over zero ligature with a polybutylene coating. Before proceeding, verify the correct placement of the antegrade cardioplegia cannulas in the main pulmonary artery and ascending aorta.
Once the heart is made ready to open, transect the aorta. Remove the cardioplegia cannula and grab the ascending aorta with forceps on each side of the opening. Then enlarge the opening with an 18 blade knife and finish with scissors.
Now verify the absence of the left coronary ostium inside the aorta in the left sinus of valsalva. To proceed, transect the main pulmonary artery. Remove the cardioplegia cannula and grab the main pulmonary artery on each side of the opening.
Enlarge the opening with an 18 blade knife and finish with scissors. Then confirm the presence of the left coronary ostium originating from the right facing sinus one of the pulmonary artery. After preparing the pulmonary artery, grab a large surrounding patch of the proximal main pulmonary root wall and cut the left coronary ostium from the right facing sinus one.
Take care to not injure the pulmonary valve. Before proceeding, mobilize the main left coronary artery up to its bifurcation. To begin, prepare for the reimplantation of the left coronary ostium.
Grip the proximal ascending aorta and use a straight blade to create a neo-ostium in the left sinus two of the aorta. Leave a 10 millimeter margin of aortic root wall around the neo-ostium towards the commissure between the left sinus two and the right coronary sinus. Also, leave a 10 millimeter margin towards the aortic annulus.
Next, connect the main left coronary ostium end to end to the neo-ostium in the left sinus two of the aorta using a running six over zero propylene monofilament suture. Start the anastomosis at the deepest point of the main left coronary ostium and allow it to come up on the right hand side of the anastomosis. To relieve suture tension on the tissue, manually bring the aorta and the main left coronary ostium together when pulling sutures.
Complete the anastomosis by running the left hand side of the suture to meet the other end. Now repair the defect in the pulmonary artery root using a non-treated autologous pericardial patch. Connect the patch at the deepest point of the right facing sinus one of the pulmonary artery using a running six over zero propylene monofilament suture.
First, run up the left end of the suture to mid height of the defect. Then do the same with the right end of the suture. Keep the two suture ends under tension.
Now reestablish the continuity of the great vessel. Reconnect the proximal party of the aorta to its distal part using an end to end anastomosis with running five over zero propylene monofilament suture. Start at the deepest point and come up on the right hand side.
Complete the anastomosis by running the left hand side of the suture to meet the other end. Now de-air the aorta by removing the aortic cross clamp. At this point, start rewarming the patient.
Next reconnect the pulmonary artery. First, place a pump sucker into the distal pulmonary artery to remove the site of the operative field. Then from the patched defect, continue a running suture from the left end to complete the posterior and left aspects of the anastomosis.
Then from the right end of the patch, continue the suture to complete the posterior and right aspects of the anastomosis. Tie the two ends of the suture to finish the connection. A 48 year old woman presented with recent onset of angina grad three and occasional palpitations.
Transthoracic echocardiography showed a moderately impaired left ventricular ejection fraction and no mitral regurgitation. Coronary angiography demonstrated the absence of the left main coronary artery, LCA, arising from the aorta. The right coronary artery, RCA, was considerably enlarged and perfused the main left coronary artery via intraseptal collaterals.
Thus the diagnosis of ALCAPA was made. The anatomical type of ALCAPA was further defined by biplane and three dimensional CT scans. The described surgical procedure was then performed.
Post operatively the patient was separated from the cardiopulmonary bypass at a core temperature of 37 degrees celsius. No myocardial ischemia occurred. Bleeding from the chest tube drain was less than 30 milliliters per hour and the patient was weaned from the ventilator and extubated within six hours.
A year later the patient was leading a productive life. A CT scan showed the re-implanted ALCAPA was widely patent at the site of anastomosis to the aorta. The pulmonary artery did not present any narrowing at the site of reconstruction.
With the autologous pericardial patch used to repair the defect in the right facing sinus of the PA.Once mastered, this technique can be done in five hours if it is performed properly. While attempting this procedure, it is important to remember to achieve a good immobilization of the left coronary artery. After its development, this technique paved the way for researchers in the field of cardiac surgery to explore a direct re-implantation of anomalous left coronary artery from pulmonary artery in adults.
Don't forget that working with coronary ostia can be extremely hazardous and precautions such as gentle handling and enough immobilization of the left coronary ostium should always be taken while performing this procedure.
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