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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 13  |  Issue : 3  |  Page : 267-268
End to end anastomosis of an injured left anterior descending coronary artery


1 Department of Anesthesiology, G.B. Pant Hospital, New Delhi, India
2 Department of Cardio-vascular and Thoracic Surgery, G.B. Pant Hospital, New Delhi, India

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Date of Web Publication6-Sep-2010
 

How to cite this article:
Tomar AS, Agarwal S, Singh A, Mandiye S, Dutta D, Datt V. End to end anastomosis of an injured left anterior descending coronary artery. Ann Card Anaesth 2010;13:267-8

How to cite this URL:
Tomar AS, Agarwal S, Singh A, Mandiye S, Dutta D, Datt V. End to end anastomosis of an injured left anterior descending coronary artery. Ann Card Anaesth [serial online] 2010 [cited 2019 Jul 21];13:267-8. Available from: http://www.annals.in/text.asp?2010/13/3/267/69071


The Editor,

We present a case of a 2-year-old child weighing 7 kg with a diagnosis of Tetralogy of Fallot (TOF), in whom inadvertent division of the left anterior descending coronary artery (LAD) occurred at surgery. It was successfully managed by end to end anastomosis. Bypass grafting using saphenous vein or left internal mammary artery are the only reported methods to restore blood supply distal to an inadvertently transected LAD. [1],[2],[3] .To the best of our knowledge, this is the first report of end to end anastomosis of an injured LAD.

Pre-operatively, transthoracic echocardiogram revealed the diagnosis of TOF with a large perimembranous ventricular septal defect and infundibular pulmonary stenosis. Coronary angiography in the patient was inconclusive of anomalous LAD. However, anomalous LAD from the right coronary artery coursing across the right ventricular outflow tract (RVOT) over the epicardium was observed intra-operatively. The left circumflex artery was arising normally from the left sinus. It was decided to perform total correction via the transatrial approach, as the pulmonary annulus seemed to be adequate in size. However, the LAD was bisected during vigorous dissection of muscle bands from the RVOT. Considering that precious time might be lost in taking down a mammary or a vein of uncertain caliber, and as both the ends of the artery were visible, it was decided to perform end to end anastomosis of the injured artery. This was successfully accomplished using an 8-0 polypropylene suture. The opened-up area of the right ventricle was patched by autologous pericardium. Initially, there was difficulty in weaning the patient off cardiopulmonary bypass, probably due to myocardial ischemia in LAD territory, but with the empirical addition of diltiazem (0.5 mg/h) to milrinone (0.5 mics/kg/min) and dobutamine (5 mics/kg/min), he could be weaned off successfully from cardiopulmonary bypass. I was assumed at that time that diltiazem helped in relieving spasm in the repaired LAD. The post-operative right ventricular to left ventricular pressure ratio was acceptable at 0.5. The remaining course was uneventful and the patient was extubated after 36 h of elective ventilation. Transthoracic echocardiography on the third post-operative day revealed normal biventricular function. He was discharged on the seventh day after surgery.

Anomalous coronary artery anatomy occurs in 2-9% of the patients with TOF, with LAD arising from the right coronary artery and coursing across the RVOT being the commonest. [ 4] LAD injury during intra-cardiac repair for TOF is a catastrophic complication that must be prevented (and repaired if injury is suspected) at all costs. However, in the unfortunate circumstance of such an event occurring, end to end anastomosis of the divided artery, as we have demonstrated, remains a viable surgical option. However, long-term follow-up with coronary angiography or exercise testing when the child is older would be indicated to conclusively demonstrate the patency of the repaired LAD.

 
   References Top

1.Bhutani AK, Koppala MM, Abraham KA, Balakrishnan KR, Desai RN. Inadvertent transection of anomalously arising left anterior descending artery during tetralogy of Fallot repair: Bypass grafting with left internal mammary artery. J Thorac Cardiovasc Surg 1994;108:589-90.  Back to cited text no. 1  [PUBMED]    
2.Berry BE, McGoon DC. Total correction for tetralogy of Fallot with anomalous coronary artery. Surgery 1973;74:894-8.  Back to cited text no. 2  [PUBMED]    
3.Ruzmetov M, Jimenez MA, Pruitt A, Turrentine MW, Brown JW. Repair of tetralogy of fallot with anomalous coronary arteries coursing across the obstructed right ventricular outflow tract. Pediatr Cardiol 2005;26:537-42.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Cooley DA, Duncan JM, Gillette PC, McNamara DG. Reconstruction of coronary artery anomaly in an infant using the internal mammary artery. Pediatr Cardiol 1987;8:257-9.  Back to cited text no. 4  [PUBMED]    

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Correspondence Address:
Saket Agarwal
Department of Cardiovascular & Thoracic Surgery, G.B. Pant Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.69071

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