Anomalous origin of the left coronary artery from the pulmonary artery: collective review of surgical therapy Ali Dodge-Khatami, MD, Constantine Mavroudis,

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Anomalous origin of the left coronary artery from the pulmonary artery: collective review of surgical therapy Ali Dodge-Khatami, MD, Constantine Mavroudis, MD, Carl L Backer, MD The Annals of Thoracic Surgery Volume 74, Issue 3, Pages 946-955 (September 2002) DOI: 10.1016/S0003-4975(02)03633-0

Fig 1 Normal coronary distribution (inset), and sinus numeration in anomalous left coronary artery from the pulmonary artery (ALCAPA) as viewed from above. (Ao = aorta; L = left; LMCA = left main coronary artery, NF = nonfacing sinus; PA = pulmonary artery; R = right; RCA = right coronary artery; 1, 2 = sinuses of pulmonary valve.) (Reprinted from Dodge-Khatami A, Mavroudis C, Backer CL. Congenital Heart Surgery Nomenclature and Database Project: anomalies of the coronary arteries. Ann Thorac Surg 2000;694: Suppl S270–97); by permission of Elsevier Science Inc.) The Annals of Thoracic Surgery 2002 74, 946-955DOI: (10.1016/S0003-4975(02)03633-0)

Fig 2 After the second dose of cardioplegia, an opening is created in the left posterolateral wall of the ascending aorta for implantation of the anomalous left coronary button. Care is taken not to injure the aortic valve. This opening is typically approximately one third smaller in size than the button that was created. The large button of coronary artery can then act as a “conduit” for elongation of the left coronary artery. With proper mobilization of the left coronary artery, it is usually quite easy to perform this anastomosis. Once the anastomosis is created (inset), the aortic cross-clamp is removed, and now both right and left coronary arteries are directly perfused (Reprinted from Backer CL, Hillman N, Dodge-Khatami A, Mavroudis C. Anomalous origin of the left coronary artery from the pulmonary artery: successful surgical strategy without assist devices. Semin Thorac Cardiovasc Surg Pediatr Cardiac Surg Annu 2000;3:165–172 [36]; by permission of W. B. Saunders, a Harcourt Health Sciences Co.) The Annals of Thoracic Surgery 2002 74, 946-955DOI: (10.1016/S0003-4975(02)03633-0)

Fig 3 The aortic cross-clamp is off. The posterior sinus of the pulmonary artery where the button was harvested is reconstructed with a patch of fresh autologous pericardium. The pulmonary artery is reanastomosed at the site of the transection (inset). This reconstruction of the pulmonary artery with the cross-clamp off helps to minimize the aortic cross-clamp time. In almost all instances, it is possible to perform the entire procedure with two doses of cardioplegia given in the sequence described [36]. (Reprinted from Backer CL, Hillman N, Dodge-Khatami A, Mavroudis C. Anomalous origin of the left coronary artery from the pulmonary artery: successful surgical strategy without assist devices. Semin Thorac Cardiac Surg Pediatr Cardiac Surg Annu 2000;3:165–72 [36]; by permission of W. B. Saunders, a Harcourt Health Sciences Co.) The Annals of Thoracic Surgery 2002 74, 946-955DOI: (10.1016/S0003-4975(02)03633-0)

Fig 4 Takeuchi operation: (A) After aortic cross-clamping and cardioplegic arrest, a flap incision in the pulmonary artery is made. (B) Using the pulmonary artery wall flap, an intrapulmonary tunnel is fashioned, running from the anticipated takeoff of the aorta to the orifice of the anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). (C) Anastomosis between the intrapulmonary tunnel orifice and a punch opening in the aorta is performed. The Takeuchi repair is completed by patching the defect in the pulmonary artery wall with autologous pericardium or homograft. The arrow shows the newly directed blood flow from the aorta, through the tunnel, and into the ALCAPA orifice. The Annals of Thoracic Surgery 2002 74, 946-955DOI: (10.1016/S0003-4975(02)03633-0)