- Email: [email protected]
Beating Heart Off-Pump Myocardial Revascularization in an Infant
Ann Thorac Surg 2005;79:2151–3
CASE REPORT WALTHER ET AL OFF-PUMP MYOCARDIAL REVASCULARIZATION IN INFANT
2151
The intervention was conducted under extracorporeal circulation with aortic cross clamping and antegrade cardioplegia under hypothermia at 28°C (esophageal temperature). The mitral valve was exposed from the right atrium by the transseptal approach. The valvular cusps were removed; consequently the pulmonary autograft was inserted and sutured using a continuous running 5-0 Prolene suture (Ethicon, Somerville, NJ). Valvular continence was optimal as checked with saline.
Fig 2. Top view of the Gore-Tex prosthesis with the sutured encased autograft.
started with only a partial improvement of clinical conditions. After arriving at our center, we confirmed the clinical and echocardiographic findings, and because the medical treatment did not improve his clinical conditions, we decided to submit the infant (aged 80 days) to surgical correction. The operative findings indicated serious technical difficulties for a valve repair. Therefore, intervention was made with the Ross-Kabbani operation. The predischarge echocardiogram showed a mild regurgitation of the autograft with normal left ventricular function. In the postoperative course, nitrous oxide and inotropic agents were used for 4 and 7 days, respectively. At 2 months follow-up the infant was clinically well with a mild gradient of the autograft in the mitral position.
In conclusion, the Ross-Kabbani operation [3] was a unique solution for these 2 infants, because the surgical treatment was mandatory and neither a mitral valve repair nor a mitral valve replacement with a prosthetic valve were technically feasible for the small dimension of the left atrium. In addition, the young age of these infants did not allow an adequate anticoagulant therapy. The technique we used on our infant patients is relatively new and complex. We believe that we can improve the technique with experience in time. However, the late efficacy of this approach for small infants remains uncertain and long-term follow-up is necessary [4].
References 1. Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet 1967;2(523):956 – 8. 2. Sarraf A, Bruniaux J, Planche C. Ross mitral procedure for massive congenital mitral insufficiency. Arch Mal Coeur Vaiss 2001;94(5):509 –12. 3. Kabbani SS, Jamil H, Hammoud A. Technique for replacing the mitral valve with a pulmonary autograft: the RossKabbani operation. Ann Thorac Surg 2001;72:947––50. 4. Kabbani SS, Jamil H, Hammoud A, et al. Use of the pulmonary autograft for mitral replacement: short- and mediumterm experience. Eur J Cardiothorac Surg 2001;20:257– 61.
Surgical Technique The heart was approached through a median sternotomy and normothermic cardiopulmonary bypass was established. The pulmonary trunk was isolated to the beating heart. Distally the trunk was sectioned just proximal to its bifurcation, and at proximal level it was cut “under” the valvular cusps, leaving a rim of infundibular muscle of about 3 mm. The right ventricular outflow tract was reconstructed with a homograft. Next, the mitral substitute was constructed by encasing the autologous pulmonary valve inside an armed Gore-Tex prosthesis (IMPRA, C. R. Bard, Murray Hill, NJ) (Fig 2). The pulmonary valve was attached to the tube with proximal and distal running 7-0 Prolene sutures (Ethicon, Somerville, NJ). The circumference of the prosthesis was interrupted by performing one longitudinal incision in patient 1 and two longitudinal incisions in the patient 2. The incisions were performed through the whole height of the prosthesis, thus obtaining a cleft about 1 to 2 mm in width; in this way we hope to ensure growth of the encased autograft with the growth of the child. The size of the prosthesis was chosen according to the size of the pulmonary autograft (ie, 15 mm in the patient 1 and 14 mm in patient 2). © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Beating Heart Off-Pump Myocardial Revascularization in an Infant Thomas Walther, MD, PhD, Ingo Dähnert, MD, Herbert Kiefer, MD, Volkmar Falk, MD, PhD, Martin Kostelka, MD, PhD, and Friedrich W. Mohr, MD, PhD Klinik für Herzchirurgie, Klinik für Kinderkardiologie, and Klinik für Anästhesie, Herzzentrum, Universität Leipzig, Leipzig, Germany
A 6-week-old patient weighing 4 kg was admitted for surgical correction of anomalous left coronary artery from the pulmonary artery. Reimplantation of the coronary arAccepted for publication Dec 2, 2003. Address reprint requests to Dr Walther, Klinik für Herzchirurgie, Herzzentrum, Universität Leipzig, Strümpellstr 39, 04289 Leipzig, Germany; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.12.044
FEATURE ARTICLES
Comment
2152
CASE REPORT WALTHER ET AL OFF-PUMP MYOCARDIAL REVASCULARIZATION IN INFANT
Fig 1. Exposure of proximal left anterior descending coronary artery (LAD) using an Octopus stabilizer. The view is from the head of the patient caudally, and the left side of the patient is to the left. The two tips of the stabilizer are beside the most proximal part of the LAD; the white base of the stabilizer is just above the apex of the heart. FEATURE ARTICLES
tery with cardiopulmonary bypass was impossible because the patient also had hereditary spherocytosis, which put him at risk for hemolytic anemia. Thus, closure of the left main stem and left internal mammary artery–left anterior descending coronary artery bypass grafting were performed successfully with the heart beating. (Ann Thorac Surg 2005;79:2151–3) © 2005 by The Society of Thoracic Surgeons
A
Ann Thorac Surg 2005;79:2151–3
IU), the proximal left anterior descending coronary artery was exposed using a stay suture and with an Octopus 4 stabilizer applying direct pressure and suction (Fig 1). The anastomosis was performed using interrupted sutures of 8-0 Prolene. Postoperative flow measurement was 18 mL/ min, and myocardial function was slightly improved. Primary chest closure was feasible. With moderate inotropic support, the patient was transferred to the pediatric intensive care unit. Extubation was performed after 11 hours. There was a regression of preexisting ST-segment elevation. Inotropic agents were withdrawn gradually, and therapy with an angiotensin-converting enzyme inhibitor was initiated. Echocardiography after 10 days revealed improvement in global left ventricular function (ejection fraction, 0.35), no more akinsis of the left ventricular wall, and only moderate residual (1°) mitral incompetence. Control angiography revealed an open graft with good perfusion of the left anterior descending coronary artery as well as marked improvement in myocardial function (Fig 2). The infant had an uneventful further recovery and was discharged on postoperative day 15.
Comment Anomalous left coronary artery from the pulmonary artery in combination with hereditary spherocytosis is an extremely rare condition. Standard corrective surgical therapy cannot be performed, as the use of CPB is contraindicated. Only 11 patients (aged 1.3 to 67 years; median age, 16 years) with hereditary spherocytosis and undergoing an open
nomalous left coronary artery from the pulmonary artery is a serious diagnosis associated with coronary steal and ischemia as well as progressive deterioration in left ventricular function. Standard therapy consists of coronary artery reimplantation or creation of a transpulmonary artery baffle with cardiopulmonary bypass (CPB). Eventually, postoperative circulatory assistance is required. However, in patients who also have hereditary spherocytosis, CPB is contraindicated because of the risk of severe hemolysis leading to multiple-organ failure. We present an alternative approach.
A 6-week-old patient weighing 4 kg, and measuring 55 cm long with hereditary spherocytosis was admitted because of a cardiac malformation. The electrocardiogram revealed myocardial ischemia with a deep Q wave in leads I, II, and aVl and ST segment elevation in V5 and V6. Echocardiography showed a severe decrease in left ventricular function (ejection fraction, 0.21) and moderate to severe (2–3) mitral incompetence. At cardiac catheterization, the diagnosis of anomalous coronary artery from the pulmonary artery with the left main stem originating posteriorly from the main pulmonary artery was confirmed. Operation was performed through a median sternotomy. Myocardial function was severely depressed, and the heart was enlarged. After careful dissection, the left main stem was closed using two titanium clips. The left internal mammary artery with an internal diameter of less than 1 mm was dissected as a pedicle. After heparinization (100
Fig 2. Postoperative angiogram, left anterior oblique 90-degree view showing good left internal mammary artery–left anterior descending coronary artery perfusion with satisfactory filling of the septal branches.
Ann Thorac Surg 2005;79:2153–5
References 1. Aoyagi S, Kawano H, Tomoeda H, Hiratsuka R, Kawara T. Open heart operation in a patient with hereditary spherocytosis: a case report. Ann Thorac Cardiovasc Surg 2001;7:375–7. 2. De Leval MR, Taswell HF, Bowie EJW, Danielson GK. Open heart surgery in patients with inherited hemoglobinopathies, red cell dyscrasias, and coagulopathies. Arch Surg 1974;109: 618 –22. 3. Gayyed NL, Bouboulis N, Holden MP. Open heart operation in patients suffering from hereditary spherocytosis. Ann Thorac Surg 1993;55:1497–500. 4. Dal A, Kumar RS. Open heart surgery in presence of hereditary spherocytosis. J Cardiovasc Surg (Torino) 1995;36:447– 8. 5. Brackenbury E, Gardiner H, Chan K, Hickey M. Internal mammary artery to coronary artery bypass in paediatric cardiac surgery. Eur J Cardio-thorac Surg 1998;14:639 – 42.
Mild Supravalvular Aortic Stenosis With Left Coronary Obstruction in a Neonate Neville A. G. Solomon, MCh, Kirsten A. Finucane, FRACS, Jonathan R. Skinner, FRACP, and Alan Kerr, FRACS Departments of Pediatric Cardiac Surgery and Pediatric Cardiology, Green Lane Hospital, Auckland, New Zealand
A premature infant with a large patent ductus arteriosus and mild supravalvular aortic stenosis had evidence Accepted for publication Dec 2, 2003. Address reprint requests to Dr Solomon, Department of Cardiothoracic Surgery, Green Lane Hospital, Auckland, New Zealand; e-mail: [email protected].
© 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
2153
of severe myocardial ischemia after ductus ligation. Urgent reoperation was required to relieve severe obstruction of the left coronary orifice and the supravalvular stenosis was repaired. This unusual presentation early in infancy emphasizes that left coronary artery obstruction should be suspected even in the presence of mild supravalvular stenosis. (Ann Thorac Surg 2005;79:2153–5) © 2005 by The Society of Thoracic Surgeons
C
hildren with supravalvular aortic stenosis (SVAS) rarely require surgical treatment in early infancy. The association of SVAS with left coronary artery obstruction is well known, but the degree of SVAS present in this situation is usually severe. We report the case of a premature infant with mild SVAS and large patent ductus arteriosus in whom the presence of myocardial ischemia was not initially appreciated. A male infant weighing 930 g was delivered by emergency cesarean section at 28 weeks gestation after intrauterine death of a twin secondary to twin to twin transfusion. The child was ventilated for 5 days and was on inotropic agents for 7 days. Early echocardiograms showed a patent ductus arteriosus that failed to close with a single course of indomethacin. A later echocardiogram showed a large patent ductus arteriosus with significant dilatation of the left atrium and left ventricle. There was mild SVAS with a peak velocity of 2.4 m/s, and the aortic valve was domed in systole, but was tricuspid and only mildly thickened. Moderate left ventricular hypertrophy was noted and left ventricular function was low to normal. There was associated mild pulmonary valvar stenosis with a peak velocity of 3.2 m/s and doming of the pulmonary valve leaflets. The baby had no features of Williams syndrome and no family history of SVAS. An electrocardiogram (ECG) at 6 weeks showed widespread mild segment elevation depression with Twave inversion in leads V2 and V6 I and augmented ventricular left (AVL), (see Fig 1; ECG 1). The echocardiogram had shown some brightness of the papillary muscles and endocardium, and these features did give rise to concern about ischemia, although their full significance was not appreciated at this stage. At 10 weeks of age (weight 2.9 kg) the infant’s progress was satisfactory without oxygen or respiratory support, but he required regular diuretics. The segment elevation changes had become slightly more noticeable (see Fig 1; ECG 2). Echocardiographic features of SVAS remained mild. In view of the clinical and echocardiographic evidence of a large left to right ductal shunt, the ductus was ligated through a left thoracotomy. The procedure was uneventful. That evening, the patient had progressive low cardiac output develop with worsening myocardial ischemia, possibly aggravated by administration of phenoxybenzamine. After a brief period of cardiac massage and commencement of norepinephrine, there was some improvement in hemodynamics. Echocardiography revealed moderate impairment of left ventricular function. 0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.12.064
FEATURE ARTICLES
heart operation with CPD have been described in the literature [1– 4]. Seven of them had undergone a previous splenectomy when they were older than 5 years. Preoperatively we discussed whether corrective surgical intervention was feasible in our patient, but we judged the potential risk of hemolytic crisis to be too high and decided on the alternative approach presented. Left internal mammary artery–left anterior descending coronary artery bypass grafting has been performed successfully in 3 children with anomalous left coronary artery from the pulmonary artery using CPB [5]. Thus, although not the current standard, left internal mammary artery– left anterior descending coronary artery bypass is a legitimate approach to treat patients with anomalous left coronary artery from the pulmonary artery. Furthermore, we did not have any other option, as the use of CPB was clearly contraindicated in our patient. Left anterior descending coronary artery ligation alone seems to be acceptable only as an emergency procedure. We are not aware of other reports of successful beating-heart offpump myocardial revascularization in an infant with a body weight of 4 kg. This operation can be performed successfully even in very young patients.
CASE REPORT SOLOMON ET AL LEFT CORONARY OBSTRUCTION IN A NEONATE
CASE REPORT WALTHER ET AL OFF-PUMP MYOCARDIAL REVASCULARIZATION IN INFANT
2151
The intervention was conducted under extracorporeal circulation with aortic cross clamping and antegrade cardioplegia under hypothermia at 28°C (esophageal temperature). The mitral valve was exposed from the right atrium by the transseptal approach. The valvular cusps were removed; consequently the pulmonary autograft was inserted and sutured using a continuous running 5-0 Prolene suture (Ethicon, Somerville, NJ). Valvular continence was optimal as checked with saline.
Fig 2. Top view of the Gore-Tex prosthesis with the sutured encased autograft.
started with only a partial improvement of clinical conditions. After arriving at our center, we confirmed the clinical and echocardiographic findings, and because the medical treatment did not improve his clinical conditions, we decided to submit the infant (aged 80 days) to surgical correction. The operative findings indicated serious technical difficulties for a valve repair. Therefore, intervention was made with the Ross-Kabbani operation. The predischarge echocardiogram showed a mild regurgitation of the autograft with normal left ventricular function. In the postoperative course, nitrous oxide and inotropic agents were used for 4 and 7 days, respectively. At 2 months follow-up the infant was clinically well with a mild gradient of the autograft in the mitral position.
In conclusion, the Ross-Kabbani operation [3] was a unique solution for these 2 infants, because the surgical treatment was mandatory and neither a mitral valve repair nor a mitral valve replacement with a prosthetic valve were technically feasible for the small dimension of the left atrium. In addition, the young age of these infants did not allow an adequate anticoagulant therapy. The technique we used on our infant patients is relatively new and complex. We believe that we can improve the technique with experience in time. However, the late efficacy of this approach for small infants remains uncertain and long-term follow-up is necessary [4].
References 1. Ross DN. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet 1967;2(523):956 – 8. 2. Sarraf A, Bruniaux J, Planche C. Ross mitral procedure for massive congenital mitral insufficiency. Arch Mal Coeur Vaiss 2001;94(5):509 –12. 3. Kabbani SS, Jamil H, Hammoud A. Technique for replacing the mitral valve with a pulmonary autograft: the RossKabbani operation. Ann Thorac Surg 2001;72:947––50. 4. Kabbani SS, Jamil H, Hammoud A, et al. Use of the pulmonary autograft for mitral replacement: short- and mediumterm experience. Eur J Cardiothorac Surg 2001;20:257– 61.
Surgical Technique The heart was approached through a median sternotomy and normothermic cardiopulmonary bypass was established. The pulmonary trunk was isolated to the beating heart. Distally the trunk was sectioned just proximal to its bifurcation, and at proximal level it was cut “under” the valvular cusps, leaving a rim of infundibular muscle of about 3 mm. The right ventricular outflow tract was reconstructed with a homograft. Next, the mitral substitute was constructed by encasing the autologous pulmonary valve inside an armed Gore-Tex prosthesis (IMPRA, C. R. Bard, Murray Hill, NJ) (Fig 2). The pulmonary valve was attached to the tube with proximal and distal running 7-0 Prolene sutures (Ethicon, Somerville, NJ). The circumference of the prosthesis was interrupted by performing one longitudinal incision in patient 1 and two longitudinal incisions in the patient 2. The incisions were performed through the whole height of the prosthesis, thus obtaining a cleft about 1 to 2 mm in width; in this way we hope to ensure growth of the encased autograft with the growth of the child. The size of the prosthesis was chosen according to the size of the pulmonary autograft (ie, 15 mm in the patient 1 and 14 mm in patient 2). © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Beating Heart Off-Pump Myocardial Revascularization in an Infant Thomas Walther, MD, PhD, Ingo Dähnert, MD, Herbert Kiefer, MD, Volkmar Falk, MD, PhD, Martin Kostelka, MD, PhD, and Friedrich W. Mohr, MD, PhD Klinik für Herzchirurgie, Klinik für Kinderkardiologie, and Klinik für Anästhesie, Herzzentrum, Universität Leipzig, Leipzig, Germany
A 6-week-old patient weighing 4 kg was admitted for surgical correction of anomalous left coronary artery from the pulmonary artery. Reimplantation of the coronary arAccepted for publication Dec 2, 2003. Address reprint requests to Dr Walther, Klinik für Herzchirurgie, Herzzentrum, Universität Leipzig, Strümpellstr 39, 04289 Leipzig, Germany; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.12.044
FEATURE ARTICLES
Comment
2152
CASE REPORT WALTHER ET AL OFF-PUMP MYOCARDIAL REVASCULARIZATION IN INFANT
Fig 1. Exposure of proximal left anterior descending coronary artery (LAD) using an Octopus stabilizer. The view is from the head of the patient caudally, and the left side of the patient is to the left. The two tips of the stabilizer are beside the most proximal part of the LAD; the white base of the stabilizer is just above the apex of the heart. FEATURE ARTICLES
tery with cardiopulmonary bypass was impossible because the patient also had hereditary spherocytosis, which put him at risk for hemolytic anemia. Thus, closure of the left main stem and left internal mammary artery–left anterior descending coronary artery bypass grafting were performed successfully with the heart beating. (Ann Thorac Surg 2005;79:2151–3) © 2005 by The Society of Thoracic Surgeons
A
Ann Thorac Surg 2005;79:2151–3
IU), the proximal left anterior descending coronary artery was exposed using a stay suture and with an Octopus 4 stabilizer applying direct pressure and suction (Fig 1). The anastomosis was performed using interrupted sutures of 8-0 Prolene. Postoperative flow measurement was 18 mL/ min, and myocardial function was slightly improved. Primary chest closure was feasible. With moderate inotropic support, the patient was transferred to the pediatric intensive care unit. Extubation was performed after 11 hours. There was a regression of preexisting ST-segment elevation. Inotropic agents were withdrawn gradually, and therapy with an angiotensin-converting enzyme inhibitor was initiated. Echocardiography after 10 days revealed improvement in global left ventricular function (ejection fraction, 0.35), no more akinsis of the left ventricular wall, and only moderate residual (1°) mitral incompetence. Control angiography revealed an open graft with good perfusion of the left anterior descending coronary artery as well as marked improvement in myocardial function (Fig 2). The infant had an uneventful further recovery and was discharged on postoperative day 15.
Comment Anomalous left coronary artery from the pulmonary artery in combination with hereditary spherocytosis is an extremely rare condition. Standard corrective surgical therapy cannot be performed, as the use of CPB is contraindicated. Only 11 patients (aged 1.3 to 67 years; median age, 16 years) with hereditary spherocytosis and undergoing an open
nomalous left coronary artery from the pulmonary artery is a serious diagnosis associated with coronary steal and ischemia as well as progressive deterioration in left ventricular function. Standard therapy consists of coronary artery reimplantation or creation of a transpulmonary artery baffle with cardiopulmonary bypass (CPB). Eventually, postoperative circulatory assistance is required. However, in patients who also have hereditary spherocytosis, CPB is contraindicated because of the risk of severe hemolysis leading to multiple-organ failure. We present an alternative approach.
A 6-week-old patient weighing 4 kg, and measuring 55 cm long with hereditary spherocytosis was admitted because of a cardiac malformation. The electrocardiogram revealed myocardial ischemia with a deep Q wave in leads I, II, and aVl and ST segment elevation in V5 and V6. Echocardiography showed a severe decrease in left ventricular function (ejection fraction, 0.21) and moderate to severe (2–3) mitral incompetence. At cardiac catheterization, the diagnosis of anomalous coronary artery from the pulmonary artery with the left main stem originating posteriorly from the main pulmonary artery was confirmed. Operation was performed through a median sternotomy. Myocardial function was severely depressed, and the heart was enlarged. After careful dissection, the left main stem was closed using two titanium clips. The left internal mammary artery with an internal diameter of less than 1 mm was dissected as a pedicle. After heparinization (100
Fig 2. Postoperative angiogram, left anterior oblique 90-degree view showing good left internal mammary artery–left anterior descending coronary artery perfusion with satisfactory filling of the septal branches.
Ann Thorac Surg 2005;79:2153–5
References 1. Aoyagi S, Kawano H, Tomoeda H, Hiratsuka R, Kawara T. Open heart operation in a patient with hereditary spherocytosis: a case report. Ann Thorac Cardiovasc Surg 2001;7:375–7. 2. De Leval MR, Taswell HF, Bowie EJW, Danielson GK. Open heart surgery in patients with inherited hemoglobinopathies, red cell dyscrasias, and coagulopathies. Arch Surg 1974;109: 618 –22. 3. Gayyed NL, Bouboulis N, Holden MP. Open heart operation in patients suffering from hereditary spherocytosis. Ann Thorac Surg 1993;55:1497–500. 4. Dal A, Kumar RS. Open heart surgery in presence of hereditary spherocytosis. J Cardiovasc Surg (Torino) 1995;36:447– 8. 5. Brackenbury E, Gardiner H, Chan K, Hickey M. Internal mammary artery to coronary artery bypass in paediatric cardiac surgery. Eur J Cardio-thorac Surg 1998;14:639 – 42.
Mild Supravalvular Aortic Stenosis With Left Coronary Obstruction in a Neonate Neville A. G. Solomon, MCh, Kirsten A. Finucane, FRACS, Jonathan R. Skinner, FRACP, and Alan Kerr, FRACS Departments of Pediatric Cardiac Surgery and Pediatric Cardiology, Green Lane Hospital, Auckland, New Zealand
A premature infant with a large patent ductus arteriosus and mild supravalvular aortic stenosis had evidence Accepted for publication Dec 2, 2003. Address reprint requests to Dr Solomon, Department of Cardiothoracic Surgery, Green Lane Hospital, Auckland, New Zealand; e-mail: [email protected].
© 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
2153
of severe myocardial ischemia after ductus ligation. Urgent reoperation was required to relieve severe obstruction of the left coronary orifice and the supravalvular stenosis was repaired. This unusual presentation early in infancy emphasizes that left coronary artery obstruction should be suspected even in the presence of mild supravalvular stenosis. (Ann Thorac Surg 2005;79:2153–5) © 2005 by The Society of Thoracic Surgeons
C
hildren with supravalvular aortic stenosis (SVAS) rarely require surgical treatment in early infancy. The association of SVAS with left coronary artery obstruction is well known, but the degree of SVAS present in this situation is usually severe. We report the case of a premature infant with mild SVAS and large patent ductus arteriosus in whom the presence of myocardial ischemia was not initially appreciated. A male infant weighing 930 g was delivered by emergency cesarean section at 28 weeks gestation after intrauterine death of a twin secondary to twin to twin transfusion. The child was ventilated for 5 days and was on inotropic agents for 7 days. Early echocardiograms showed a patent ductus arteriosus that failed to close with a single course of indomethacin. A later echocardiogram showed a large patent ductus arteriosus with significant dilatation of the left atrium and left ventricle. There was mild SVAS with a peak velocity of 2.4 m/s, and the aortic valve was domed in systole, but was tricuspid and only mildly thickened. Moderate left ventricular hypertrophy was noted and left ventricular function was low to normal. There was associated mild pulmonary valvar stenosis with a peak velocity of 3.2 m/s and doming of the pulmonary valve leaflets. The baby had no features of Williams syndrome and no family history of SVAS. An electrocardiogram (ECG) at 6 weeks showed widespread mild segment elevation depression with Twave inversion in leads V2 and V6 I and augmented ventricular left (AVL), (see Fig 1; ECG 1). The echocardiogram had shown some brightness of the papillary muscles and endocardium, and these features did give rise to concern about ischemia, although their full significance was not appreciated at this stage. At 10 weeks of age (weight 2.9 kg) the infant’s progress was satisfactory without oxygen or respiratory support, but he required regular diuretics. The segment elevation changes had become slightly more noticeable (see Fig 1; ECG 2). Echocardiographic features of SVAS remained mild. In view of the clinical and echocardiographic evidence of a large left to right ductal shunt, the ductus was ligated through a left thoracotomy. The procedure was uneventful. That evening, the patient had progressive low cardiac output develop with worsening myocardial ischemia, possibly aggravated by administration of phenoxybenzamine. After a brief period of cardiac massage and commencement of norepinephrine, there was some improvement in hemodynamics. Echocardiography revealed moderate impairment of left ventricular function. 0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.12.064
FEATURE ARTICLES
heart operation with CPD have been described in the literature [1– 4]. Seven of them had undergone a previous splenectomy when they were older than 5 years. Preoperatively we discussed whether corrective surgical intervention was feasible in our patient, but we judged the potential risk of hemolytic crisis to be too high and decided on the alternative approach presented. Left internal mammary artery–left anterior descending coronary artery bypass grafting has been performed successfully in 3 children with anomalous left coronary artery from the pulmonary artery using CPB [5]. Thus, although not the current standard, left internal mammary artery– left anterior descending coronary artery bypass is a legitimate approach to treat patients with anomalous left coronary artery from the pulmonary artery. Furthermore, we did not have any other option, as the use of CPB was clearly contraindicated in our patient. Left anterior descending coronary artery ligation alone seems to be acceptable only as an emergency procedure. We are not aware of other reports of successful beating-heart offpump myocardial revascularization in an infant with a body weight of 4 kg. This operation can be performed successfully even in very young patients.
CASE REPORT SOLOMON ET AL LEFT CORONARY OBSTRUCTION IN A NEONATE