Coronary artery bypass grafting for coronary artery anomalies in infants and young children

Abstract

Objectives: Coronary artery bypass grafting (CABG) has been reported for coronary artery diseases in patients with Kawasaki disease and coronary artery complications after arterial switch operations for transposition of the great arteries. However, only a few studies have explored this modality for congenital coronary artery anomalies. As congenital coronary artery anomalies, particularly left coronary artery atresia and stenosis, are one of the reasons for sudden death, coronary revascularization is often required in infants and young children. Therefore, we aimed to investigate the outcome of CABG for such anomalies in infants and young children.

Methods: From 2014 to 2018, 3 infants and 2 children (median age: 10 months; range: 6-40 months) with coronary artery anomalies underwent CABG at our hospital. The indications for the procedure included left main coronary artery atresia and stenosis in 2 and 3 patients, respectively. Graft patency was evaluated postoperatively by contrast-enhanced computed tomography or coronary angiography, and postoperative outcomes (including death and cardiac events) were assessed during the follow-up period.

Results: No 30-day or in-hospital mortalities were noted. Postoperative examinations revealed patent grafts in all patients. They were discharged without any cardiac complications. Regarding the outcomes at the follow-up period, the graft patency rate was 80.0% (4/5 grafts), with no deaths or cardiac events.

Conclusions: CABG is a useful strategy for coronary revascularization in infants and young children with coronary artery anomalies. Although the mid-term outcomes and patency are satisfactory, careful follow-up is necessary because the long-term outcomes remain unknown.

Keywords: Congenital coronary artery anomalies; Coronary artery bypass grafting; Coronary revascularization; Internal thoracic artery; Paediatric cardiac surgery.

Figure 1:

Comparison of preoperative and postoperative LVEF. LVEF was not significantly different between the preoperative and postoperative stages. LVEF: left ventricular ejection fraction.

Figure 2:

Results of preoperative coronary angiography in Case 4. The left coronary artery could not be catheterized directly because the left main coronary artery was occluded. When we catheterized the right coronary artery, the left coronary artery was lightly contrasted. LCA: left coronary artery.

Figure 3:

Results of preoperative and postoperative Quantitative Perfusion SPECT in Case 4. (A) Preoperative Tc-TF scintigraphy. This examination documents a reversible perfusion defect at rest (bottom rows) and during stress (top rows). The polar plots depict the extent of the ischaemic area in the anterior (white arrow) and lateral left ventricular walls (brown arrow). (B) Postoperative TI scintigraphy. Perfusion polar maps during stress (top rows) and at rest (bottom rows) show remarkably improved myocardial perfusion. SPECT: single-photon emission computed tomography; Tc-TF: technetium-tetrofosmin; TI: thallium.

Figure 4:

Results of postoperative and follow-up coronary angiography in Case 4. (A) Postoperative coronary angiography revealed a patent graft. (B) Follow-up coronary angiography revealed graft patency at 17 months postoperatively. These results revealed that the left internal thoracic artery graft remained patent during the follow-up period. LITA: left internal thoracic artery.

Figure 5:

Results of preoperative, postoperative and follow-up coronary angiography in Case 1. (A) Preoperative coronary angiography: left main coronary artery stenosis is observed. (B) Postoperative coronary angiography: the left internal thoracic artery graft is patent. (C) Follow-up angiography performed at 2.5 years postoperatively: the left internal thoracic artery is occluded. LITA: left internal thoracic artery.

Figure 6:

Coronary angiographies were performed at 2.5 and 4.5 years postoperatively in Case 1. (A) Follow-up coronary angiography performed at 2.5 years postoperatively. The left coronary artery flow increased. The left internal thoracic artery was contrasted retrogradely from the native coronary artery flow. (B) Follow-up coronary angiography performed at 4.5 years postoperatively. Restenosis of the left main coronary artery was not observed. LITA: left internal thoracic artery.