法洛四联症伴冠状动脉畸形的外科治疗

目的：总结法洛四联症伴冠状动脉畸形手术治疗经验,探讨冠状动脉畸形在法洛四联症纠治手术中的意义。方法：自1994年1月至1999年12月,手术治疗法洛四联症伴冠状动脉畸形15例,年龄43d-8岁,其中右冠状动脉起源于左冠状动脉或左前降支6例,单支左冠状动脉和左前降支起源于右冠状动脉各3例。双前降支,单支右冠状动脉和右冠状动脉肺动脉瘘各1例。一期根治手术13例,姑息手术2例。结果：姑息手术无死亡,根治手术早期死亡1例;无冠状动脉手术意外损伤;随访结果满意。结论：根据肺血管条件和畸形冠状动脉走行特点,选择适当的手术方式和右室流出道重建方法可提高手术效果;冠状动脉畸形不再是法洛四联症纠治手术中的风险因素。     

Surgical treatment of coronary artery-pulmonary artery fistula with coronary aneurysm]

We experienced 4 cases of coronary artery-pulmonary artery fistula with coronary aneurysm, three patients had symptoms of chest pain, and 1 patient had cardiac murmur. Coronary arteriography showed that three patients had fistulas from the left coronary artery to the pulmonary artery; and that 1 patient had a fistula from both the right and left coronary arteries to the pulmonary artery. Moreover, 1 patient had 90% diameter stenosis of segment 7. The maximum diameter of the coronary aneurysm ranged from 12 to 20 mm (average: 15.3 mm). One patient underwent closure of the opening of the fistula, 2 patients underwent multiple ligatures of fistulas, and 1 patient underwent multiple ligatures of fistulas with coronary artery bypass grafting. The postoperative course of every patient was uneventful. There have been 42 reports on this abnormality in Japan. We should treat the fistula as early as possible to prevent cardiac complications such as myocardial ischemia and rupture of coronary aneurysm.     

Off-pump coronary artery bypass grafting for a patient with anomalous origin of the right coronary artery from the pulmonary artery.

We report on a case of a 70-year-old chronic hemodialysis patient. He presented with anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) and severe left anterior descending coronary artery (LAD) stenosis, which supplied collateral flow to the right coronary artery (RCA). The patient complained of myocardial ischemic symptoms during routine hemodialysis. We performed off-pump coronary artery bypass grafting (OPCABG) surgery and ligation of the origin of the ARCAPA. Previous reports described that the myocardial ischemia was a rare complication with the ARCAPA patients. However, this case required coronary revascularization because of the atherosclerotic LAD stenosis as a collateral source of the RCA.     

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.     

Left ventricular function and coronary morphology with anomalous origin of the left coronary artery from the pulmonary artery

Reconstructive surgery of the left coronary artery system was performed in two adult patients with anomalous origin of the left coronary artery from the pulmonary artery. Postoperative studies were carried out at 2 months and at 49 months. Left ventricular volume, left ventricular myocardial mass, and ejection fraction were normal postoperatively in one patient. In the second patient, the left ventricular volume was markedly reduced, but the decrease in left ventricular mass was less pronounced. Dilatation and tortuosity of the right coronary artery disappeared postoperatively in both patients. However, the dilatation and tortuosity of the left coronary artery persisted on coronary arteriogram.     

Catastrophic myocardial ischemia resulting from a left coronary artery anomaly with an origin in the right sinus of Valsalva

A congenital left coronary artery anomaly originating from the right aortic sinus is a rare congenital defect associated with the risk of sudden death in young individuals. In most cases, the proximal portion of the anomalous left coronary artery exists between the ascending aorta and pulmonary trunk, and it has an intramural aortic course; this could critically impair the left coronary flow owing to compression of the anomalous left main trunk between the great vessels during exercise. Herein, we report a 14-year-old boy who experienced cardiac collapse due to an acute myocardial infarction after long-distance running. After resuscitation using percutaneous cardiopulmonary support, computed tomography and coronary angiography revealed an anomalous origin of the left main coronary artery in the right sinus of Valsalva and a proximal course between the aorta and pulmonary trunk. The patient was successfully treated using an unroofing procedure of the intramural left coronary artery.     

Urgent coronary artery bypass graft operation of a patient with acute anterior myocardial infarction,congenital right coronary artery to main pulmonary artery fistula and left hilar hamartoma of the lung

BACKGROUND: Coronary artery fistulas are rare congenital or acquired coronary artery anomalies that can originate from any of the three major coronary arteries and drain into all the cardiac chambers and great vessels. METHODS (CASE REPORT): A 67-year-old male patient administered to the emergency department with a severe unstable angina pectoris. Patient underwent a three-vessel coronary artery bypass graft surgery, liga-clip occlusion of coronary artery to pulmonary artery fistula and a direct diagnostic punch biopsy from the left hilar mass lesion. RESULTS: No complications were encountered postoperatively. The patient was discharged on postoperative day eleven with a referral to the thoracic surgery department for further treatment of his lung tumor. CONCLUSIONS: In this report we present successful combination of an urgent coronary artery bypass graft operation in acute anterior myocardial infarction status with concomitant pathologies of congenital right coronary artery to main pulmonary artery fistula and left hilar mass lesion of the lung.     

Two cases of anomalous origin of LAD from right coronary artery requiring coronary artery bypass

We experienced two cases with anomalous origin of the left anterior descending artery (LAD) from the proximal right coronary artery requiring coronary artery bypass grafting. A 66-yr old female with a long history of angina and a positive stress test had the anomalous artery coursing anterior to the right ventricular outflow tract. A 42-yr old male with worsening angina after an anteroseptal myocardial infarction had the anomalous artery running between the great vessels. Both patients underwent left internal mammary artery-to-LAD bypass on the beating heart with complete resolution of ischemic symptoms.Isolated coronary artery anomaly is an uncommon disease (0.6-1.2%) in patients undergoing cardiac catheterization. An anomalous origin of the LAD from the proximal right coronary artery (RCA) or the right sinus of Valsalva (RSV) is very rare, found in 1.2-6.1% of all coronary anomalies. This coronary anomaly has been considered potentially serious but functionally unimportant. We report two cases of anomalous LAD from the proximal RCA resulting in anterior wall ischemia which was effectively treated by coronary artery bypass surgery.     

Anomalous right coronary artery originating from the left main coronary artery

A 54-year-old man with no cardiac history presented with exertional angina. Cardiac catheterization revealed an anomalous right coronary artery originating from the left main coronary artery with external compression during its course between the aorta and the pulmonary artery. He was successfully managed with surgical reimplantation of the right coronary artery into the aorta.     

Left coronary artery originating from the pulmonary artery correction and total myocardial blood flow measurements

In a boy aged 12 years correction of an anomalous coronary artery system was performed by suture of the left coronary artery origin at the pulmonary artery trunk and a vein by-pass to the proximal LAD. Peroperative blood flow gives values for myocardial perfusion before and after by-pass with relation to patency of the vein graft. Before correction pure coronary blood flow was 540 ml/min, shunt flow 540 ml/min; in total 1,080 ml/min through the right coronary artery. After correction the vein by-pass conducted 310 ml/min and the right coronary artery 180 ml/min. At follow-up 2 months later coronary angiography showed a normal right coronary artery without collateral connections to the left coronary artery system which was well perfused from the by-pass. Left heart hypertrophy was reduced from 568 ml/m2. A weak systolic murmur at the apex could be a slight unimportant mitral insufficiency.     

Anomalous left main coronary artery arising from the pulmonary artery in an adult: Treatment by direct reimplantation

We herein report the case of a 37-year-old woman in whom an anomalous origin of the left coronary artery from the pulmonary artery was surgically corrected. A magnetic resonance angiogram showed the left main coronary artery connecting to the right posterior portion of the pulmonary trunk, and exercise-stressed thallium-201 perfusion scintigrams demonstrated a large reversible anterior defect. She was successfully treated by direct aortic reimplantation of the abnormal left coronary artery. We were able to obtain a sufficient length of the left main trunk by excising the large cuff of pulmonary artery wall surrounding the ostium of the anomalous left coronary artery while transecting the pulmonary artery. Postoperative angiograms demonstrated a widely patent left coronary artery, a decrease in the size of the right coronary artery, and no collaterals, and exercise-stressed thallium-201 perfusion scintigrams demonstrated no remaining ischemic defect at all. Direct aortic reimplantation is an ideal operation but is still limited by the anatomical position of the left coronary artery. In this case, magnetic resonance angiography was an excellent method for deciding the optimum operative procedure for the anomalous left coronary artery. In addition, exercise thallium-201 scintigraphy was found to be useful in recognizing the revascularized effect of the left ventricle.     

Anomalous left anterior descending coronary artery from pulmonary artery with ventricular septal defect

Anomalous origin of the left anterior descending coronary artery with associated congenital defects is very rare. An angiogram of a 47-year-old woman admitted for a ventricular septal defect closure revealed an anomalous left anterior descending coronary artery arising from the left posterior sinus of the pulmonary artery. During the surgical procedure, the origin of the left anterior descending coronary artery was closed with pledgetted polypropylene sutures through the pulmonary artery. The ventricular septal defect was closed with a patch through the right atrium, and the left anterior descending coronary artery was bypassed with the left internal mammary artery.     

Anomalous origin of the left coronary artery from the pulmonary artery. Surgical repair of an unusual form

The authors present a case of a 24-year-old woman with anomalous left coronary artery originating from the pulmonary artery. Surgical correction was performed by the direct transposition of the anomalous left coronary artery from the pulmonary artery to the ascending aorta, without interposed graft. Pre- and postoperative evaluations, including angiograms and cycloergometer stress test are presented. The advantages of this technique are discussed, emphasizing the creation of a two-coronary system without the use of prosthetic, arterial or venous grafts. In the present case the left coronary artery originated from the right posterior sinus of the pulmonary artery. The patient is doing well 23 months after operation.     

Surgical treatment for innominate artery aneurysm with a coronary pulmonary artery fistula: a case report.

A 50-year-old woman complained of hoarseness and chest X-ray demonstrated a widening of the superior mediastinum. Computed tomography scanning and aortography demonstrated aneurysmal dilatation at the innominate artery. Coronary arteriography showed a coronary pulmonary artery fistula originating from the left anterior descending artery. The surgical procedure was prosthetic bifurcated bypass grafting from the ascending aorta to the right common carotid artery and right subclavian artery. During the period of innominate artery occlusion, the patient was cooled to 25 degrees C with selective cerebroperfusion and circulatory arrest. Pathologic diagnosis of the specimen was that of a true aneurysm with atherosclerotic plaque and calcification. The coronary pulmonary artery fistula was closed inside the pulmonary artery. There were no signs of neurologic deficit noted. Innominate artery aneurysm is uncommon and the surgical approach varies in each case. A coronary artery fistula is also an uncommon congenital malformation but has been recognized more often with the improvement in diagnostic techniques such as selective coronary arteriography. We performed successful surgical treatment for a rare case of innominate artery aneurysm with a coronary pulmonary artery fistula.     

Anomalous origin of the left main coronary artery from the right anterior aortic sinus.

Anomalous origin of the left main coronary artery from the right sinus of Valsalva is an uncommon problem, occurring in four distinct patterns. When the left main coronary artery passes between the aorta and the pulmonary trunk, acute myocardial ischemia or sudden death may occur. Angiography is required in establishing a diagnosis. Surgical correction or bypass surgery are sometimes indicated. The authors report two cases of anomalous origin of the left main coronary artery and discuss the anatomic variants, clinical significance, and technical considerations in both diagnosis and management.     

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.     

An alternative procedure for correction of anomalous origin of left coronary artery from the pulmonary artery

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenital cardiac malformation that is commonly associated with mitral insufficiency. Direct implantation of the anomalous origin of the left coronary artery from the pulmonary artery into the aorta is ideal, but it may not be fit for some patients whose anomalous left coronary arteries arise remotely from the ascending aorta. To solve the same technical problem in a boy with anomalous origin of the left coronary artery from the pulmonary artery in combination with moderate mitral insufficiency, we successfully elongated the anomalous coronary artery by creating a tube-shape graft using part of the pulmonary arterial wall. Simultaneous mitral annuloplasty was performed after a dual-coronary repair.     

Aortopulmonary window with anomalous origin of the right coronary artery

We report a case of an aortopulmonary window with a right coronary artery arising from the pulmonary trunk. This exceedingly rare anomaly with anomalous coronary artery presented without myocardial ischemia owing to the aortopulmonary window. The correct diagnosis was made by angiography and a successful surgical correction was performed.     

Anomalous left coronary artery from pulmonary artery with mitral stenosis

The usual presentation of anomalous left coronary artery from pulmonary artery is severe left-sided heart failure and mitral valve insufficiency presenting during the first months of life. The manifestations of left heart failure may be masked if pulmonary artery pressure remains high. We believe this is a rarest of rare case of anomalous left coronary artery from pulmonary artery with severe mitral stenosis and pulmonary hypertension in which pulmonary hypertension, along with good collateral circulation helped to preserve left ventricular function.     

A case of coronary arterial fistula originating from both coronary artery and draining to the right atrium]

We encountered a case with bilateral fistulas of coronary arteries into the right atrium, a rare cardiac anomaly. The case was a 17-year-old woman, who visited our hospital at the age of 11 because of fever. At that time, the patient was diagnosed as having a left coronary artery-right atrial fistula through cardiac catheterization (CAG). When the patient developed staphylococcus infected endocarditis at the age of 16, a thick fistula of the coronary artery, directly running from the deformed left coronary arterial sinus, a fistula of the left circumflex branch, and also a fistula of the right coronary artery into the right atrium were detected by CAG. The outlets of these fistulas were closed from the inside of the right atrium under artificial cardiopulmonary circulation and cardiac arrest, and each fistula was ligated at the outside of cardiac chambers. At that time, we took particular care that any branch of the sinuatrial node was not injured. Although all fistulas were confirmed to be closed by postoperative CAG, and no evidence of ischemia was detected by myocardial scintigraphy, deformity of the left coronary arterial sinus remained, requiring further follow up.