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Origin of the left anterior descending coronary artery from the left mammary artery
Volume
108
Number
5
19.
20.
21.
22.
23.
24.
25.
27.
1377
Occluder disruption of Wada-Cutter valve prosthesis. Ann Thorac Sure 20~256. 1975. Roberts AK: Lambert CJ, Mitchel BF: Embolization of disc occluder of a Wada-Cutter mitral prosthesis with survival. Ann Thorac Surg 21:361, 1976. :Montoya A, Sullivan JH, Pifarre R: Disc variance: A potentially lethal complication of the Beall valve prosthesis. J Thorac Cardiovasc Surg 71:904, 1976. Ansbro J, Clark R, Gerbode F: Successful surgical correction of an embolized prosthetic valve poppet: Case report.J Thorat Cardiovasc Surg 72:130, 1976. Pifarre R, Montoya A, Bakhos M, Fishman D, Scanlon PJ, Gunner RM: Poppet embolization from Braunwald-Cutter aortic valve. JAMA 238:2057, 1977. Norenberg DD, Evans EW, Gundersen AE, Abellera RM: Fracture and embolization of a Bjork-Shiley disc. J Thorac Cardiovasc Surg 74:925, 1977. Arvan SB, Kunstadt DZ Disc embolism to the left atrium. Dislodgment of disc of Beall prosthetic mitral valve into the left atrium. Chest 73:562, 1978. Gelfand ET, Callaghan JC, Taylor RF: Survival after late disc dislodgment of a mitral Wada-Cutter prosthesis. Can J Surg 2 1:248,
26.
Brief communications
1978.
Schachner A, Vidne B, Levy MJ: Retrograde (atrial) dislodgement of a Cross-Jones mitral valve occluder. Stand J Thorac Cardiovasc Surg 13:263, 1979. McEnany MT, Wheeler EO, Austen G: Survival following fracture of strut from mitral prosthesis with disc translocation. J Thorac Cardiovasc Surg 78:136, 1979. 1. Schematic presentation of the coronary arterial circulation.
Fig.
Origin of the left anterior descending coronary artery from the left mammary artery
worthwhile to report our case in which such a situation indeed occurred. Our patient
Francis Robicsek, M.D. Charlotte, N.C.
With the more and more extensive applications of techniques of coronary angiography, anomaliesof the origin of the coronary arteries are discovered with increasing frequency. Most cases reported in the literature involve either misplacement of the ostia within the sinusesof Valsalva or the rise of one or both coronary arteries from the main pulmonary trunk.1~3~5~7-8 There are only a handful of reports which describethe origin of the coronary vessels from peripheral arteries, the innominatelOand the carotid arteries,4,6respectively, and we know of no account regarding the rise of the anterior descending coronary artery from the mammary artery. Becausesuch a casemore or lessestablishesa “physiological basis” for a now commonly practiced operation, i.e., anastomosisof the left mammary to the anterior descendingcoronary, we thought it From the Department Heineman Medical and Medical Center.
of Thoracic and Research Laboratories,
Reprint requests: Francis gery, The Sanger Clinic, Charlotte, NC 28207.
Cardiovascular Charlotte
Robicsek, M.D., P.A., P.O. Box
Surgery Memorial
Thoracic/Cardiovaacular 220868, 1960 Randolph
and the Hospital SurRd.,
was a b-year-old
boy known to have a heart
murmur and cyanosissincebirth. At the age of 3 months, the tentative clinical diagnosisof tetralogy of Fallot was established,but becauseof his well compensatedcondition, he did not undergo hemodynamic studies until the age of four. At that time, pertinent studies confirmed the presenceof a typical tetralogy of Fallot anomaly. The dye injected in the right atrium rapidly entered the right ventricle and from there traveled into the ascendingaorta as well as the pulmonary artery. Presenceof an infundibular stenosiswas also well demonstrated on angiogram. The right ventricular pressurewasmeasuredas 110/Oand the pulmonary arterial pressurewasmeasuredas 10/5 mm Hg. Oxygen saturation in the ascending aorta was 76%. Becauseof these findings, it was decided to proceed with complete repair of the tetralogy of Fallot. The heart was exposed through a median sternotomy incision. The right ventricle wasfound to be enlargedand a systolic thrill waspalpated over the outflow tract. While exposing the heart, it was observed that the right coronary, instead of originating from the right sinusof Valsalva, rose from the trunk of the left coronary artery behind the main puhnonary artery, crossedthe pulmonary conus, and continued in the right atrioventricular groove in a further normal course(Fig. 1). It wasalsonoted that at the region of the apex there were some“adhesions” which on closer inspection turned out to be a well-developed free
November,
1378
Brief communications
Fig.
REFERENCES
2. 3. 4. 5. 6. 7.
Heart
1884 Journal
2. The anomalousleft anterior descendingcoronary artery asseenduring surgery.
band of connective tissuescontaining a sizable artery as well as a vein. These vesselsoriginated from the supradiaphragmatic portion of the mammary artery and vein and continued upward in the interventricular groove as a left anterior descending coronary vessel (Fig. 2). They gave off several branchesuntil they gradually terminated at the level of the pulmonic valve. No other arterial or venous supply was found in the anterior portion of the heart which could have been identified asthe left anterior descendingcoronary artery and vein. Being careful not to injure these vessels,repair of the tetralogy of Fallot wascarried out, which included patch closureof a large interventricular septal defect and resection of the infundibular stenosis.To avoid injury to the right coronary artery crossing the outflow tract, the ventriculotomy incision was done in a transverse fashion.rrv The recovery of the patient was uneventful and he left the hospital 8 days after the surgery.
1.
American
Bland EF, White PD, Garland J: Congenital anomalies of the coronary arteries: Report of an unusual case associated with cardiac hypertrophy. AM HEART J 8:787,1933. Henle J: Handbuch des systematischen Anatomic des menschen. Braunschweig, 1868. Kimbiris D, Iskandrian AS, Segal BL, Bemis CE: Anomalous aortic origin of coronary arteries. Circulation S&606, 1978. Mayer: quoted by Bland et al.’ J Chir Augen-Heilk 10~44, 1827. Ogden JA: Congenital anomalies of the coronary arteries. Am J Cardiol25:474, 1970. Pitachel: quoted by Bland et al.’ Robicsek F, Sanger PW, Taylor FH: The repair of ventricular septal defer% A technical modification for the prevention of
recurrence and heart block. J Thorac Cardiovasc Surg 41:782, 1961. 8. Sanger PW, Taylor FH, Robicsek F, Cobey WG: Coronary arterio-venous fistula: A clinical and physiologic report of a successfully operated case. Ann Surg 149~572, 1959. 9. Sangei PW, Robicsek F, Taylor FH: The surgical repair of ventricular septal defects through transverse ventriculotomy. Surgery 51:601, 1962. 10. Vernon HI-h quoted by Bland et al.’ Medico-Chir Trans 39:297, 1856.
Decreased therapy
serum tithium during verapamil
Larry A. Weinrauch, M.D., Steele Belok, M.D., and John A. D’Elia, M.D. Cambridge and Boston, Mass.
Known drug interactions involving verapamil include competition for protein binding sites-i.e., sodiumwarfarin is less highly bound, which could lead to profound prolongation of the prothrombin time if verapamil occupied all the available binding sites.’ Convemely, if diphenylhydantoin, another drug with high protein binding,
From the Departmente of Medicine, Mount Auburn and New England Deaconess Hospitals and the Harvard Medical School. Reprint requests John A. D’Elia, M.D., Joelin Renal Unit, One Jo&n Place, Boston, MA 02215.
108
Number
5
19.
20.
21.
22.
23.
24.
25.
27.
1377
Occluder disruption of Wada-Cutter valve prosthesis. Ann Thorac Sure 20~256. 1975. Roberts AK: Lambert CJ, Mitchel BF: Embolization of disc occluder of a Wada-Cutter mitral prosthesis with survival. Ann Thorac Surg 21:361, 1976. :Montoya A, Sullivan JH, Pifarre R: Disc variance: A potentially lethal complication of the Beall valve prosthesis. J Thorac Cardiovasc Surg 71:904, 1976. Ansbro J, Clark R, Gerbode F: Successful surgical correction of an embolized prosthetic valve poppet: Case report.J Thorat Cardiovasc Surg 72:130, 1976. Pifarre R, Montoya A, Bakhos M, Fishman D, Scanlon PJ, Gunner RM: Poppet embolization from Braunwald-Cutter aortic valve. JAMA 238:2057, 1977. Norenberg DD, Evans EW, Gundersen AE, Abellera RM: Fracture and embolization of a Bjork-Shiley disc. J Thorac Cardiovasc Surg 74:925, 1977. Arvan SB, Kunstadt DZ Disc embolism to the left atrium. Dislodgment of disc of Beall prosthetic mitral valve into the left atrium. Chest 73:562, 1978. Gelfand ET, Callaghan JC, Taylor RF: Survival after late disc dislodgment of a mitral Wada-Cutter prosthesis. Can J Surg 2 1:248,
26.
Brief communications
1978.
Schachner A, Vidne B, Levy MJ: Retrograde (atrial) dislodgement of a Cross-Jones mitral valve occluder. Stand J Thorac Cardiovasc Surg 13:263, 1979. McEnany MT, Wheeler EO, Austen G: Survival following fracture of strut from mitral prosthesis with disc translocation. J Thorac Cardiovasc Surg 78:136, 1979. 1. Schematic presentation of the coronary arterial circulation.
Fig.
Origin of the left anterior descending coronary artery from the left mammary artery
worthwhile to report our case in which such a situation indeed occurred. Our patient
Francis Robicsek, M.D. Charlotte, N.C.
With the more and more extensive applications of techniques of coronary angiography, anomaliesof the origin of the coronary arteries are discovered with increasing frequency. Most cases reported in the literature involve either misplacement of the ostia within the sinusesof Valsalva or the rise of one or both coronary arteries from the main pulmonary trunk.1~3~5~7-8 There are only a handful of reports which describethe origin of the coronary vessels from peripheral arteries, the innominatelOand the carotid arteries,4,6respectively, and we know of no account regarding the rise of the anterior descending coronary artery from the mammary artery. Becausesuch a casemore or lessestablishesa “physiological basis” for a now commonly practiced operation, i.e., anastomosisof the left mammary to the anterior descendingcoronary, we thought it From the Department Heineman Medical and Medical Center.
of Thoracic and Research Laboratories,
Reprint requests: Francis gery, The Sanger Clinic, Charlotte, NC 28207.
Cardiovascular Charlotte
Robicsek, M.D., P.A., P.O. Box
Surgery Memorial
Thoracic/Cardiovaacular 220868, 1960 Randolph
and the Hospital SurRd.,
was a b-year-old
boy known to have a heart
murmur and cyanosissincebirth. At the age of 3 months, the tentative clinical diagnosisof tetralogy of Fallot was established,but becauseof his well compensatedcondition, he did not undergo hemodynamic studies until the age of four. At that time, pertinent studies confirmed the presenceof a typical tetralogy of Fallot anomaly. The dye injected in the right atrium rapidly entered the right ventricle and from there traveled into the ascendingaorta as well as the pulmonary artery. Presenceof an infundibular stenosiswas also well demonstrated on angiogram. The right ventricular pressurewasmeasuredas 110/Oand the pulmonary arterial pressurewasmeasuredas 10/5 mm Hg. Oxygen saturation in the ascending aorta was 76%. Becauseof these findings, it was decided to proceed with complete repair of the tetralogy of Fallot. The heart was exposed through a median sternotomy incision. The right ventricle wasfound to be enlargedand a systolic thrill waspalpated over the outflow tract. While exposing the heart, it was observed that the right coronary, instead of originating from the right sinusof Valsalva, rose from the trunk of the left coronary artery behind the main puhnonary artery, crossedthe pulmonary conus, and continued in the right atrioventricular groove in a further normal course(Fig. 1). It wasalsonoted that at the region of the apex there were some“adhesions” which on closer inspection turned out to be a well-developed free
November,
1378
Brief communications
Fig.
REFERENCES
2. 3. 4. 5. 6. 7.
Heart
1884 Journal
2. The anomalousleft anterior descendingcoronary artery asseenduring surgery.
band of connective tissuescontaining a sizable artery as well as a vein. These vesselsoriginated from the supradiaphragmatic portion of the mammary artery and vein and continued upward in the interventricular groove as a left anterior descending coronary vessel (Fig. 2). They gave off several branchesuntil they gradually terminated at the level of the pulmonic valve. No other arterial or venous supply was found in the anterior portion of the heart which could have been identified asthe left anterior descendingcoronary artery and vein. Being careful not to injure these vessels,repair of the tetralogy of Fallot wascarried out, which included patch closureof a large interventricular septal defect and resection of the infundibular stenosis.To avoid injury to the right coronary artery crossing the outflow tract, the ventriculotomy incision was done in a transverse fashion.rrv The recovery of the patient was uneventful and he left the hospital 8 days after the surgery.
1.
American
Bland EF, White PD, Garland J: Congenital anomalies of the coronary arteries: Report of an unusual case associated with cardiac hypertrophy. AM HEART J 8:787,1933. Henle J: Handbuch des systematischen Anatomic des menschen. Braunschweig, 1868. Kimbiris D, Iskandrian AS, Segal BL, Bemis CE: Anomalous aortic origin of coronary arteries. Circulation S&606, 1978. Mayer: quoted by Bland et al.’ J Chir Augen-Heilk 10~44, 1827. Ogden JA: Congenital anomalies of the coronary arteries. Am J Cardiol25:474, 1970. Pitachel: quoted by Bland et al.’ Robicsek F, Sanger PW, Taylor FH: The repair of ventricular septal defer% A technical modification for the prevention of
recurrence and heart block. J Thorac Cardiovasc Surg 41:782, 1961. 8. Sanger PW, Taylor FH, Robicsek F, Cobey WG: Coronary arterio-venous fistula: A clinical and physiologic report of a successfully operated case. Ann Surg 149~572, 1959. 9. Sangei PW, Robicsek F, Taylor FH: The surgical repair of ventricular septal defects through transverse ventriculotomy. Surgery 51:601, 1962. 10. Vernon HI-h quoted by Bland et al.’ Medico-Chir Trans 39:297, 1856.
Decreased therapy
serum tithium during verapamil
Larry A. Weinrauch, M.D., Steele Belok, M.D., and John A. D’Elia, M.D. Cambridge and Boston, Mass.
Known drug interactions involving verapamil include competition for protein binding sites-i.e., sodiumwarfarin is less highly bound, which could lead to profound prolongation of the prothrombin time if verapamil occupied all the available binding sites.’ Convemely, if diphenylhydantoin, another drug with high protein binding,
From the Departmente of Medicine, Mount Auburn and New England Deaconess Hospitals and the Harvard Medical School. Reprint requests John A. D’Elia, M.D., Joelin Renal Unit, One Jo&n Place, Boston, MA 02215.