Anomalous origin of left coronary artery from pulmonary artery

Anomalous origin of left coronary artery from pulmonary artery Significance of saphenous vein bypass between aorta and left coronary artery Two forms of therapy for anomalous origin of the left coronary artery from the pulmonary artery ("adult type") were compared hemodynamically: (1) ligation of the left coronary artery and (2) insertion of a saphenous vein bypass graft between the aorta and the left coronary artery. In the former method, the mean and systolic pressures of the left coronary artery approached those of the aorta, but the essential diastolic pressure did not. After aorto-Ie]t coronary artery bypass, the left coronary pressure became equal with the aortic pressure. Blood flow through the graft was 200 mi. per minute. The postoperative course was favorable.

Masahiro Endo, M.D., * Shunsuke Takayasu, M.D., ** Yoshio Obunai, M.D., * * Makoto Nakazawa, M.D., * and Soji Konno, M.D., * Tokyo, Japan

Anomalous ongm of the left coronary artery from the pulmonary artery, an unusual cardiovascular lesion, can be surgically managed. We recently performed an autogenous saphenous vein bypass in a case of the "adult" type of this disease. During the operation, the left coronary arterial pressure and blood flow were measured to compare the methods of left coronary artery ligation versus saphenous vein bypass. Our studies demonstrated the advantage of the latter from the viewpoint of hemodynamics. Case report T. M., a 12-year-old boy, was admitted to Mitaka Central Hospital on Feb. 27, 1973, with From Mitaka Central Hospital and Tokyo Women's Medical College, Tokyo, Japan. Received for publication Oct. 20, 1973. Address for reprints: Masahiro Endo, M.D., The Heart Institute of Japan, Tokyo Women's Medical College, 10 Kawadacho, Shinjuku-ku, Tokyo, Japan. • Department of Cardiovascular Surgery, Tokyo Women's Medical College. •• Department of Cardiovascular Surgery, Mitaka Central Hospital.

896

palpitation. His history included a normal gestation period. No abnormalities were detected al birth, and his development was normal during infancy. A cardiac murmur was an incidental finding at the age of 3 years. He remained asymptomatic until the age of II years. Six months before admission, Sept. 2, 1972, he experienced an episode of palpitation, shortness of breath, and slight pain in the chest with radiation to the left shoulder and arm. On examination the patient appeared healthy. The blood pressure was 130/70 mm. Hg. The apex beat was in the fifth intercostal space and shifted to the left anterior axillary line. There was no evidence of cardiac failure. A Grade 2/6 continuous murmur was heard at the upper left sternal border, and a Grade 1/6 ejection systolic murmur was noted at the apex. The electrocardiogram showed increased left ventricular hypertrophy with tall R waves in Lead Y5 • Results of the exercise test were positive, with SoT depression in Leads II, III, aY,·, VI, and Y5 (Fig. I). The chest x-ray film showed a slightly enlarged heart. Right heart catheterization revealed normal pressures, and serial determinations of blood oxygen saturation disclosed a left-to-right shunt entering the main pulmonary artery. The pulmonaryto-systemic flow ratio was 1.4 to I . Retrograde aortography demonstrated a very

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Anomalous origin of left coronary artery

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Fig. 1. Preoperative exercise electrocardiogram showed SoT depression in Leads II, III, aV.-, V 4 , and Vslarge , tortuous right coronary artery with retrograde filling of the left coronary artery; the latter terminated in the main pulmonary artery (Fig. 2). Surgical procedure. The operation was performed on March 27, 1973. The heart was exposed through a medi an sternotomy incision. Many tortuous dilated coronary vessels were visible on the cardiac surface. The left coronary artery arose from the posterolateral wall of the pulmonary artery. No areas of gross myocardial injury were noted. A suture was passed beneath the origin of the anoma lous left coronary artery but was not tied. A 15 gauge needle was dire ctly inserted into the ao rta and anomalous left coronary artery for continuous monitoring of pressure (Fig. 3, a). Pressure in the aorta before ligation was 105/85 mm. Hg ( mea n 90) , and pressure in the left ma in coronary artery was 96/44 mm . Hg (mean 78) (Fig. 4, A) . The suture passed below the origin of the anomalous left coronary artery was tied as shown in Fig . 3, b. Aortic pressure after ligation was 98/83 mm. Hg (mean 87), and the pressure in the left main coronary artery was 98/44 rnm, Hg (mean 80) (Fig. 4, B) _ Next, a segment of saphenous vein was isolated, resected, and prepared for use as an autogenous bypass graft. Partial cardiopulmonary bypas s was begun after anticoagulation with 2 mg. per kilogram of

heparin. Anastomosis was first accomplished endto-side to the anomalous left main coronary artery and then end-to-side to the anterolateral wall of the ascending aorta. Partial cardiopulmonary bypass was discontinued in the usual fashion on completion of the procedure. Flow through the bypass graft was found by electromagnetic flowmeter to be 500/0 rnrn. Hg with a mean flow of 200 mI. per minute (Fig. 5). After the saphenous vein graft was completed, the pressures in the aorta and the left main coronary artery became equal ( Fig. 4, C ) . The patient's postoperative con valescence was uneventful. Before discharge (twenty-first day after operation), repeat angiographic studies demonstrated a patent aorto-Ieft coronary artery bypass (Fig. 6, A). In the selective right coronary angiogram, anastomosis with the left coronary artery (present preoperatively) had disappeared, and the left coronary artery was no longer visualized (Fig. 6, B). Even in the electrocardiogram taken 3 months after loading, the SoT changes seen preoperatively were markedly improved (Fig. 7).

Discussion Anomalous origm of the left coronary artery from the pulmonary artery was described for the first time by Abbott'! in

Endo et al.

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The Journal of Thoracic and Card iovascular Surgery

Fig. 2. A, Retrograde aortography. The right coronary artery (RCA) was dominant, large, and tortuous. It communicated with the left coronary artery through large collateral vessels. B. The left coronary artery filled from the right side in a retrograde manner and drained into the pulmonary artery (PA ). Ao, Aorta. LAD, Left anterior descending coronary artery.

Fig. 3. a, Before ligation of left coronary artery. b, After ligation of left coronary artery. After aorto-left coronary bypass graft.

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1908. The incidence is said to be about 1 per 300,000 births.> Many of the patients die during the neonatal period. Various kinds of surgical treatments have been carried out for this disease, such as (1) ligation of the left coronary artery and (2) systemic-left coronary artery bypass grafting. In the past, ligation of the left coronary artery has been performed in the "adult" type of the disease, in which there is relatively good development of intercoronary collateral anastomoses between the right and left coronary arteries." The significance of this method consists in interrupting the steal of the retrograde flow from the left coronary artery to the pulmonary artery and bringing the left coronary artery pressure close to the systemic pressure. For the

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LAD ® Fig. 6. A , Postoperative angiographic evaluation showed good caliber of graft. LMA, Left main artery. LCX, Left circumflex. LAD, Left anterior descending coronary artery. B, In the selective right coronary angiogram, anastomosis with the left coronary (present preoperatively) had disappeared. RCA, Right coronary artery.

" adult" type of this disease, ligation of the left coronary artery is sufficient; some investigators" I ~ maintain that no systemicleft coronary artery bypass graft is required. Even after ligation of the left coronary art ery, however, no improvement in ischemic changes will appear on the electrocardiogram , according to some reports .' : [; On the other hand, El-Said," Cooley," and their colleagues used a Dacron graft to achieve a two-coronary system and later used a saphenous vein graft between the aorta and coronary artery. Meyer and his associates ' anastomosed the left coronary artery to the left subclavian artery. Subsequently, several cases of successful aorto-left coronary artery bypass grafting were reported in which the saphenous vein was used,"- 8 , 9 , 13, 14 We have successfully performed this operation by similar methods. During the operation, pressures in the aorta and left main coronary arter y were measured before and after ligation of the left main coronary artery . Before ligation, the systolic, diastolic, and mean pressures

in the left main coronary artery were lower than those in the aorta. After ligation, the systolic pressure in the left coronary was equal to that in the aorta and the mean pressure approached the mean aortic pressure. However, the diastolic pressure remained low, Thus the area irrigated by the left coronary artery showed a pattern of coronary blood flow similar to that in aortic insufficiency. Blood through the left coronary artery flows mainly in the diastolic phase, so that the low diastolic pressure in the left coronary artery is a distinct disadvantage. It is not clear why the diastolic pressure fails to rise. One possible cause is the intramyocardial pressure exerted via the vessels that run deeply through the myocardium among the anastomotic branches between the right and left coronary arteries . With the diastolic pressure low, the pressure curve within the myocardium is somewhat similar to ·that of the pressure within the left ventricle." This might be the reason for the low diastolic pressure of the left coro-

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nary artery. In other words, the hemodynamic states produced by ligation of the left coronary artery and by single coronary artery are different. Ligation of the left coronary artery is naturally contraindicated in the "infantile" type of this disease, G and it is less advantageous than saphenous vein bypass grafting in the "adult" type, Regardless of the etiology of coronary artery obstruction (i.e., congenital or acquired) or the degree of development of the collateral circulation, the postoperative flow is expected to be less than the original antegrade flow. REFERENCES Harthorne, J. W., Scannell, J. G., and Dinsmore, R. E.: Anomalous Origin of the Left Coronary Artery, N. Engl. 1. Med. 275: 660, 1966. 2 Ogden, J. A, and Stansel, H. c., Jr.: Roentgenographic Manifestation of Congenital Coronary Artery Disease, Am. J. Roentgeno\. Radium Ther. Nuc\. Med. 113: 538, 1971. 3 EI·Said, G. M., Ruzyllo, W., Williams, R. L., Mullins, C. E., Hallman, G. L., Cooley, D. A., and McNamara, D. G.: Early and Late Result of Saphenous Vein Graft for Anomalous Origin of Left Coronary Artery From Pulmonary Artery, Circulation 48: 2, 1973 (Supp\. III).

4 Massih, N. A, Lawler, J., and Vermellion, M.: Myocardial Ischemia After Ligation of an Anomalous Left Coronary Artery Arising From the Pulmonary Artery, N. Eng\. J. Med. 269: 483, 1963. 5 Roche, A H. G.: Anomalous Origin of the Left Coronary Artery in the Adult, Am. J. Cardio\. 20: 561, 1967. 6 Cooley, D. A., Hallman, G. L., and Bloodwell, R. D.: Definitive Surgical Treatment of Anomalous Origin of Left Coronary Artery From Pulmonary Artery, 1. THORAC. CARDJO· VASCo SURG. 52: 798, 1966. 7 Meyer, B. N., Stefanik, G., Stiles, Q. R., Lindesmith, G. G., and Jones, J. c.: A Method of Definitive Treatment of Anomalous Origin of Left Coronary Artery, 1. THORAC. CARDIOVASC. SURG. 56: 104, 1968. 8 Reis, R. L., Cohen, L. S., and Mason, D. T.: Direct Measurement of Instantaneous Coronary Blood Flow After Total Correction of Anornalous Left Coronary Artery, Circulation 39, 40: 229, 1969 (Suppl. I). 9 Gasior, R. M., Winter, W. L., Glick, H., Sandiford, F., Chapman, D. W., and Morris, G. c.: Anomalous Origin of Left Coronary Artery, Am. J. Cardio\. 27: 215, 1971. 10 Perry, L. W., and Scott, L. P.: Anomalous Left Coronary Artery From Pulmonary Artery, Circulation 41: 1043, 1~70. 11 Abbott, M. E.: Congenital Cardiac Disease, ill Osler's Modern Medicine, vol, 4, Philadelphia, 1908, Lea & Febiger, Publishers, pp. 323-325. 12 Keith, J. D.: The Anomalous Origin of the

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Left Coronary Artery From the Pulmonary Artery, Br. Heart 1. 21: 149, 1959. 13 Somerville, J., and Ross, D. N.: Left Coronary Artery From the Pulmonary Artery: Physiological Consideration of Surgical Correction, Thorax 25: 207, 1970. 14 Akhtar, N., Hyland, J. W., and Adam, M.: Anomalous Origin of the Coronary Artery From the Pulmonary Artery in an Adult, J. THORAC. CARDIOVASC. SURG. 66: 112, 1973. 15 Baird, R. J., Manktelow, R. T., Shah, P. A.,

The Journol of Thoracic and Cordiovascular Surgery

and Ameli, F. M.: Intramyocardial Pressure: A Study of its Regional Variations and its Relationship to Intraventricular Pressure, 1. THORAC. CARDIOVASC. SURG. 59: 810, 1970. 16 Yokoyama, M., Nogi, M., Yokoyama, K., and Sakakibara, S.: Experimental Studies Concerning the Blood Flow Direction in the Anomalous Left Coronary Artery Arising From the Pulmonary Artery, Jap. Heart J. 13: 250, 1972.