In this article, we present a pediatric case with anomalous origin and course of the left coronary artery, in which surgical correction with lateral translocation of the pulmonary trunk to the left pulmonary artery (PA) was performed successfully.

Figure 1: Three-dimensional computed tomography images. An anomalous origin of left main coronary artery arising from right cusp in a malignant configuration and course between aorta and pulmonary trunk.
Ao: Aorta; MPA: Main pulmonary artery.

Figure 2: Intraoperative view. Division of main pulmonary artery with reanastomosis to left pulmonary artery. Note the increased distance between pulmonary artery and aorta (black arrows).
Ao: Aorta; LMCA: Left main coronary artery; PA: Pulmonary artery; RVOT: Right ventricular outflow tract; RCA: Right coronary artery.

During surgery, the mediastinum was approached via median sternotomy. The pericardium was incised and an aorto-bicaval cannulation was performed. Cardiopulmonary bypass was initiated and antegrade blood cardioplegia was infused for diastolic arrest.

Following diastolic arrest, the interarterial segment between the aortic root and main PA was dissected out carefully to avoid damage to the coronary artery and branches. The main PA was transected prior to pulmonary bifurcation. The gap at the pulmonary confluence was repaired using a pericardial patch. An incision was made on the left PA and the main PA was anastomosed to this incision. Following completion of the anastomosis, the space between aorta and PA increased (Figure 2). The cross-clamp time was 35 min. Total bypass time was 55 min. Following decannulation, the chest was closed in a routine fashion. The patient underwent successful surgical ventricular septal defect closure and reimplantation of the main PA to the left PA. Postoperative echocardiography demonstrated normal flow to the left PA. The patient recovered gradually without any complication. On the fifth postoperative day, he was eventually discharged.

The true incidence of this anomaly remains unknown due to the fact sudden cardiac arrest often represents as the initial symptom.[4] Early presymptomatic diagnosis presents as a serious challenge. This issue is the major drawback of the diagnosis before a cardiac event.[2] However, the minority of patients may refer to a consultant about non-specific chest pain, syncope, and arrhythmia.

An understanding of the anatomy of the coronary artery is required for optimal imaging. Transthoracic echocardiography is a non-invasive, effective, and firstline diagnostic tool.[3] However, echocardiography is operator-dependent, and image quality can vary depending on the operator's experience and the patient's acoustic window. On routine echocardiographic exam, certain markers of the anomaly may be present. These include a fail to see the coronary ostium in a routine fashion, unusual coronary ostia, and coronary artery images at unexpected areas. In these cases, further evaluation is needed. Although some cardiologists can diagnose the abnormal coronary pattern, it is not recommended to plan surgery solely based on with this examination.[3] In case of echocardiographic diagnosis or suspected existence, further evaluation is needed. Computed tomography angiography is the most appropriate imaging study for this indication which is considered as Class 1 indication.[4]

Surgical indication is in accordance with the most accepted expert consensus on surgical treatment.[4] The optimal management and surgical decision making for patients with coronary artery anomaly depend on multiple factors such type of coronary artery anomaly, age, and symptoms.[6] The key factor in the surgical procedure selection is detailed anomalous coronary artery anatomy. The important points on coronary artery anatomy include aortic sinuses and coronary ostia, intramural course, and acute angles.[5] Patients with LMCA and interarterial course should be treated surgically, even if there are no symptoms.[4] In our case, the coronary artery anatomy was negative for intramural course and acute angulations.

Although the most optimal surgical approach is still controversial, current surgical options include unroofing procedure, button detachment and reattachment procedure, coronary artery bypass grafting, and PA translocation.[4-6] Surgical planning should be performed based on the coronary artery anatomy. In our case, no intramural anatomy was observed and, therefore, the unroofing procedure was unnecessary. Additionally, there was no left main coronary ostium and, thus, the coronary button detachment and reattachment procedure was abandoned. There was another unfavorable option; coronary artery bypass grafting.[4,6] The reason why the bypass procedure is not favorable is the competitive flow due to anastomosis, iatrogenic injury to non-atherosclerotic, and stenosis-free artery via anastomosis.[5,6] The last procedure was PA translocation,[5] as it was thought to be the most appropriate option for our patient depending on his coronary artery anatomy. The PA lateral translocation procedure widens the gap between PA and aorta. Coronary artery compression is relieved via this maneuver. In our case, the surgical team decided performing PA lateral translocation procedure as the most optimal treatment option.

In conclusion, favorable surgical outcomes can be achieved with the appropriate method of surgical treatment of anomalies of the left coronary artery. As in our case, the lateral translocation procedure allows an anatomical reconstruction and is technically feasible as an effective surgical approach for patients with a suitable anatomy.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

1) Angelini P. Coronary artery anomalies: an entity in search of an identity. Circulation 2007;115:1296-305.

2) Cheezum MK, Liberthson RR, Shah NR, Villines TC, O’Gara PT, Landzberg MJ, et al. Anomalous aortic origin of a coronary artery from the inappropriate sinus of valsalva. J Am Coll Cardiol 2017;69:1592-608.

3) Lorber R, Srivastava S, Wilder TJ, McIntyre S, DeCampli WM, Williams WG, et al. Anomalous aortic origin of coronary arteries in the young: echocardiographic evaluation with surgical correlation. JACC Cardiovasc Imaging 2015;8:1239-49.

4) Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008;52:e143-e263.

5) Rodefeld MD, Culbertson CB, Rosenfeld HM, Hanley FL, Thompson LD. Pulmonary artery translocation: a surgical option for complex anomalous coronary artery anatomy. Ann Thorac Surg 2001;72:2150-2.

6) Padalino MA, Franchetti N, Sarris GE, Hazekamp M, Carrel T, Frigiola A, et al. Anomalous aortic origin of coronary arteries: Early results on clinical management from an international multicenter study. Int J Cardiol 2019;291:189-93.