Ann Thorac Surg 2004;77:1457-1459
© 2004 The Society of Thoracic Surgeons
Case report
Autologous patch angioplasty of the left main coronary artery in a pediatric patient: 7-year follow-up
Petros V. Anagnostopoulos, MDa,
Frank A. Pigula, MDa,
John L. Myers, MDa,
Lee B. Beerman, MDb,
Ralph D. Siewers, MDa,
Sanjiv K. Gandhi, MDa*
a Divisions of Pediatric Cardiothoracic Surgery and Pediatric Cardiology, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
b Division of Pediatric Cardiothoracic Surgery, Pennsylvania State Children's Hospital, Hershey, Pennsylvania, USA
Accepted for publication April 9, 2003.
* Address reprint requests to Dr Gandhi, Division of Cardiothoracic Surgery, Children's Hospital of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA 15213, USA
e-mail: sanjiv.gandhi{at}chp.edu
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Abstract
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We present a patient who developed ischemia after an arterial switch procedure for transposition of the great vessels secondary to left coronary artery stenosis. The excellent intermediate-term result of patch angioplasty of the left main coronary artery with the use of an internal thoracic artery patch is outlined.
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Introduction
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The most critical step in the arterial switch operation for surgical correction of transposition of the great arteries is the reimplantation of the coronary arteries. Problems with this reimplantation can lead to short-term and long-term complications, including myocardial ischemia, hemodynamic instability, inability to wean from cardiopulmonary bypass, and chronic cardiomyopathy. We report a case of a patient who developed left main coronary artery occlusion after a switch operation and was treated with patch angioplasty of the left main coronary artery with the use of an internal thoracic artery patch.
A male infant born with simple D-transposition of the great arteries was treated with an arterial switch operation at 10 days of age. The coronary anatomy was 1L, 2RCx. Initial difficulty in weaning from cardiopulmonary bypass was attributed to left coronary insufficiency, requiring anastomotic revision. Although the patient recovered well, postoperative echocardiography demonstrated lateral wall and apical akinesis. There was an electrocardiographic pattern of a lateral wall infarct. A thallium scan 1 month postoperatively showed a fixed perfusion defect in the apical region. Subsequent cardiac catheterization demonstrated a right dominant coronary artery giving rise to the circumflex artery. The left coronary system was smaller than the right with narrowing of the left main, but no discrete areas of stenosis (Fig 1).
At 2 years of age the patient underwent elective follow-up cardiac catheterization that showed persistent akinesis of the lateral wall with paradoxical contraction of the apex with an estimated ejection fraction of 34%. The left main coronary artery was occluded and the left system filled through right-to-left collaterals (Fig 2).
The patient remained symptom free and was medically treated with digoxin, aspirin, and angiotensin-converting enzyme inhibition.
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Fig 1. Coronary angiogram performed at 6 weeks old (4 weeks post arterial switch operation) showing diffuse narrowing of the left main coronary artery (*).
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Fig 2. Coronary angiogram performed at 2 years old showing complete occlusion of the proximal left main coronary artery with retrograde filling of the left system through collaterals from the right coronary artery.
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At 6 years old the patient began experiencing exertional angina. Repeat catheterization estimated an ejection fraction of 26% and no change in the occluded left coronary artery. The decision was made to proceed with coronary revascularization. The operation was performed through a median sternotomy. Standard cardiopulmonary bypass and antegrade cardioplegic arrest of the heart were used. The left main coronary artery was incised toward the coronary ostium and a 1-mm discrete proximal occlusion of the artery was detected. An oval patch was fashioned using a short segment of left internal thoracic artery (ITA) and a patch angioplasty was performed with the use of running 7-0 Prolene suture. The operation was well tolerated and resulted in complete resolution of the patient's angina.
At age 13, the child remained asymptomatic but developed moderate ventricular ectopy. Holter monitor evaluation showed sinus node dysfunction, multiform ventricular beats, bigeminy, triplets, and occasional runs of nonsustained ventricular tachycardia. Angiography revealed stable left ventricular dysfunction, with an estimated ejection fraction of 40%, anterolateral wall akinesis and widely patent coronary arteries (Fig 3).
An electrophysiologic study confirmed sinus node dysfunction, but no ventricular arrhythmias could be induced. Despite the lack of inducibility, the presence of complex ventricular ectopy in the setting of left ventricular dysfunction and a previous infarct was the indication for placement of a dual-chamber pacemaker and automatic implantable cardioverter defibrillator. This was performed with no complications.
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Fig 3. Coronary angiogram performed at 13 years old (7 years after autologous patch angioplasty of the left main) demonstrating widely patent left coronary system.
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Comment
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Pediatric coronary revascularization, although uncommon, has been well reported in the literature. Congenital lesions, Kawasaki's disease, coronary complications associated with the arterial switch operation, and iatrogenic injuries are the most common causes of coronary insufficiency in pediatric patients [1]. Management strategies for significant coronary lesions include surgical intervention and percutaneous transluminal coronary angioplasty with or without stent placement [1–3].
Myocardial ischemia after the arterial switch operation is a well-documented complication that can result in severe myocardial dysfunction. Revision of the coronary anastomosis is usually indicated, although an ITA to coronary artery bypass is a described operative strategy [4]. The ITA is the conduit of choice in pediatric coronary artery bypass grafting secondary to superior patency, compared to saphenous vein grafts and the inherent characteristic of growth potential [5, 6]. In our case, the problem appeared to be very proximal implantation of the left coronary system on the pulmonary trunk. This led to kinking upon filling of the heart, which was alleviated by reimplantation of the left coronary artery. Although this strategy reinstituted flow to the left system and allowed the patient to wean from cardiopulmonary bypass, follow-up coronary catheterization showed diffuse narrowing of the left main coronary artery, which later progressed to complete ostial occlusion.
As elucidated by Mavroudis et al, management options for late-term coronary lesions after the arterial switch operation include proximal arterioplasty, coronary artery bypass, or both [1]. Three of 4 patients in their series received a combination of arterioplasty with bypass grafting out of fear of development of neointimal hyperplasia, which has been reported in adult patients, and the technical difficulty of extending a patch arterioplasty onto the branches of the main coronary artery. Our patient had a discrete proximal stenosis; therefore, extension of the patch beyond the mid left main coronary artery was not needed. As documented by the excellent intermediate-term angiographic result in our patient, the development of neointimal hyperplasia may be less common in children. Whether the same outcome can be achieved with the use of any arterial patch is not known. In adult patients, the ITA is quite resistant to the development of intimal hyperplasia, and may be the ideal material for coronary angioplasty in a child. Native aorta, pulmonary artery, autologous pericardium, and saphenous vein have all been used as angioplasty material with variable results [1, 7]. Finally, although ITA grafting is a well-established coronary revascularization technique, the issue of competitive flow may result in failure of patency of the mammary graft [1].
Our patient developed both short-term and long-term ischemia after an arterial switch procedure for transposition of the great vessels. The excellent intermediate-term result of patch angioplasty of the left main coronary artery stenosis with the use of an ITA patch may prove to be an ideal revascularization option in the management of this complex pediatric cardiac surgery problem.
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References
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- Mavroudis C., Backer C.L., Duffy C.E., Pahl E., Wax D.F. Pediatric coronary artery bypass for Kawasaki, congenital, post arterial switch and iatrogenic lesions. Ann Thor Surg 1999;68:506-512.[Abstract/Free Full Text]
- Khanal S., Ribeiro P.A., Platt M., Kuhn M.A. Right coronary artery occlusion as a complication of accessory pathway ablation in a 12 year old treated with stenting. Cathet Cardiovasc Intervent 1999;46:59-61.[Medline]
- Hanshmi A., Lazzam C., McCrindle B.W., Benson L.N. Stenting of coronary artery stenosis in Kawasaki disease. Cathet Cardiovasc Intervent 1999;46:333-336.[Medline]
- Merlo M., Brunelli F., Annechino F.P., Crupi G., Terzi A., Ziolokowska L. Arterial switch operation: myocardial ischemia reversed by internal mammary artery graft. Ann Thorac Surg 1996;62:586-588.[Abstract/Free Full Text]
- Kameda Y., Kitamura S., Taniguchi S., et al. Differences in adaptation to growth of children between internal thoracic artery and saphenous vein coronary bypass grafts. J Cardiovasc Surg 2001;42:9-16.[Medline]
- Mavroudis C., Backer C.L., Muster A.J., et al. Expanding indications for pediatric coronary artery bypass. J Thorac Cardiovasc Surg 1996;111:181-189.[Abstract/Free Full Text]
- Meseguer J., Hurle A., Fernandez-Latorre F., Alonso S., Llamas P., Casillas J.A. Left main coronary artery patch angioplasty: midterm experience and follow-up with spiral computed tomography. Ann Thorac Surg 1998;65:1594-1597.[Abstract/Free Full Text]
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Abstract
Introduction
