Incipient left ventricular rupture complicating anomalous left coronary artery

A 4-month-old girl presented with 2 weeks of symptoms and physical signs of heart failure. Echocardiography demonstrated marked left ventricular dilation, thinning of the myocardium with anterolateral akinesis, mitral regurgitation, a moderate pericardial collection, and an anomalous left coronary artery from the pulmonary artery. At operation there was a tense hemopericardium and a site of imminent rupture through a transmural anterior infarction. The anomalous artery was reimplanted in the ascending aorta, and an extensive infarct resection and ventricular repair performed. Support with a left ventricular assist device was required for 3 days, but the infant subsequently made a satisfactory recovery. Left ventricular rupture is a very rare complication of this lesion, but should be considered if there is evidence of a pericardial collection.     

Separate arch origin of the left external carotid artery with common trunk giving rise to the left internal carotid artery and left subclavian artery

We present a case of a 3-year-old boy with tetralogy of Fallot having the direct origin of the left external carotid artery from the aorta with a common trunk giving rise to the left internal carotid artery and left subclavian artery, in a right-sided aortic arch. We also highlight the potential implications in management.     

Heart transplant for anomalous origin of left coronary artery from pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery is a congenital coronary artery malformation most commonly present in infancy. A variety of surgical procedures have been described to achieve physiological correction of the coronary flow abnormalities. These techniques are effective as long as there is potential for myocardial recovery. However the sequelae of chronic myocardial ischemia that characterize this entity often irreversibly damage the heart and preclude correction and palliation of the native anomaly. In this type of setting, heart transplantation is a realistic option. Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) occasionally presents in adulthood. Anatomic repair with a two coronary artery system may not be optimal in patients presenting with ischemic cardiomyopathy. We report an adult patient with platelet factor 4 (PF4) antibodies who underwent orthotopic heart transplantation (OHT) for ALCAPA.     

Correction of anomalous origin of the left coronary artery.

Successful surgical treatment for anomalous origin of the left coronary artery from the pulmonary artery was performed in one patient by left coronary artery-subclavian anastomosis and in two patients by direct implantation of the left coronary artery into the aorta. The excellent early and late results obtained with these methods and the suboptimal results reported with saphenous vein grafting for this lesion make these other alternatives more attractive. Direct implantation of the left coronary artery into the aorta utilizing cardiopulmonary bypass and hypothermic (4 degrees C.) potassium-induced (20 mEq. per liter) cardioplegia is now our preferred approach for most patients with this lesion.     

Hypoplastic left heart syndrome with an anomalous origin of the left coronary artery

Abnormal origin of the coronary artery in children with hypoplastic left heart syndrome is an extremely rare defect. We describe a newborn with concomitant hypoplastic left heart syndrome and abnormal origin of the left coronary artery arising from the right pulmonary artery. A Norwood procedure and direct reimplantation of the left coronary artery to the ascending aorta was performed.     

Surgical treatment for anomalous origin of left coronary artery from pulmonary artery.

Anomalous origin of the left coronary artery from the pulmonary artery carries a poor prognosis; most patients die early in life from myocardial infarction and congestive heart failure. During a 12-year period at the Texas Heart Institute, 13 patients with this congenital malformation ranging in age from 1 to 24 years underwent operation. The anomalous coronary artery was sutured or ligated, or both, close to the pulmonary artery in 3 patients, 2 before 1965. Aortocoronary bypass was performed in the remaining 10 patients, using an autogenous saphenous vein graft in 9 and a Dacron tube in 1. More recently a distal end-to-side anastomosis has been employed and is not the preferred method. If necessary, a pump oxygenator may be used to complete the procedure. The only death was that of the first patient in the series who underwent ligation of the left coronary artery and mitral annuloplasty for severe mitral insufficiency; Of the 12 patients available for long-term follow-up study, all but 1 were asymptomatic. Follow-up angiographic studies showed the graft to be patent in 7 patients; the longest period of graft patency was 8 years. Definitive operative therapy is preferable to simple ligation because it eliminates the left-to-right shunt from the right coronary artery to the pulmonary artery and establishes a double coronary artery system.     

Innominate artery rupture. A fatal complication of tracheostomy

Tracheo-innominate artery fistula is an uncommon but frequently fatal complication of tracheostomy. The case histories of three patients with tracheo-innominate artery fistula are presented, and one is a longterm survivor. The haemorrhage can be controlled by hyperinflation of the cuff of the tracheostomy tube or by direct digital compression of the artery. The damaged segment of the eroded artery should be resected and the ends oversewn. Measures to prevent this complication are described.     

Surgical implications of anomalous aortic origin of the left coronary artery

We report a patient with exertional chest pain and anomalous aortic origin of the left coronary artery from the right coronary sinus. This patient also had circumflex coronary and right coronary artery stenoses. Following coronary bypass grafting of the circumflex and right coronary arteries in this patient, angina persisted and there was abnormal septal perfusion shown on the exercise thallium imaging despite patent grafts. The angina and perfusion defect were improved by bypass grafting of the unstenosed left anterior descending coronary artery in this patient. Thallium imaging may be useful in the preoperative assessment of patients with this anomaly.     

左冠状动脉起源于肺动脉的外科治疗

目的　探讨左冠状动脉起源于肺动脉的术前诊断、手术治疗的术式和疗效。　方法　1991年 8月～ 1999年 3月 ,8例患者进行了手术治疗 ,其中 7例采用肺动脉内隧道成形术 ,1例采用冠状动脉旁路移植术 ,1例患者合并二尖瓣关闭不全 ,同时进行了二尖瓣成形术。术前进行了心电图、心脏超声和心导管、心脏造影等全面检查。术后随访 7例 ,随访时间平均 (4 6 8± 10 7)个月。　结果　 8例患者无住院死亡和严重并发症 ,7例随访无晚期死亡 ,1例患者因肺动脉内隧道缝线撕脱 ,导致主动脉 主肺动脉瘘 ,二次手术修补成功。随访患者NYHA心功能Ⅰ级 ,LVED平均 (4 6 4± 3 7)mm ,较术前平均 (5 4 4± 2 8)mm明显减少 (P <0 0 1) ,EF值 (6 9 4± 2 3) %较术前 (5 9 6± 2 8) %明显提高(P <0 0 5 )。　结论　左冠状动脉起源于肺动脉是一种较为罕见的先天性心脏病 ,治疗的主要原则为重建 2支冠状动脉系统并处理好合并病变。肺动脉内隧道矫治方法 ,简便易行 ,疗效满意     

Echocardiographic assessment of anomalous origin of the left coronary artery from the pulmonary artery

Transthoracic echocardiography of a 4-month-old boy with heart failure revealed poor left ventricular contractility with severe mitral regurgitation. Deformation analysis revealed significantly decreased circumferential strain in the anterior and anteroseptal segments. Furthermore, post-systolic shortening was evident in the anterior and lateral segments. The pulmonary arterial short-axis view showed that the left coronary artery originated from the pulmonary artery and color Doppler flow mapping showed retrograde flow in the left coronary artery. These findings were quite helpful for concluding the anomalous origin of the left coronary artery from the pulmonary artery.     

Enlargement and rupture of distal basilar artery aneurysm after iatrogenic carotid occlusion

A case of angiographic enlargement and fatal rupture of a previously asymptomatic distal basilar aneurysm in a 12-year-old girl is reported. She had been treated by carotid sacrifice for a giant intracavernous carotid aneurysm. After superficial temporal-middle cerebral artery bypass, this patient underwent a trapping procedure and decompression of her symptomatic giant aneurysm. Despite postoperative patency of her bypass graft, the involved middle cerebral circulation was irrigated substantially by retrograde flow through her posterior communicating artery. An incidental distal basilar aneurysm involving the origin of her superior cerebellar arteries, posterior cerebral arteries, and multiple perforators was treated by a wrapping procedure. Eleven days after carotid ligation, she suffered a fatal subarachnoid hemorrhage from her basilar aneurysm. This catastrophe was undoubtedly produced by our failure to consider the additional hemodynamic stress placed upon the distal basilar artery by carotid sacrifice and may have been preventable by a more aggressive attack on this previously asymptomatic lesion.     

Surgical treatment of anomalous origin of the left coronary artery in infancy

Two cases of anomalous origin of the left coronary artery (LCA) from the pulmonary artery (PA) are reported in which early surgical correction was achieved by an end-to-end anastomosis of the left subclavian artery (LSA) to the LCA, with cardiopulmonary bypass and deep hypothermia. The clinical improvement was rapid and the left ventricular function recovered almost completely. We recommend this type of surgical correction, early in life, for infants in severe cardiac failure and anomalous origin of the LCA.     

Hypoplastic left heart syndrome with anomalous origin of the right coronary artery

Hypoplastic left heart syndrome in association with an anomalous origin of a coronary artery from the pulmonary artery is a very rare congenital malformation. In the few reported cases, the left coronary artery or the circumflex artery arises from the right pulmonary artery. We describe a newborn who presented with hypoplastic left heart syndrome, and at the time of operation had an anomalous origin of the right coronary artery from the right pulmonary artery that was detected. The patient underwent a successful modified Norwood procedure with direct reimplantation of the right coronary artery to the neo-aorta.     

Four cases of the anomalous origin of the left coronary artery from the pulmonary artery

We report perioperative management of 4 patients with anomalous origin of the left coronary artery from the pulmonary artery. This report involves with 3 infant cases and an adult. Two infants underwent coronary reimplantation procedure and Takeuchi's method was performed on the other infant. In all infant cases, mitral valve plasty was performed to correct mitral regurgitation secondary to papillary muscle dysfunction. The adult patient underwent CABG with ligation of LCA. General anesthesia was performed with high doses of fentanyl in all cases. We employed a relatively high PaCO2 and low FIO2 in order to maintain a high pulmonary vascular resistance. It aims to decrease the incidence of left to right shunt. We used epinephrine to wean one infant and the adult from cardiopulmonary bypass. Perioperative course was uneventful with the use of catecholamines and high doses of vasodilators for left ventricular dysfunction and coronary perfusion under mechanical ventilation.     

Innominate artery rupture after transcervical drainage for descending necrotizing mediastinitis

We present a case of innominate artery rupture after descending necrotizing mediastinitis (DNM) on day 36 of cervicomediastinal drainage. The patient recovered after aortosubclavian arterial bypass grafting followed by resection of the eroded artery. Because mechanical pressure caused by drains in addition to the inflammatory process can cause major vessel erosion, prolonged transcervical tube drainage for treating descending necrotizing mediastinitis should be avoided even if the drains applied are soft and thin.