1. Repair of Anomalous Coronary Artery From the Pulmonary Artery by Aortic Implantation 
Anthony Azakie, MD 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 20, Issue 2, Pages (June 2015)
DOI: /j.optechstcvs
Copyright © 2015 Elsevier Inc. Terms and Conditions

2. Figure 1
After induction of general anesthesia, central venous and radial arterial monitoring lines are placed. Reduction in pulmonary vascular resistance—as seen with hyperventilation, alkalosis, or administration of high FiO2—is avoided. A median sternotomy is performed and the thymus gland is removed. The pericardium is opened and a patch is harvested for later use. The child is systemically heparinized and purse strings are placed in the distal ascending aorta, right superior vena cava, and inferior vena cava. The pulmonary arteries are dissected and encircled with heavy silk snares. The ALCAPA may be visualized at this point and fine polypropylene suture can be used to mark the recipient site on the ascending aorta. After ascending aortic and bicaval cannulation, a cardioplegia needle is inserted into the ascending aorta. High-flow CPB is instituted to support the child with mild-moderate hypothermia. CPB = cardiopulmonary bypass.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

3. Figure 2
Soon after the institution of CPB, the aorta is cross-clamped and cold blood cardioplegia is administered through the aortic root. Immediate clamping of the aorta is performed after initiation of CPB, so as to prevent coronary steal into the decompressed PA. The PA tourniquets are tightened to prevent runoff of cardioplegia into the PA via the ALCAPA. A 30-40ml/kg of a 4:1 ratio of Buckberg or del Nido cardioplegia solution to blood, enriched with aspartate and glutamate, is given at the initial dose, and if necessary 5-10ml/kg is given every minutes thereafter. CPB = cardiopulmonary bypass. The caval snares are tightened, the right atrium is opened, and the left heart is decompressed through the atrial septum. Attention is then turned to the PA that is transected proximal to the bifurcation. The coronary orifice that in most cases originates from the posterior (facing) sinus is identified, and then a large button is excised and the proximal coronary artery is mobilized. An anterior aortotomy is made to allow for direct visualization of the aortic valve, and extension of the incision to the point where the coronary artery is translocated. CPB = cardiopulmonary bypass.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

4. Figure 3
(A) An incision has been made in the ascending aorta above the sinotubular junction and extended leftward. The aortotomy allows for direct visualization, so that a medially based trapdoor incision is made in the recipient aortic root site. The coronary artery is minimally rotated, so that it is implanted without tension.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

5. Figure 3
(A) An incision has been made in the ascending aorta above the sinotubular junction and extended leftward. The aortotomy allows for direct visualization, so that a medially based trapdoor incision is made in the recipient aortic root site. The coronary artery is minimally rotated, so that it is implanted without tension.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

6. Figure 3
(A) An incision has been made in the ascending aorta above the sinotubular junction and extended leftward. The aortotomy allows for direct visualization, so that a medially based trapdoor incision is made in the recipient aortic root site. The coronary artery is minimally rotated, so that it is implanted without tension.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

7. Figure 3
(A) An incision has been made in the ascending aorta above the sinotubular junction and extended leftward. The aortotomy allows for direct visualization, so that a medially based trapdoor incision is made in the recipient aortic root site. The coronary artery is minimally rotated, so that it is implanted without tension.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

8. Figure 3
Continued (B) After “reimplantation” of the coronary artery, the aortic root is closed with polypropylene suture with the cardioplegia site used to vent the aortic root and LV. A patch may be used to minimize tension on the aortic root closure or suture line.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

9. Figure 3
Continued (C and D) The trapdoor method uses minimal rotation of the coronary artery, allowing the coronary artery to remain almost in situ for the aortic implantation. The use of the trapdoor decreases the arc or the rotation used to transfer the coronary artery, and minimizes the risk of ischemia from stretching or kinking.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

10. Figure 3
Continued (C and D) The trapdoor method uses minimal rotation of the coronary artery, allowing the coronary artery to remain almost in situ for the aortic implantation. The use of the trapdoor decreases the arc or the rotation used to transfer the coronary artery, and minimizes the risk of ischemia from stretching or kinking.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

11. Figure 4
(A) The anomalous coronary artery can originate leftward from the lateral aspect of the posterior-facing sinus or from the anterior nonfacing pulmonary sinus, making its implantation more challenging because of its distant relationship with the aortic root. In this case, a ring of MPA tissue is harvested together with the coronary sinus button. MPA = main pulmonary artery.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

12. Figure 4
(A) The anomalous coronary artery can originate leftward from the lateral aspect of the posterior-facing sinus or from the anterior nonfacing pulmonary sinus, making its implantation more challenging because of its distant relationship with the aortic root. In this case, a ring of MPA tissue is harvested together with the coronary sinus button. MPA = main pulmonary artery.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

13. Figure 4
(A) The anomalous coronary artery can originate leftward from the lateral aspect of the posterior-facing sinus or from the anterior nonfacing pulmonary sinus, making its implantation more challenging because of its distant relationship with the aortic root. In this case, a ring of MPA tissue is harvested together with the coronary sinus button. MPA = main pulmonary artery.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

14. Figure 4
Continued (B) The ring is then divided at a point most distal from the coronary orifice.
Continued (C) The MPA tissue is tubularized, thus elongating the coronary artery, allowing for (D) minimal tension during aortic implantation. MPA = main pulmonary artery.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

15. Figure 4
Continued (E) Alternatively, an anterior flap of PA wall is harvested with the coronary artery sinus button and augmented posteriorly with an autologous pericardial patch to elongate the coronary artery.
The interatrial defect is closed, the heart aggressively deaired, and the cross-clamp is released. The patient is given a loading dose of milrinone during the rewarming phase of CPB, and the aortic root is vented through the cardioplegia cannula. CPB = cardiopulmonary bypass.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

16. Figure 5
(A) The sinus defect in the pulmonary root is filled with a redundant autologous pericardial patch. The pulmonary arteries are extensively mobilized and the MPA anastomosis is completed. Care is taken to avoid compression of the implanted coronary artery by the posterior PA anastomosis.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

17. Figure 5
(A) The sinus defect in the pulmonary root is filled with a redundant autologous pericardial patch. The pulmonary arteries are extensively mobilized and the MPA anastomosis is completed. Care is taken to avoid compression of the implanted coronary artery by the posterior PA anastomosis.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

18. Figure 5
Continued (B) When an extensive amount of PA wall is used for coronary elongation, a generous autologous pericardial patch is used for the PA reconstruction, and direct tissue-to-tissue contact in the PA anastomosis is used to allow for growth.
The patient is fully warmed and weaned from CPB on dopamine, adrenaline, and milrinone infusions. A left atrial pressure line is inserted for continuous monitoring in the postoperative setting. The chest may be left open for delayed sternal closure. Infrequently, the child may have to be placed on ECMO. In that event, VA ECMO is preferentially used via transsternal cannulation of the ascending aorta and right atrium. A cannula is placed in the left atrial appendage to optimize LV decompression and recovery. CPB = cardiopulmonary bypass; ECMO = extracorporeal membrane oxygenation; VA = venoarterial.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions

19. Figure 6
Time course (months) for ventricular recovery of (A) ejection fraction (%).
Continued (B) Ventricular dilation (ratio of measured left ventricular end-diastolic [LVED] diameter to 95% of normal).
Continued (C) Mitral valve regurgitation (0 = none, 0.5 = trace, 1= mild, 1.5 = mild to moderate, 2 = moderate, 2.5 = moderate to severe) as determined by repeated measures of mixed linear regression ananlysis.
Operative Techniques in Thoracic and Cardiovascular Surgery  , DOI: ( /j.optechstcvs )
Copyright © 2015 Elsevier Inc. Terms and Conditions