Surgical Strategy to Establish a Dual-Coronary System for the Management of Anomalous Left Coronary Artery Origin From the Pulmonary Artery Bahaaldin.

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Surgical Strategy to Establish a Dual-Coronary System for the Management of Anomalous Left Coronary Artery Origin From the Pulmonary Artery Bahaaldin Alsoufi, MD, Ahmed Sallehuddin, MD, Ziad Bulbul, MD, Mansour Joufan, MD, Fareed Khouqeer, MD, Charles C. Canver, MD, Avedis Kalloghlian, MD, Zohair Al-Halees, MD The Annals of Thoracic Surgery Volume 86, Issue 1, Pages 170-176 (July 2008) DOI: 10.1016/j.athoracsur.2008.03.032 Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Direct coronary transfer for treatment of anomalous left coronary artery from the pulmonary artery. (Left panel) The pulmonary artery is transected. The coronary artery is excised with a wide cuff of pulmonary arterial wall to form a coronary button. (Middle panel) The coronary button is widely mobilized to allow a tension-free anastomosis. (Right panel) An incision is made at the posteromedial wall of the aorta to serve as the site of the anastomosis of the anomalous coronary artery to the aorta. The Annals of Thoracic Surgery 2008 86, 170-176DOI: (10.1016/j.athoracsur.2008.03.032) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Coronary implantation with autologous flap extensions from aorta posteriorly and pulmonary artery anteriorly. (Left panel) The pulmonary artery is transected. The anomalous left coronary artery is excised as a button together with a tongue of tissue from the anterior pulmonary artery wall. This tongue is used to form the anterior half of the planned tunnel. (Middle panel) The aortic incision is fashioned to create a flap to form the posterior half of the tunnel. The aortic flap is first sutured to the lower margin of the coronary button. (Right panel) The tongue of pulmonary artery wall is then sutured to complete the tunnel as well to close the aortotomy. The Annals of Thoracic Surgery 2008 86, 170-176DOI: (10.1016/j.athoracsur.2008.03.032) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Coronary implantation with autologous flap extension from pulmonary artery sinuses. (Left panel) The pulmonary artery is transected. Two transverse parallel incisions, one proximal and the other distal to the anomalous coronary artery orifice, are made and extended an equal distance on both sides of the coronary orifice. (Middle panel) The isolated segment of the pulmonary artery containing the origin of the anomalous artery at its center is folded with the orifice of the coronary artery as its fulcrum, and its side edges sutured to each other to form an extension tube of tissue that lengthens the coronary artery. (Right panel) With the use of a 5-mm aortic punch, an incision is made at the posteromedial wall of the aorta to serve as the site of the anastomosis of the lengthened coronary artery to the aorta. The Annals of Thoracic Surgery 2008 86, 170-176DOI: (10.1016/j.athoracsur.2008.03.032) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Freedom from reoperation after anomalous left coronary artery from the pulmonary artery implantation stratified by implantation technique for direct coronary transfer (dashed line) and coronary extension (solid line) techniques. The Annals of Thoracic Surgery 2008 86, 170-176DOI: (10.1016/j.athoracsur.2008.03.032) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions