Early Outcomes of Transconal Repair of Transseptal Anomalous Left Coronary Artery From Right Sinus.

BACKGROUND: Anomalous aortic origin of the left coronary artery (AAOCLA) with an extended transseptal course behind the right ventricular outflow tract (RVOT) is a rare variant that poses challenges not addressed by current surgical techniques. We utilized a novel transconal approach in 7 consecutive patients. METHODS: A retrospective review was made of a prospectively collected database for consecutive patients undergoing transconal unroofing of transseptal AAOLCA. Surgical repair entails transection of the RVOT, unroofing the septal course of the AAOLCA, followed by RVOT extension with a rectangular strip of autologous pericardium. Preoperative characteristics, operative details, and postoperative course were abstracted. RESULTS: All 7 patients identified were symptomatic. Median age was 48 years (range, 12 to 62). The AAOLCA with transseptal course was confirmed by computed tomography angiography. Three patients had provocative testing demonstrating anterolateral ischemia. Four patients underwent cardiac catheterization with intravascular ultrasound and indexed fractional flow reserve, confirming flow-limiting lesion. Importantly, 3 patients had negative provocative noninvasive testing for ischemia. Median postoperative hospital length of stay was 6 days (range, 4 to 12). No mortality or major complications occurred during a median follow-up of 0.75 years. Postoperative evaluation demonstrated anatomically patent unroofed AAOLCA with improved indexed fractional flow reserve compared with preoperative (0.59 ± 0.16 vs 0.90 ± 0.03, P = .05). CONCLUSIONS: Complete unroofing of AAOLCA with transseptal course repaired with posterior extension of RVOT is an effective technique with excellent early outcome. Multimodality provocative testing is critical to evaluate these lesions as individual studies may be misleading. Intravascular ultrasound with indexed fractional flow reserve is clinically useful to confirm the hemodynamic significance of specific lesions.

Surgical outcomes for anomalous left coronary artery from the pulmonary artery: Influence of late presentation.

OBJECTIVES: Although surgical outcomes for anomalous left coronary artery from the pulmonary artery (ALCAPA) are excellent in the modern era with the coronary reimplantantion technique, mortality remains high in Chinese population. This study was undertaken to review the surgical management for ALCAPA in our center and assess the midterm outcomes. METHODS: This was a retrospective review of 105 patients who underwent surgical repair for ALCAPA from January 2008 to January 2018. RESULTS: The diagnosis of ALCAPA was not made before referred to our hospital in 31 patients (30%). Median age at repair was 7.6 months (interquartile range, 4.3-25.4 months). Mean preoperative left ventricular ejection fraction was 47.3% ± 16.9%. Concomitant mitral intervention was performed in 52 patients (50%). Mechanical circulatory support was used in 15 patients (14%). Early mortality was 14%. Classification and regression tree analysis identified 3 risk groups for early mortality, among which patients with preoperative left ventricular ejection fraction ≤41.6% and age at repair >127 days were the most likely to suffer from mortality. Using nonlinear mixed-effect model to assess the time course for postoperative left ventricular ejection fraction, patients of this group also needed significantly longer time for recovery of left ventricular function after surgery (P < .0001). CONCLUSIONS: Late referral of patients with ALCAPA is not uncommon in our center. Older age at repair in patients with preoperative left ventricular dysfunction is the main reason for higher early mortality, and is also associated with longer time to normalization of left ventricular function after surgery.

Anomalous left anterior descending artery diagnosed on pulmonary artery computed tomography.

Typically, the left anterior descending artery (LAD) and left circumflex artery (LCX) arise from the left main coronary artery. However, uncommon coronary anomalies may be found in clinical practice. This case presents with a rare finding where the LAD originates from the right coronary artery (RCA) separately from the LCX and takes an interarterial pathway to reach its perfusion territory. A 49-year-old Hispanic female with hypertension and diabetes mellitus presented to the emergency department with a 7-day history of chest pain. She denied nausea, diaphoresis, syncope, or other symptoms. A grade 3 out of 6 systolic murmur was noted on physical examination. Computed tomography of the pulmonary arteries (CTPA) revealed that the patient had no left main coronary artery. The patient's LAD arose from the proximal RCA and took an inter-arterial course. Subsequent coronary catheterization showed no stenosis of the coronary arterial system. The patient's chest pain subsided during the course of her admission and she was deemed stable for discharge with close cardiology follow up. In general, coronary artery anomalies are an uncommon finding in clinical practice. However, it is important to realize the different pathways of coronary artery anomalies because those with the inter-arterial subtype, such as our patient, may result in sudden cardiac death. All cases of clinically suspected inter-arterial coronary artery anomalies are recommended to undergo imaging studies to help visualize anatomic features as a guide for further management. This case represents the first reported diagnosis of this type of anomalous coronary artery on CTPA.