title: Creation of a dual-coronary system for anomalous origin of the left coronary artery from the pulmonary artery utilizing the trapdoor flap method.
abstract: OBJECTIVE
  Results of the repair of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) have improved. Direct implantation of the anomalous coronary artery into the ascending aorta establishes a dual-coronary system and is the goal of current surgical approaches. We report the development of our surgical technique for ALCAPA.
  
  
  METHODS
  Between September 1993 and December 2000, 13 patients underwent surgery for ALCAPA. There were four males and nine females. Ages ranged from 1 month to 25 years (median=3.9) and weight ranged from 2.6 to 102kg (median=16.8). One patient had previously undergone an operative procedure at an outside institution.
  
  
  RESULTS
  Direct implantation of the anomalous coronary artery into the ascending aorta was feasible in 12 of 13 patients. In situ transfer was performed in one patient with an intramural coronary artery. The first case in the series required an intrapulmonary baffle reconstruction (Takeuchi procedure) because the coronary artery arose remotely from the ascending aorta from the left-anterior sinus of the PA. For coronary transfer, a trapdoor flap was created on the ascending aorta for the implantation of the coronary button and the sinus defect in the main PA was augmented with a pericardial patch. The left ventricular (LV) shortening fraction was improved from a median value of 27% (range 12-36%) preoperatively to 33% (range 24-45%) in the immediate postoperative period (P=0.004). The LV end-diastolic dimension decreased from a median value of 36 mm (range 22-70 mm) preoperatively to 29 mm (range 19-56 mm) in the immediate postoperative period (P=0.004). There has been no mortality or reoperation during a median follow-up of 36 months.
  
  
  CONCLUSIONS
  Using a standard technique, direct implantation of the anomalous coronary artery into the ascending aorta was achieved in all cases but one. At intermediate follow-up, LV function had improved by echocardiography. No postoperative mechanical circulatory support was required in any of these patients. This operative technique is reproducible and is applicable to the majority of patients with ALCAPA.
authors.affiliation: Pediatric and Congenital Heart Surgery, Cleveland Clinic Children's Hospital, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
authors.forename: Makoto
authors.initials: M
authors.lastname: Ando
authors.forename: Roger B B
authors.initials: RB
authors.lastname: Mee
authors.forename: Brian W
authors.initials: BW
authors.lastname: Duncan
authors.forename: Jonathan J
authors.initials: JJ
authors.lastname: Drummond-Webb
authors.forename: Shivaprakash G
authors.initials: SG
authors.lastname: Seshadri
authors.forename: C Igor
authors.initials: CI
authors.lastname: Igor Mesia
mesh_terms: D000293:Adolescent; D000328:Adult; D001011:Aorta / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D003330:Coronary Vessel Anomalies / Q000503:physiopathology / Q000601:surgery*; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008297:Male; D011651:Pulmonary Artery / Q000002:abnormalities* / Q000601:surgery*; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000503:physiopathology