Surgical treatment of coronary artery anomalies: report of a 37 1/2-year experience at the Texas Heart Institute

Abstract

The surgical treatment of coronary artery anomalies continues to evolve. The most common coronary artery anomalies requiring surgical intervention include coronary artery fistulae, anomalous pulmonary origins of the coronary arteries, and anomalous aortic origins of the coronary arteries. The choice of surgical intervention for each type of coronary anomaly depends on several anatomic, physiologic, and patient-dependent variables. As surgical techniques have progressed, outcomes have continued to improve, however, controversy still exists about many aspects of the proper management of patients who have these coronary artery anomalies. We reviewed the surgical treatment of 178 patients who underwent surgery for the above-mentioned types of coronary artery anomalies at the Texas Heart Institute from December 1963 through June 2001. On the basis of this experience, we discuss historical aspects of the early treatment of these anomalies and describe their present-day management.

Fig. 1 First successful repair of a coronary artery fistula using a bypass graft (1963). A) A single left coronary artery terminated in a coronary artery fistula and drained into the right ventricular outflow tract. B) The terminal end was ligated and divided. C) Aortocoronary bypass was performed, with use of a Dacron graft, to create a 2-coronary system. (From Hallman GL, Cooley DA, Singer DB. Congenital anomalies of the coronary arteries: anatomy, pathology, and surgical treatment. Surgery 1966;59:133–44. Reprinted with permission from Mosby, Inc.)

Fig. 2 Techniques to repair coronary artery fistulae. A) Coronary artery fistulae from the right coronary artery (RCA) to the right ventricle are shown, consisting of multiple openings. B) Multiple horizontal mattress sutures are placed between the artery of origin and the heart. C) The fistulous openings are obliterated while restoring the patency of the RCA. D) Coronary artery fistula from the RCA to the pulmonary artery is shown. E, F) The pulmonary artery is opened, the fistulous opening is identified, and the fistula is ligated from within the pulmonary artery under direct vision. G) Coronary artery fistula from the RCA with an aneurysm is shown. H) The aneurysm is opened and the fistula is repaired from within the aneurysm. I) The aneurysm is plicated. (From Urrutia-S CO, Falaschi G, Ott DA, Cooley DA. Surgical management of 56 patients with congenital coronary artery fistulas. Ann Thorac Surg 1983;35:300–7. Reprinted with permission from the Society of Thoracic Surgeons. Illustrations by Bill Andrews.)

Fig. 3 The 1st creation of a 2-coronary system for an anomalous left coronary artery from the pulmonary artery (1965). A) The left coronary artery (LCA) originated from the posterior pulmonary artery. B) A Dacron graft was anastomosed to the aorta using a partial-occlusion clamp. C) The LCA was ligated proximally and divided with strong backflow in the LCA. D) The Dacron graft was anastomosed end-to-end to the LCA. E) The graft was positioned with no tension across the pulmonary artery or on the graft. (From Cooley DA, Hallman GL, Bloodwell RD. Definitive surgical treatment of anomalous origin of left coronary artery from pulmonary artery: indications and results. J Thorac Cardiovasc Surg 1966;52:798–808. Reprinted with permission from Mosby, Inc. Illustrations by Herb Smith.)

Fig. 4 Reimplantation of an anomalous left coronary artery (LCA) from the pulmonary artery onto the aorta. A) The pulmonary artery (PA) is transected above the pulmonary valve. B) The LCA ostium is resected from the pulmonary artery with a button of surrounding pulmonary artery tissue. The LCA is mobilized to the bifurcation. C) The LCA ostium is anastomosed end-to-end to the left side of the aorta. D) The reimplanted LCA is placed posterior to the pulmonary artery and an appropriate tension-free position is ensured. E) The pulmonary artery is closed. (Note: The pulmonary artery is routinely closed with a pericardial patch [not shown].) (From Grace RR, Angelini P, Cooley DA. Aortic implantation of anomalous left coronary artery arising from pulmonary artery. Am J Cardiol 1977;39:609–13. ©1977. Reprinted with permission from Excerpta Medica Inc.)

Fig. 5 Preoperative left ventriculogram of an infant with ALCAPA and an extensive left ventricular aneurysm. This patient presented in cardiogenic shock and underwent emergency reimplantation of the left coronary artery onto the aorta and resection of the left ventricular aneurysm.