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Tetralogy of Fallot with anomalous origin of left anterior descending coronary artery
J
THoRAc CARDIOVASC SURG
1987;94:784-7
Tetralogy of Fallot with anomalous origin of left anterior descending coronary artery Surgical options Anomalous origin of the left anterior descending coronary artery from the right coronary artery can interfere with the location of the usual ventriculotomy during repair of tetralogy of FaUot. The purpose of thisstudy was to compare the results of twooperative techniques: (1) a "tailored" right ventricular incision and outflow patch reconstruction and (2) placement of a conduit from the right ventricle to the main pulmonary artery. We reviewed the records of 416 patients who hadcomplete repair of tetralogy of FaUot at the Mayo Clinic from 1973 through 1984. Twenty (5 % ) (median age 6.5 years) hadanomalous origin of the left anterior descending coronary artery from the right coronary artery. Twelve of these patients had right ventricular outflow patch reconstruction, and eight had placement of a conduit from the right ventricle to the pulmonary artery. Three deaths occurred, aU during hospitalization, two in the patch reconstruction group and one in the conduit group. The average reduction in right ventricular pressure postoperatively was slightly but not significantly greater for the conduit group. These data indicate that correction of tetralogy of FaUot with anomalous origin of theleft anterior descending coronary artery can be done with either patch reconstruction or conduit placement. Selection of the more appropriate procedure depends on the exact location and degree of tortuosity of the anomalous artery and the level and severity of right ventricular outflow obstruction.
Richard A. Humes, MD, David J. Driscoll, MD, Gordon K. Danielson, MD, and Francisco J. Puga, MD, Rochester, Minn.
Origin of the left anterior descending coronary artery from the right coronary artery is the most commonly encountered coronary artery anomaly in the tetralogy of Fallot, occurring in 2% to 9% of patients.l-! This abnormality is important surgically because the anomalous artery courses across the right ventricular outflow tract where the ventriculotomy incision is usually made during surgical repair of the lesion.' We reviewed the recent Mayo Clinic experience with this problem in an effort to compare the efficacy and
From the Section of Pediatric Cardiology and the Section of Thoracic and Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn. Read at the Ninth Annual Scientific Session of the Midwest Pediatric Cardiology Society, Rochester, Minn, September 19-20, 1985. Received for publication Dec. 8, 1986. Accepted for publication Jan. 7, 1987. Address for reprints: David J. Driscoll, MD, Section of Pediatric Cardiology, Mayo Clinic, 200 First S1. S.W., Rochester, MN 55905.
784
outcome of the two procedures for repair of tetralogy of Fallot with anomalous origin of the left coronary artery: (1) right ventricular outflow patch reconstruction and pulmonary valvotomy and (2) conduit from right ventricle to pulmonary artery. From 1973 through 1984,416 patients had complete repair of tetralogy of Fallot at the Mayo Clinic. Twenty patients (5%) had an associated anomalous origin of the left anterior descending coronary artery. The patients' ages ranged from 1.9 years to 39 years (mean 9.9 years, median 6.5 years) at the time of operation. There were 12 male and eight female patients. Thirteen patients had had previous cardiac operations, and several patients had more than one procedure. These procedures included Blalock-Taussig, Waterston, and Potts shunts (four each). There was one open and one closed pulmonary valvotomy. One patient had previous repair of total anomalous pulmonary venous return, and one patient had had an exploratory thoracotomy at another institution for complete repair, at which time the coronary anomaly was discovered and the repair deferred.
Volume 94 Number 5 November 1987
Twelve patients had right ventricular outflow patch reconstruction, and eight had placement of a conduit from the ventricle to the main pulmonary artery (Table I). The mean age of patients in the conduit group (16.3 years) was significantly greater (p < 0.05) than the mean age in the patch reconstruction group (5.8 years). The coronary artery anatomy was known before operation in five of eight patients in the conduit group but in only two of 12 patients in the patch reconstruction group. The number and types of previous cardiac operations were similar for both groups. At the time of operation, pressures in the right ventricle, left ventricle, and pulmonary artery were measured before and after repair. The results of these measurements are shown in Table II. Preoperative and postoperative right ventricular systolic pressures and the ratios of right ventricular to left ventricular pressure were not significantly different between the patch reconstructionand conduit groups. Prerepair peak systolic pressure gradient between the right ventricle and the pulmonary artery was similar for the two groups. .However, this gradient was significantly lower (p < 0.05) in the conduit group after repair. The higher right ventricular pressure after repair in the conduit group may reflect the result in one patient who had significant distal right pulmonary artery obstruction despite surgical attempts at correction. Three deaths occurred, all during hospitalization. There were two deaths in the patch reconstruction group. The first patient had sudden ventricular fibrillation in the operating room, remained in a state of low cardiac output after a difficult resuscitation, and died 2 days after the operation. The second patient in the patch reconstruction group died at 31 days as a result of pneumonia and renal failure that developed 1 week after the operation. The patient in the conduit group had significant unrelieved distal right pulmonary artery obstruction at the site of a previousWaterston shunt despite attempts to enlarge this area. She had a sudden cardiac arrest and died on postoperative day 38. There were no instances of inadvertent coronary artery division.
Discussion Anomalous origin of the left coronary artery from the right coronary artery in tetralogy of Fallot has long been recognized as a potential complicating factor in the corrective operation for this defect.' Standard operative technique usually involves a vertical ventriculotomy along the right ventricular outflow tract, resection of the subpulmonary obstruction, and closure of the ventricu-
Tetralogy of Fallot with anomalous coronary artery
785
Table I. Definitive repair in 20 patients with anomalous origin of the left anterior descending coronary artery
Patch reconstruction RV-PA conduit Total
No. of patients
No. of deaths'
12 8
2 I 3 (15%)
20
Legend: RV, Right ventricle. PA, Pulmonary artery. 'None related to coronary artery injury. All deaths occurred during hospitalization.
lar septal defect.' The anomalous artery arising from the right coronary cusp courses anterior to the aorta and crosses the site where the ventriculotomy usually is made. Inadvertent division of this artery can lead to serious myocardial ischemia, infarction, or death. Because of this potential complication, investigators have advocated precise preoperative delineation of coronary anatomy in tetralogy of Fallot to avoid inadvertent damage to this vessel at operation.>6 In a previous series from our institution, 27 patients with this anomaly were seen from 1955 to 1973.3 The overall mortality in this early series was 30%. The mortality declined to 17% in the last 11 years of that study (1961 to 1972), a figure closer to the 15% mortality in our series. In five of the eight deaths in the earlier series, the anomalous coronary artery was inadvertently divided at the time of operation. Division did not occur in our more recent series. Only two patients in the earlier studies had repair by right ventricle-pulmonary artery conduit, and both survived. The development of synthetic conduits has increased the options for surgical repair of tetralogy of Fallot.'-' In this series, the incidence of anomalous origin of the left coronary artery and its predominance in male patients are similar to findings in other series.v" The choice of operative method was influenced by several factors. In all operations performed between 1973 and 1976, a ventriculotomy and patch outflow reconstruction method was used. The mean age of the patients in the conduit group was significantly greater (16 years) than that in the group having right ventricular outflow tract reconstruction (5.8 years), which may reflect the reluctance to place an artificial conduit in younger children, in whom somatic growth is important. In addition, preoperative knowledge of the abnormal coronary anatomy (62% in the conduit group but only 17% in the patch reconstruction group) may have affected the choice of a conduit insertion. It is clear that patients in this series were not assigned randomly to one of the
The Journal of
786
Humes et al.
Thoracic and Cardiovascular Surgery
Table II. Hemodynamic results in 20 patients with anomalous origin of the left anterior descending coronary artery No. oj patients Patch reconstruction Before repair After repair Conduit Before repair After repair
RV pressure (mmHg)
RV-PA gradient (mm Hg)
Mean
Range
RV:LV ratio*
Mean
Range
90 53
80-100 40-85
1 0.55
63 31
45-85 5-60
2
88 62
75-105 22-85
1 0.64
60 12
23-80 2-20t
5
Anatomy known (No. oj patients)
12
8
Legend: RV, Right ventricle. LV, Left ventricle. PA, Pulmonary artery. * Intraoperative measurement. tp = 0.05, postoperative comparison of reconstruction and conduit.
two operative options. Nevertheless, the hemodynamic results of the two groups were quite similar. The only significant difference between the two methods was more effective reduction of the pressure gradient from right ventricle to pulmonary artery after conduit insertion. Several guidelines may aid in the selection of the preferable operative procedure and the proper timing of operation. Patch reconstruction is the preferred method of repair of tetralogy of Fallot with anomalous origin of the left anterior descending coronary artery. The major advantages of this method are the potential for somatic growth because of the use of autogenous tissue and the avoidance of coronary or cardiac compression by an extracardiac conduit. One must then assess whether adequate relief of pulmonary obstruction can be obtained with this method. The two factors influencing the success of this approach are the coronary artery location and the nature of the right ventricular outflow obstruction. The proximity of the anomalous coronary artery to the right ventricular outflow tract obstruction and the degree of tortuosity of the vessel affect the amount of dissection and retraction of the artery that can be accomplished safely. Inability to adequately retract the artery may limit the extent of the ventriculotomy and hence the degree of relief of obstruction. Similarly, the nature and extent of the subpulmonary obstruction dictate the degree of resection that is necessary. Discrete right ventricular outflow tract stenosis may be resected easily without much coronary dissection or elevation, whereas extensive muscular obstruction may require a more extensive ventriculotomy and coronary artery manipulation. These interrelated anatomic factors may be best evaluated by the surgeon at the time of operation. No specific angiographic criteria exist to aid in this decision. Conduit repair generally is less preferable than right
ventricular outflow tract reconstruction because of potential obstruction of the conduit and absence of growth potential. This is a particular problem in infants and young children. Conduit repair is preferred when previous cardiac operations have resulted in obliteration of the coronary anatomy, making dissection potentially dangerous, or when the criteria of vessel tortuosity and location necessary for performance of the right ventricular outflow tract patch reconstruction are not adequately satisfied. Care must be taken in the location and course of the conduit, because fatal coronary artery compression by the conduit valve ring has been reported. 10 Another approach that may have utility in this group of patients is the transatrial repair of tetralogy of Fallot." Through a right atrial incision, the surgeon can often resect the subpulmonary obstruction and repair the ventricular septal defect. This technique may be more useful in patients in whom the pulmonary obstruction is primarily infundibular and the pulmonary valveis normal. Accurate preoperative diagnosis of this coronary anomaly is essential to properly plan operative intervention and minimize inadvertent coronary artery injury. Aortic root cineangiography is used routinely at our institution for all patients in whom complete repair is being considered. Complete repair of tetralogy of Fallot with anomalous origin of the left coronary artery usually is deferred until the patient is 5 or 6 years old. The operation can then be performed at an age and body size that offer the surgeon the option of patch reconstruction or conduit depending on the findings at the time of operation. These patients may require a shunt from the systemic circulation to the pulmonary artery to relieve hypoxemia until an adequate size is reached for complete repair. Our findings suggest that both methods of repair of
Volume 94 Number 5 November 1987
tetralogy of Fallot can be performed successfully in patients with anomalous origin of the left anterior .descending coronary artery. The more appropriate technique must be individualized. Preoperative identification of this anomaly should be a routine part of the diagnostic evaluation in tetralogy of Fallot.
Tetralogy of Fallot with anomalous coronary artery
6.
7.
REFERENCES
I. Fellows KE, Freed MD, Keane IF, Van Praagh R, Bernhard WF, Castaneda AC. Results of routine preoperative coronary angiography in tetralogy of Fallot. Circulation 1975;51:561-6. 2. Hurwitz RA, Smith W, King H, Girod DA, Caldwell RL. Tetralogy of Fallot with abnormal coronary artery: 1967 to 1977.1 THoRAc CARDIOVASC SURG 1980;80:129-34. 3. Berry BE, McGoon DC. Total correction for tetralogy of Fallot with anomalous coronary artery. Surgery 1973; 74:894-7. 4. Chiariello L, Meyer 1, Wukasch DC, Hallman GL, Cooley DA. Intracardiac repair of tetralogy of Fallot: five-year review of 403 patients. 1 THORAC CARDIOVASC SURG 1975;70:529-35. 5. McManus BM, Waller Bl, lones M, Epstein SE, Roberts We. The case for preoperative coronary angiography in
8.
9.
10.
11.
787
patients with tetralogy of Fallot and other complex congenital heart diseases. Am Heart 1 1982;103:451-6. Fellows KE, Smith 1, Keane IF. Preoperative angiocardiography in infants with tetrad of Fallot: review of 36 cases. Am 1 Cardiol 1981;47:1279-85. Rastelli GC, Ongley PA, Davis GD, Kirklin lW. Surgical repair of pulmonary valve atresia with coronary-pulmonary artery fistula: report of case. Mayo Clin Proc 1965;40:521-7. Kyger ER III, Chiariello L, Hallman GL, Cooley DA. Conduit reconstruction of right ventricular outflow tract: experience with 17 patients. Ann Thorac Surg 1975; 19:277-88. Meyer 1, Chiariello L, Hallman GL, Cooley DA. Coronary artery anomalies in patients with tetralogy of Fallot. 1 THORAC CARDIOVASC SURG 1975;69:373-6. Daskalopoulos DA, Edwards WD, Driscoll Dl, Danielson GK, Puga Fl. Coronary artery compression with fatal myocardial ischemia: a rare complication of valved extracardiac conduits in children with congenital heart disease. 1 THoRAc CARDIOVASC SURG 1983;85:546-51. Edmunds LH, Saxena NC, Friedman S, Rashkind WJ, Dodd PF. Transatrial repair of tetralogy of Fallot. Surgery 1976;80:681-688.
THoRAc CARDIOVASC SURG
1987;94:784-7
Tetralogy of Fallot with anomalous origin of left anterior descending coronary artery Surgical options Anomalous origin of the left anterior descending coronary artery from the right coronary artery can interfere with the location of the usual ventriculotomy during repair of tetralogy of FaUot. The purpose of thisstudy was to compare the results of twooperative techniques: (1) a "tailored" right ventricular incision and outflow patch reconstruction and (2) placement of a conduit from the right ventricle to the main pulmonary artery. We reviewed the records of 416 patients who hadcomplete repair of tetralogy of FaUot at the Mayo Clinic from 1973 through 1984. Twenty (5 % ) (median age 6.5 years) hadanomalous origin of the left anterior descending coronary artery from the right coronary artery. Twelve of these patients had right ventricular outflow patch reconstruction, and eight had placement of a conduit from the right ventricle to the pulmonary artery. Three deaths occurred, aU during hospitalization, two in the patch reconstruction group and one in the conduit group. The average reduction in right ventricular pressure postoperatively was slightly but not significantly greater for the conduit group. These data indicate that correction of tetralogy of FaUot with anomalous origin of theleft anterior descending coronary artery can be done with either patch reconstruction or conduit placement. Selection of the more appropriate procedure depends on the exact location and degree of tortuosity of the anomalous artery and the level and severity of right ventricular outflow obstruction.
Richard A. Humes, MD, David J. Driscoll, MD, Gordon K. Danielson, MD, and Francisco J. Puga, MD, Rochester, Minn.
Origin of the left anterior descending coronary artery from the right coronary artery is the most commonly encountered coronary artery anomaly in the tetralogy of Fallot, occurring in 2% to 9% of patients.l-! This abnormality is important surgically because the anomalous artery courses across the right ventricular outflow tract where the ventriculotomy incision is usually made during surgical repair of the lesion.' We reviewed the recent Mayo Clinic experience with this problem in an effort to compare the efficacy and
From the Section of Pediatric Cardiology and the Section of Thoracic and Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minn. Read at the Ninth Annual Scientific Session of the Midwest Pediatric Cardiology Society, Rochester, Minn, September 19-20, 1985. Received for publication Dec. 8, 1986. Accepted for publication Jan. 7, 1987. Address for reprints: David J. Driscoll, MD, Section of Pediatric Cardiology, Mayo Clinic, 200 First S1. S.W., Rochester, MN 55905.
784
outcome of the two procedures for repair of tetralogy of Fallot with anomalous origin of the left coronary artery: (1) right ventricular outflow patch reconstruction and pulmonary valvotomy and (2) conduit from right ventricle to pulmonary artery. From 1973 through 1984,416 patients had complete repair of tetralogy of Fallot at the Mayo Clinic. Twenty patients (5%) had an associated anomalous origin of the left anterior descending coronary artery. The patients' ages ranged from 1.9 years to 39 years (mean 9.9 years, median 6.5 years) at the time of operation. There were 12 male and eight female patients. Thirteen patients had had previous cardiac operations, and several patients had more than one procedure. These procedures included Blalock-Taussig, Waterston, and Potts shunts (four each). There was one open and one closed pulmonary valvotomy. One patient had previous repair of total anomalous pulmonary venous return, and one patient had had an exploratory thoracotomy at another institution for complete repair, at which time the coronary anomaly was discovered and the repair deferred.
Volume 94 Number 5 November 1987
Twelve patients had right ventricular outflow patch reconstruction, and eight had placement of a conduit from the ventricle to the main pulmonary artery (Table I). The mean age of patients in the conduit group (16.3 years) was significantly greater (p < 0.05) than the mean age in the patch reconstruction group (5.8 years). The coronary artery anatomy was known before operation in five of eight patients in the conduit group but in only two of 12 patients in the patch reconstruction group. The number and types of previous cardiac operations were similar for both groups. At the time of operation, pressures in the right ventricle, left ventricle, and pulmonary artery were measured before and after repair. The results of these measurements are shown in Table II. Preoperative and postoperative right ventricular systolic pressures and the ratios of right ventricular to left ventricular pressure were not significantly different between the patch reconstructionand conduit groups. Prerepair peak systolic pressure gradient between the right ventricle and the pulmonary artery was similar for the two groups. .However, this gradient was significantly lower (p < 0.05) in the conduit group after repair. The higher right ventricular pressure after repair in the conduit group may reflect the result in one patient who had significant distal right pulmonary artery obstruction despite surgical attempts at correction. Three deaths occurred, all during hospitalization. There were two deaths in the patch reconstruction group. The first patient had sudden ventricular fibrillation in the operating room, remained in a state of low cardiac output after a difficult resuscitation, and died 2 days after the operation. The second patient in the patch reconstruction group died at 31 days as a result of pneumonia and renal failure that developed 1 week after the operation. The patient in the conduit group had significant unrelieved distal right pulmonary artery obstruction at the site of a previousWaterston shunt despite attempts to enlarge this area. She had a sudden cardiac arrest and died on postoperative day 38. There were no instances of inadvertent coronary artery division.
Discussion Anomalous origin of the left coronary artery from the right coronary artery in tetralogy of Fallot has long been recognized as a potential complicating factor in the corrective operation for this defect.' Standard operative technique usually involves a vertical ventriculotomy along the right ventricular outflow tract, resection of the subpulmonary obstruction, and closure of the ventricu-
Tetralogy of Fallot with anomalous coronary artery
785
Table I. Definitive repair in 20 patients with anomalous origin of the left anterior descending coronary artery
Patch reconstruction RV-PA conduit Total
No. of patients
No. of deaths'
12 8
2 I 3 (15%)
20
Legend: RV, Right ventricle. PA, Pulmonary artery. 'None related to coronary artery injury. All deaths occurred during hospitalization.
lar septal defect.' The anomalous artery arising from the right coronary cusp courses anterior to the aorta and crosses the site where the ventriculotomy usually is made. Inadvertent division of this artery can lead to serious myocardial ischemia, infarction, or death. Because of this potential complication, investigators have advocated precise preoperative delineation of coronary anatomy in tetralogy of Fallot to avoid inadvertent damage to this vessel at operation.>6 In a previous series from our institution, 27 patients with this anomaly were seen from 1955 to 1973.3 The overall mortality in this early series was 30%. The mortality declined to 17% in the last 11 years of that study (1961 to 1972), a figure closer to the 15% mortality in our series. In five of the eight deaths in the earlier series, the anomalous coronary artery was inadvertently divided at the time of operation. Division did not occur in our more recent series. Only two patients in the earlier studies had repair by right ventricle-pulmonary artery conduit, and both survived. The development of synthetic conduits has increased the options for surgical repair of tetralogy of Fallot.'-' In this series, the incidence of anomalous origin of the left coronary artery and its predominance in male patients are similar to findings in other series.v" The choice of operative method was influenced by several factors. In all operations performed between 1973 and 1976, a ventriculotomy and patch outflow reconstruction method was used. The mean age of the patients in the conduit group was significantly greater (16 years) than that in the group having right ventricular outflow tract reconstruction (5.8 years), which may reflect the reluctance to place an artificial conduit in younger children, in whom somatic growth is important. In addition, preoperative knowledge of the abnormal coronary anatomy (62% in the conduit group but only 17% in the patch reconstruction group) may have affected the choice of a conduit insertion. It is clear that patients in this series were not assigned randomly to one of the
The Journal of
786
Humes et al.
Thoracic and Cardiovascular Surgery
Table II. Hemodynamic results in 20 patients with anomalous origin of the left anterior descending coronary artery No. oj patients Patch reconstruction Before repair After repair Conduit Before repair After repair
RV pressure (mmHg)
RV-PA gradient (mm Hg)
Mean
Range
RV:LV ratio*
Mean
Range
90 53
80-100 40-85
1 0.55
63 31
45-85 5-60
2
88 62
75-105 22-85
1 0.64
60 12
23-80 2-20t
5
Anatomy known (No. oj patients)
12
8
Legend: RV, Right ventricle. LV, Left ventricle. PA, Pulmonary artery. * Intraoperative measurement. tp = 0.05, postoperative comparison of reconstruction and conduit.
two operative options. Nevertheless, the hemodynamic results of the two groups were quite similar. The only significant difference between the two methods was more effective reduction of the pressure gradient from right ventricle to pulmonary artery after conduit insertion. Several guidelines may aid in the selection of the preferable operative procedure and the proper timing of operation. Patch reconstruction is the preferred method of repair of tetralogy of Fallot with anomalous origin of the left anterior descending coronary artery. The major advantages of this method are the potential for somatic growth because of the use of autogenous tissue and the avoidance of coronary or cardiac compression by an extracardiac conduit. One must then assess whether adequate relief of pulmonary obstruction can be obtained with this method. The two factors influencing the success of this approach are the coronary artery location and the nature of the right ventricular outflow obstruction. The proximity of the anomalous coronary artery to the right ventricular outflow tract obstruction and the degree of tortuosity of the vessel affect the amount of dissection and retraction of the artery that can be accomplished safely. Inability to adequately retract the artery may limit the extent of the ventriculotomy and hence the degree of relief of obstruction. Similarly, the nature and extent of the subpulmonary obstruction dictate the degree of resection that is necessary. Discrete right ventricular outflow tract stenosis may be resected easily without much coronary dissection or elevation, whereas extensive muscular obstruction may require a more extensive ventriculotomy and coronary artery manipulation. These interrelated anatomic factors may be best evaluated by the surgeon at the time of operation. No specific angiographic criteria exist to aid in this decision. Conduit repair generally is less preferable than right
ventricular outflow tract reconstruction because of potential obstruction of the conduit and absence of growth potential. This is a particular problem in infants and young children. Conduit repair is preferred when previous cardiac operations have resulted in obliteration of the coronary anatomy, making dissection potentially dangerous, or when the criteria of vessel tortuosity and location necessary for performance of the right ventricular outflow tract patch reconstruction are not adequately satisfied. Care must be taken in the location and course of the conduit, because fatal coronary artery compression by the conduit valve ring has been reported. 10 Another approach that may have utility in this group of patients is the transatrial repair of tetralogy of Fallot." Through a right atrial incision, the surgeon can often resect the subpulmonary obstruction and repair the ventricular septal defect. This technique may be more useful in patients in whom the pulmonary obstruction is primarily infundibular and the pulmonary valveis normal. Accurate preoperative diagnosis of this coronary anomaly is essential to properly plan operative intervention and minimize inadvertent coronary artery injury. Aortic root cineangiography is used routinely at our institution for all patients in whom complete repair is being considered. Complete repair of tetralogy of Fallot with anomalous origin of the left coronary artery usually is deferred until the patient is 5 or 6 years old. The operation can then be performed at an age and body size that offer the surgeon the option of patch reconstruction or conduit depending on the findings at the time of operation. These patients may require a shunt from the systemic circulation to the pulmonary artery to relieve hypoxemia until an adequate size is reached for complete repair. Our findings suggest that both methods of repair of
Volume 94 Number 5 November 1987
tetralogy of Fallot can be performed successfully in patients with anomalous origin of the left anterior .descending coronary artery. The more appropriate technique must be individualized. Preoperative identification of this anomaly should be a routine part of the diagnostic evaluation in tetralogy of Fallot.
Tetralogy of Fallot with anomalous coronary artery
6.
7.
REFERENCES
I. Fellows KE, Freed MD, Keane IF, Van Praagh R, Bernhard WF, Castaneda AC. Results of routine preoperative coronary angiography in tetralogy of Fallot. Circulation 1975;51:561-6. 2. Hurwitz RA, Smith W, King H, Girod DA, Caldwell RL. Tetralogy of Fallot with abnormal coronary artery: 1967 to 1977.1 THoRAc CARDIOVASC SURG 1980;80:129-34. 3. Berry BE, McGoon DC. Total correction for tetralogy of Fallot with anomalous coronary artery. Surgery 1973; 74:894-7. 4. Chiariello L, Meyer 1, Wukasch DC, Hallman GL, Cooley DA. Intracardiac repair of tetralogy of Fallot: five-year review of 403 patients. 1 THORAC CARDIOVASC SURG 1975;70:529-35. 5. McManus BM, Waller Bl, lones M, Epstein SE, Roberts We. The case for preoperative coronary angiography in
8.
9.
10.
11.
787
patients with tetralogy of Fallot and other complex congenital heart diseases. Am Heart 1 1982;103:451-6. Fellows KE, Smith 1, Keane IF. Preoperative angiocardiography in infants with tetrad of Fallot: review of 36 cases. Am 1 Cardiol 1981;47:1279-85. Rastelli GC, Ongley PA, Davis GD, Kirklin lW. Surgical repair of pulmonary valve atresia with coronary-pulmonary artery fistula: report of case. Mayo Clin Proc 1965;40:521-7. Kyger ER III, Chiariello L, Hallman GL, Cooley DA. Conduit reconstruction of right ventricular outflow tract: experience with 17 patients. Ann Thorac Surg 1975; 19:277-88. Meyer 1, Chiariello L, Hallman GL, Cooley DA. Coronary artery anomalies in patients with tetralogy of Fallot. 1 THORAC CARDIOVASC SURG 1975;69:373-6. Daskalopoulos DA, Edwards WD, Driscoll Dl, Danielson GK, Puga Fl. Coronary artery compression with fatal myocardial ischemia: a rare complication of valved extracardiac conduits in children with congenital heart disease. 1 THoRAc CARDIOVASC SURG 1983;85:546-51. Edmunds LH, Saxena NC, Friedman S, Rashkind WJ, Dodd PF. Transatrial repair of tetralogy of Fallot. Surgery 1976;80:681-688.