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eComment: Management of mitral regurgitation associated with anomalous left coronary artery from the pulmonary artery

National Cardiothoracic Centre, Korle Bu Teaching Hospital, PO Box KB 591, Korle Bu, Accra, Ghana

Anomalous left coronary artery from the pulmonary artery: intermediate results of coronary elongation

The introduction of the coronary elongation technique as described by Novick et al. [1] presents a simpler surgical alternative to anomalous left coronary artery from the pulmonary artery (ALCAPA) repair and the authors deserve commendation for their ingenuity.

The controversy in ALCAPA repair, however, still remains in the management of associated mitral regurgitation (MR). Knowing that MR is likely to subside without a mitral procedure, the surgeon is faced with the choice of repairing the valve or hoping for a spontaneous recovery.

According to Ben Ali et al.'s report [2], regardless of the severity of MR, if patients did not undergo mitral surgery at initial operation, the severity of MR decreased in 58%, remained unchanged in 40% (of which three patients underwent reoperation for mitral valve repair) and worsened in 2%. They suggested that mitral valve surgery is probably not indicated at initial surgery, except in selected cases with a low potential of recovery [2]. The challenge therefore lies in the preoperative identification of MR with a low potential for recovery.

On the basis of its mechanism in this setting, MR may be classified as either functional or organic. Functional MR results from ischemia of the papillary muscle and the adjacent left ventricular (LV) free wall as well as annular enlargement occasioned by the LV dilatation. Functional MR is improved by successful LV revascularization. Organic MR, however, results from irreversible changes in the subvalvar apparatus (chordal elongation and papillary muscle fibrosis) and form the basis of MR that remains stable or worsens after LV revascularization. In addition, Huddleston et al. [3] have suggested that recurrent or persistent MR after successful revascularization should prompt a search for coronary stenosis. It would appear then that the preoperative evaluation of MR in ALCAPA should focus on identification of organic MR; functional MR even when severe should be adequately addressed with successful LV revascularization. Organic MR obviously requires a mitral valve procedure. Should this be performed at the initial surgery, the ischemic time will be prolonged and may jeopardize an already ischemic LV [4]. Deferring the mitral procedure may compromise the early postoperative cardiac output but with successful revascularization, LV systolic function may improve sufficiently to offset this.

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1. Novick WM, Li XF, Anic D, Baskevitch A, Sandoval N, Gilbert CL, Di Sessa TG. Anomalous left coronary artery from the pulmonary artery: intermediate results of coronary elongation. Interact CardioVasc Thorac Surg 2009;9:814–818.[Abstract/Free Full Text]
2. Ben Ali W, Metton O, Roubertie F, Pouard P, Sidi D, Raisky O, Vouhé PR. Anomalous origin of the left coronary artery from the pulmonary artery: late results with special attention to the mitral valve. Eur J Cardiothorac Surg 2009;36:244–249.[Abstract/Free Full Text]
3. Huddleston CB, Balzer DT, Mendeloff EN. Repair of anomalous left main coronary artery arising from the pulmonary artery in infants: long-term impact on the mitral valve. Ann Thorac Surg 2001;71:1985–1989.[Abstract/Free Full Text]
4. Dodge-Khatami A, Mavroudis C, Backer CL. Anomalous origin of the left coronary artery from the pulmonary artery: collective review of surgical therapy. Ann Thorac Surg 2002;74:946–955.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Frank Edwin Permission Requests Google Scholar Articles by Edwin, F. PubMed PubMed Citation Articles by Edwin, F. Related Collections Related Article