*****AMERICAN HEART JOURNAL*****

(REFERENCE 1 OF 42) 97240363

Taylor AJ Byers JP Cheitlin MD Virmani R Anomalous right or left coronary artery from the contralateral coronary sinus: "high-risk" abnormalities in the initial coronary artery course and heterogeneous clinical outcomes.

In: Am Heart J (1997 Apr) 133(4):428-35

ISSN: 0002-8703

Coronary artery anomalies are associated with sudden cardiac death, although individual patient outcomes are highly variable. We performed blinded pathologic analysis of 30 consecutive cases of anomalous right (n = 21) or left (n = 9) coronary artery from the contralateral coronary sinus to determine which, if any, features might aid in risk stratification for sudden cardiac death. We found no significant differences in length of aortic intramural segment, coronary ostial size, degree of displacement of the anomalous coronary artery from the correct coronary sinus, or angle of coronary takeoff between patients with (n = 12) and without (n = 18) sudden cardiac death. All pathologic features showed considerable interpatient variability. Age > or = 30 years was the only variable associated with a decreased incidence of sudden cardiac death. Thus no simple relation exists between variations in the initial coronary artery course and clinical outcome in these anomalies.

Institutional address: Department of Medicine Walter Reed Army Medical Center Armed Forces Institute of Pathology Washington DC 20307 USA.

*****AMERICAN JOURNAL OF CARDIOLOGY*****

(REFERENCE 2 OF 42) 97307574

Daniels C Bacon J Fontana ME Eaton G Cohen D Leier CV Anomalous origin of the left main coronary artery from the pulmonary trunk masquerading as peripartum cardiomyopathy.

In: Am J Cardiol (1997 May 1) 79(9):1307-8

ISSN: 0002-9149

We present a 16-year-old girl who developed congestive heart failure during and after delivery of her first child, and who was diagnosed as having peripartum cardiomyopathy. Cardiac catheterization with coronary arteriography confirmed the correct diagnosis of anomalous origin of the left main coronary artery from the pulmonary trunk.

Institutional address: Division of Cardiology The Ohio State University Medical Center Columbus 43210 USA.

(REFERENCE 3 OF 42) 95100116

Johnsrude CL Perry JC Cecchin F Smith EO Fraley K Friedman RA Towbin JA Differentiating anomalous left main coronary artery originating from the pulmonary artery in infants from myocarditis and dilated cardiomyopathy by electrocardiogram.

In: Am J Cardiol (1995 Jan 1) 75(1):71-4

ISSN: 0002-9149

Anomalous left main coronary artery (ALMCA) originating from the pulmonary artery is an important cause of morbidity from heart failure and mortality in infants. Discriminating ALMCA from myocarditis or other forms of dilated cardiomyopathy (DC) in infants is critical for proper early management of this treatable disease. This study was performed to characterize electrocardiographic (ECG) patterns in infants with ALMCA, and to identify features that would allow differentiation of these infants from those with myocarditis/DC. Presenting electrocardiograms from 28 patients with ALMCA < 2 years of age were analyzed for 103 variables, and compared with electrocardiograms from 28 aged-matched infants with myocarditis/DC using the t test, Fisher's exact test, and discriminant analysis using stepwise logistic regression techniques. ECG findings characteristic of infants with ALMCA were confirmed, including deep (> or = 3 mm) and wide (> or = 30 ms) Q waves and a QR pattern in at least 1 of the following leads: I, aVL, V5 to V7. Also, the complete absence of Q waves from leads II, III, and aVF in all infants with ALMCA was noted. These and other ECG patterns were more common in infants with ALMCA than in those with myocarditis/DC (p < 0.05), but were also noted in some patients with myocarditis/DC. Stepwise logistic regression analysis identified 3 ECG variables that best discriminated ALMCA from myocarditis/DC, including Q wave width (w) in lead I, and Q-wave depth (d) and ST-segment amplitude (s) in lead aVL.(ABSTRACT TRUNCATED AT 250 WORDS)

Institutional address: Division of Pediatric Cardiology Baylor College of Medicine Houston Texas.

*****ANNALS OF THORACIC SURGERY*****

(REFERENCE 4 OF 42) 97185623

Ueyama K Ramchandani M Beall AC Jr Jones JW Diagnosis and operation for anomalous circumflex coronary artery.

In: Ann Thorac Surg (1997 Feb) 63(2):377-81

ISSN: 0003-4975

BACKGROUND: Origin of the left circumflex coronary artery from the right sinus of Valsalva is the most common anatomic variation of the coronary artery circulation. However, there are few reports about the operative approach to this anomalous vessel. METHODS: Forty patients having this anomaly were identified from 10,216 adult cardiac catheterization procedures. Forty percent of the anomalous circumflex coronary arteries (ACCAs) had critical atherosclerotic lesions. Eighty cases needed bypass grafting. RESULTS: For diagnosis of ACCA, the aortic root sign was positive in 94.9% of the diagnosed patients and the nonperfused myocardium sign was found in 92.5%. Eighty percent of ACCAs were larger than 2 mm in radiographic diameter before their passage into the atrioventricular groove. However, after emerging from the atrioventricular groove, 70% measured less than 1.5 mm. Consequently, a technique was developed to bypass the proximal ACCA and was used in 2 cases. Six other patients with more distal disease and larger vessels underwent conventional bypass grafting. CONCLUSIONS: The aortic root sign and nonperfused myocardium are useful in diagnosing ACCA. The ACCA is usually too small for use of the conventional graft technique. Therefore, a technique was developed to graft more proximally and was applied successfully in 2 cases.

Institutional address: Department of Surgery Baylor College of Medicine Houston Texas USA.

(REFERENCE 5 OF 42) 99127691

Veinot JP Acharya VC Bedard P Compression of anomalous circumflex coronary artery by a prosthetic valve ring.

In: Ann Thorac Surg (1998 Dec) 66(6):2093-4

ISSN: 0003-4975

Anomalous origin of the circumflex coronary artery from the right aortic sinus, with a retroaortic course, is usually without consequence. We report a patient who underwent aortic valve replacement for bicuspid aortic valve. The prosthesis sewing ring distorted the circumflex, producing myocardial infarcts and sudden death during exercise.

Institutional address: Department of Laboratory Medicine Ottawa Civic Hospital Heart Institute University of Ottawa Ontario Canada.

(REFERENCE 6 OF 42) 99091010

Ohkado A Yashima M Ishiyama M Morishima S Tei E Delayed diagnosis of anomalous origin of the left coronary artery 16 years after mitral valve replacement.

In: Ann Thorac Surg (1998 Nov) 66(5):1819-20

ISSN: 0003-4975

Mitral insufficiency caused by ischemia is frequently found in anomalous origin of the left coronary artery from the pulmonary artery. We report a case of a 25-year-old woman who was diagnosed to have anomalous origin of the left coronary artery from the pulmonary artery and had successful left internal mammary artery bypass grafting 16 years after mitral valve replacement for mitral insufficiency of an unknown cause in her childhood.

Institutional address: Department of Cardiovascular Surgery Ayase Heart Hospital Tokyo Japan.

(REFERENCE 7 OF 42) 99090998

Eidem BW Cetta F Roughneen PT DeLeon SY Fisher EA Anomalous right coronary artery from the pulmonary artery in Taussig- Bing anomaly.

In: Ann Thorac Surg (1998 Nov) 66(5):1797-8

ISSN: 0003-4975

The presence of associated anomalies in patients with double-outlet right ventricle can significantly alter surgical intervention. Preoperative delineation of these anomalies can facilitate surgical planning and improve outcome. We describe a case in which the right coronary artery and anterior descending coronary artery arose from the pulmonary artery in a patient with double-outlet right ventricle with subpulmonary ventricular septal defect (Taussig-Bing anomaly).

Recognition of this important anomaly prevented significant intraoperative myocardial damage by altering techniques of cardioplegia administration for myocardial preservation.

Institutional address: Department of Thoracic and Cardiovascular Surgery Loyola University Medical Center Maywood Illinois 60153 USA. beidem@wpo.it.luc.edu

(REFERENCE 8 OF 42) 99015482

Radke PW Messmer BJ Haager PK Klues HG Anomalous origin of the right coronary artery: preoperative and postoperative hemodynamics.

In: Ann Thorac Surg (1998 Oct) 66(4):1444-9

ISSN: 0003-4975

Anomalous origin of the right coronary artery from the main pulmonary artery is a rare congenital cardiac malformation. Most patients

remain asymptomatic. However, there are cases of sudden cardiac death described in the literature, indicating a potentially malign course of the disease. To establish a double-ostium coronary system, correction of the aberrant vessel is recommended. Despite surgical reconstitution of normal coronary anatomy, the postoperative clinical

presentation of some patients does not improve substantially, raising the question of the functional outcome of reinserted coronary vessels. This report of a patient with anomalous origin of the right coronary artery from the pulmonary trunk, in whom a complete hemodynamic assessment including intracoronary Doppler flow measurements was performed before and after reimplantation, very strongly supports the concept of an anatomically corrective operation.

Institutional address: Medical Clinic I and Department of Cardiothoracic Surgery RWTH University Hospital Aachen Germany.

(REFERENCE 9 OF 42) 99015469

Yamagishi M Emmoto T Wada Y Oka T Transposition of the great arteries with anomalous origin of the left coronary artery from the pulmonary artery.

In: Ann Thorac Surg (1998 Oct) 66(4):1416-8

ISSN: 0003-4975

We describe an extremely rare case of successful arterial switch operation for an infantile complete transposition of the great arteries associated with ventricular septal defect and anomalous origin of the left coronary artery from the pulmonary artery in which the left main coronary artery arose from the posterior sinus of the pulmonary artery and the right coronary artery and an accessory branch arose from the aorta.

Institutional address: Department of Surgery II Children's Research Hospital Kyoto Prefectural University of Medicine Japan. myama@koto.kpu-m.ac.jp

(REFERENCE 10 OF 42) 99015462

Morell VO Feccia M Cullen S Elliott MJ Anomalous coronary artery with tetralogy of Fallot and aortopulmonary window.

In: Ann Thorac Surg (1998 Oct) 66(4):1403-5

ISSN: 0003-4975

Anomalous origin of the left main coronary artery from the pulmonary artery is rarely associated with other conditions. We report the case of an infant born with tetralogy of Fallot and aortopulmonary window who at the time of surgical repair was found to have an anomalous left main coronary artery originating from the right pulmonary artery.

Institutional address: Cardiothoracic Unit Great Ormond Street Hospital for Children London England.

(REFERENCE 11 OF 42) 95321853

Turley K Szarnicki RJ Flachsbart KD Richter RC Popper RW Tarnoff H Aortic implantation is possible in all cases of anomalous origin of the left coronary artery from the pulmonary artery.

In: Ann Thorac Surg (1995 Jul) 60(1):84-9

ISSN: 0003-4975

BACKGROUND. Anomalous origin of the left coronary artery from the pulmonary artery (PA) optimally is treated by creation of a multiple coronary system. This study explores the use of aortic implantation employing alternative methods to achieve coronary transfer in all patients, regardless of the site of origin of the anomalous coronary artery, avoiding the problems of bypass grafts and tunnel procedures. METHODS. During the period 1986 to 1994, 11 patients aged 6 months to 8 years (mean age, 2.6 years) underwent repair. Coronary artery origin from the PA included left sinus in 3, posterior in 2, right sinus in 2, intramural aorta with its orifice at the bifurcation of the main and right PA in 1, high left main PA in 1, high at the bifurcation of main and right PA in 1, and anterior in 1. Findings included angina in 4, prior infarctions in 3, ischemia in 7, left ventricular dysfunction in 6, mitral regurgitation in 5, atrial septal defect in 2, and echocardiograms suggestive of endocardial fibrosis in 4. One patient had prior ligation with ventricular dysfunction and collateralization and recanalization. A single patient was asymptomatic. Repair was accomplished by direct transfer using the PA sinus of Valsalva as a button in only 6; tubular reconstruction was used in 4 when the distance was too great to avoid tension; 2 short tubes were constructed with PA wall in 2 of the 3 left sinus origins, whereas 2 long tubes of PA wall were used (1 high on the left side of the main PA and 1 with left anterior descending origin from the anterior sinus of Valsalva in a patient with malrotation [end neo-artery to side aortic reconstruction]); finally, in situ transfer and intraaortic reconstruction (unroofing and anastomosis) was performed in 1 intramural coronary artery. Division of the PA, mobilization of the distal PA, division of the ductus, and direct reanastomosis of the PA was performed in 3 tubular reconstructions, as well as all 6 direct coronary transfers. RESULTS. There were no operative or late deaths. Follow-up of 2 to 100 months (mean, 46 months) revealed no new angina or infarctions, improved function and decreased mitral regurgitation. Echocardiographic and angiographic studies demonstrated patency and prograde flow in the new coronary systems. CONCLUSIONS. Aortic implantation is the treatment of choice for anomalous origin of the left coronary artery. Methods such as direct transfer, tubular reconstruction, and in situ transfer make such implantation possible in all patients regardless of the site of coronary origin, distance from the aorta, or coronary artery configuration.

Institutional address: California Pacific Medical Center Kaiser Permanente Medical Center San Francisco 94115 USA.

(REFERENCE 12 OF 42) 95118140

Moss RL Backer CL Zales VR Florentine MS Mavroudis C Tetralogy of Fallot with anomalous origin of the right coronary artery.

In: Ann Thorac Surg (1995 Jan) 59(1):229-31

ISSN: 0003-4975

This report describes a child with tetralogy of Fallot and acquired pulmonary valve atresia in whom the pulmonary blood flow was provided solely by retrograde flow from an anomalous right coronary artery originating from the main pulmonary artery. Complete repair with preservation of the native pulmonary valve and implantation of the right coronary artery into the ascending aorta is described.

Institutional address: Division of Cardiovascular-Thoracic Surgery Children's Memorial Hospital Chicago Illinois 60614.

(REFERENCE 13 OF 42) 95031402

Rinaldi RG Carballido J Giles R Del Toro E Porro R Right coronary artery with anomalous origin and slit ostium [see comments]

In: Ann Thorac Surg (1994 Sep) 58(3):829-32

ISSN: 0003-4975

Right coronary arteries that arise from the left sinus or ectopically from the right sinus with a slit ostium can cause myocardial ischemia, myocardial infarction, or sudden death. The surgical repair of these anomalies has evolved toward a simpler operation that widens the orifice of origin and reduces the compression of the intramural segment. We have repaired these anomalies without mortality in 8 patients. We summarize our experience and the evolution of this procedure.

Comment in: Ann Thorac Surg 1995 Apr;59(4):1043-4

Institutional address: Department of Cardiovascular Surgery Pavia Hospital San Juan Puerto Rico.

(REFERENCE 14 OF 42) 98143814

Pozzi M Santoro G Makundan S Intraaortic balloon pump after treatment of anomalous origin of left coronary artery.

In: Ann Thorac Surg (1998 Feb) 65(2):555-7

ISSN: 0003-4975

The same system of intraaortic balloon pumping has been used in 2 infants after surgical repair of anomalous origin of the left coronary artery from the main pulmonary artery. Intraaortic balloon pumping was started in the first patient on the second postoperative day, whereas in the second patient it was started before the patient was weaned from cardiopulmonary bypass. Both patients survived. In the first patient intraaortic balloon pumping improved the low cardiac output, which had failed to respond to maximal inotropic support, whereas in the second it maintained hemodynamic stability.

Institutional address: Department of Cardiac Surgery Royal Liverpool Children's Hospital-Alder Hey England. mpozzi@liverpedcard.u-net.com

(REFERENCE 15 OF 42) 98115663

Black MD McCrindle BW Freedom RM Should we address the course as well as the origin of a translocated anomalous coronary artery?

In: Ann Thorac Surg (1998 Jan) 65(1):248-50

ISSN: 0003-4975

The identification of an anomalous left coronary artery arising from the pulmonary artery demands urgent surgical attention. Myocardial infarction and ongoing myocardial ischemia are a direct consequence with subsequent left ventricular dysfunction. A modification using a combination of autogenous aortic and pulmonary artery flaps is described, which addresses both the origin and the course of the anomalous coronary artery--until now, a feature not generally considered necessary of repairs involving anomalous left coronary artery arising from the left facing pulmonary sinus.

Institutional address: Division of Cardiovascular Surgery The Hospital for Sick Children and The University of Toronto Ontario Canada. michael.black@mailhub.sickkids.on.ca

(REFERENCE 16 OF 42) 96186360

Kobayashi J Kosakai Y Kawashima Y Maze procedure and anomalous coronary artery repair.

In: Ann Thorac Surg (1996 Mar) 61(3):1008-11

ISSN: 0003-4975

A 60-year-old woman has anomalous origin of the left coronary artery from the pulmonary artery, mitral regurgitation with left ventricular dysfunction, and atrial fibrillation. We performed mitral valve annuloplasty, maze procedure, and intrapulmonary tunnel repair of anomalous origin of the left coronary artery. The patient regained normal sinus rhythm and showed improved left ventricular function and no mitral regurgitation.

Institutional address: Department of Cardiovascular Surgery National Cardiovascular Center Osaka

Japan.

(REFERENCE 17 OF 42) 96146334

Davis JT Teske DW Allen HD Cohen DM Schauer GM Anomalous course of the left main coronary artery in tetralogy of Fallot [see comments]

In: Ann Thorac Surg (1996 Jan) 61(1):229-31

ISSN: 0003-4975

An extremely rare coronary artery anomaly where the left main coronary artery arose anteriorly from the right coronary sinus and coursed in front of the right ventricular outflow tract was present in a patient with tetralogy of Fallot. Preoperative angiocardiography was interpreted as normal. Operative recognition was prevented by dense adhesions and a partial intramural course. Division of the vessel at repair resulted in death of the patient. The angiographic pattern associated with this anomaly is very unusual, and in many views looks deceptively normal. Details are presented.

Comment in: Ann Thorac Surg 1996 Jun;61(6):1879

Institutional address: Children's Hospital Ohio State University Columbus 43205 USA.

(REFERENCE 18 OF 42) 97452694

Sarris GE Drummond-Webb JJ Ebeid MR Latson LA Mee RB Anomalous origin of left coronary from right pulmonary artery in

hypoplastic left heart syndrome.

In: Ann Thorac Surg (1997 Sep) 64(3):836-8

ISSN: 0003-4975

An infant with hypoplastic left heart syndrome presented for surgical repair at 9 months of age, the ductus having remained open in the presence of a restrictive atrial septal defect. In addition, an anomalous left coronary artery originating from the right pulmonary artery was found. After preliminary blade/balloon atrial septostomy, a successful modified Norwood procedure with concomitant reimplantation of the anomalous coronary artery was performed.

Institutional address: Center for Pediatric and Congenital Heart Surgery Cleveland Clinic Foundation Ohio 44195 USA.

(REFERENCE 19 OF 42) 97408105

van Son JA Mohr FW Modified unroofing procedure in anomalous aortic origin of left or right coronary artery.

In: Ann Thorac Surg (1997 Aug) 64(2):568-9

ISSN: 0003-4975

A modified technique is reported for unroofing of the intramurally coursing segment of the left main or right coronary artery with anomalous aortic origin. This technique avoids detachment and resuspension of the intercoronary commissure and thus lessens the risk of post-operative aortic valve regurgitation.

Institutional address: Herzzentrum University of Leipzig Germany.

(REFERENCE 20 OF 42) 97116312

Schmid C Kececioglu D Konertz W Mollhoff T Scheld HH Biological bridging after repair of an anomalous origin of a left coronary artery.

In: Ann Thorac Surg (1996 Dec) 62(6):1839-41

ISSN: 0003-4975

We report on an unusual case of surgical repair for anomalous origin of the coronary artery from the pulmonary artery, in a young patient who underwent tunnel repair with concomitant heterotopic heart transplantation to support severely impaired left ventricular function. Four years later, the graft was removed after confirmation of ventricular arrest and excellent recovery of the patient's own heart.

Institutional address: Department of Thoracic and Cardiovascular Surgery University of Muenster Germany.

(REFERENCE 21 OF 42) 94058431

Francois K Provenier F Jordaens L Van Nooten GJ Anomalous origin of the left coronary artery from the pulmonary artery.

In: Ann Thorac Surg (1993 Nov) 56(5):1168-70

ISSN: 0003-4975

A 20-year-old woman underwent successful operative correction of anomalous origin of the left coronary artery from the pulmonary artery by left internal mammary artery bypass graft. The clinical, hemodynamic, and angiographic features of this unusual case are presented. Different therapeutic options are discussed.

Institutional address: Department of Cardiothoracic Surgery University Hospital Gent Belgium.

(REFERENCE 22 OF 42) 94058428

Pirk J Fabian J Kovac J Reconstructing an anomalous left coronary artery origin using the internal iliac artery.

In: Ann Thorac Surg (1993 Nov) 56(5):1163-4

ISSN: 0003-4975

We describe reconstruction of an anomalous origin of the left coronary artery from the pulmonary artery. The right internal iliac artery was used to create the trunk. The procedure was carried out using extracorporeal circulation during normothermia with a beating heart.

Institutional address: Institute for Clinical and Experimental Medicine Prague Czechoslovakia.

*****ARCHIVES OF PATHOLOGY AND LABORATORY MEDICINE*****

(REFERENCE 23 OF 42) 94361606

Land RN Hamilton AY Fuchs PC Sudden death in a young athlete due to an anomalous commissural origin of the left coronary artery, and focal intimal proliferation of aortic valve leaflet at the adjacent commissure.

In: Arch Pathol Lab Med (1994 Sep) 118(9):931-3

ISSN: 0003-9985

Sudden death occurred in a 15-year-old female athlete with an unusual anomalous left coronary artery. The left coronary artery origin was at (below) the commissure between the left and noncoronary aortic valve cusps. The ostium was slitlike and had an aortic ridge superiorly. In addition, there was an anomalous moundlike intimal proliferation of the noncoronary leaflet adjacent to the left coronary ostium that may have been an additional factor contributing to obstruction of coronary blood flow during diastole.

Institutional address: Department of Pathology St Vincent Hospital and Medical Center Portland Ore. 97225.

*****BRITISH HEART JOURNAL*****

(REFERENCE 24 OF 42) 95134598

Roynard JL Cattan S Artigou JY Desoutter P Anomalous course of the left anterior descending coronary artery between the aorta and pulmonary trunk: a rare cause of myocardial ischaemia at rest.

In: Br Heart J (1994 Oct) 72(4):397-9

ISSN: 0007-0769

When the left anterior descending coronary artery follows an anomalous course between the aorta and pulmonary artery it can cause myocardial ischaemia or sudden death during exercise in young people. Coronary arteriography in a 27 year old man with angina pectoris at rest showed a left anterior descending coronary artery arising from a common right trunk and running from the aorta to the pulmonary artery. Follow up after revascularisation was uneventful.

Institutional address: Service de Cardiologie Hopital Avicenne Bobigny France.

(REFERENCE 25 OF 42) 94176286

Saeed BT Rosin MD Murray RG Successful operation in an old survivor of anomalous origin of the left coronary artery from the pulmonary trunk (Bland-White-Garland syndrome).

In: Br Heart J (1994 Feb) 71(2):193-5

ISSN: 0007-0769

A case of anomalous origin of the left coronary artery from the

pulmonary trunk is reported. The patient, a 64-year-old woman, presented with a history of angina and cardiac failure. She was known to have had a mitral systolic murmur since school age. Echocardiography showed clinically significant mitral regurgitation and highly unusual extensive calcification of the mitral valve chordae, papillary muscle, and posterior left ventricular wall--a pattern suggesting the possibility of abnormal coronary circulation. Subsequent cardiac catheterisation confirmed considerable mitral regurgitation with a dilated left ventricle, and arteriography confirmed anomalous origin of the left coronary artery from the main pulmonary trunk. The patient was surgically treated with ligation of the origin of the anomalous left coronary and mitral valve replacement. She was alive and well 2 years after operation.

Institutional address: Cardiology Department Birmingham Heartlands Hospital NHS Trust.

(REFERENCE 26 OF 42) 94312209

Carvalho JS Silva CM Rigby ML Shinebourne EA Angiographic diagnosis of anomalous coronary artery in tetralogy of Fallot.

In: Br Heart J (1993 Jul) 70(1):75-8

ISSN: 0007-0769

OBJECTIVE--To obtain angiographic views in tetralogy of Fallot that can show whether or not an anomalous coronary artery passes anterior to the right ventricular outflow tract. DESIGN--(a) A 10 year retrospective review of all patients who underwent repair of tetralogy of Fallot up to December 1990; (b) a prospective study of 30 children undergoing routine cardiac catheterisation. PATIENTS AND METHODS--295 cases in whom standard angiographic views had been used were reviewed retrospectively. Thirty non-consecutive children with tetralogy of Fallot were studied prospectively, including one child previously studied in whom diagnosis of an unsuspected anomalous coronary artery was made only at operation. The aortogram was performed with > or = 45 degrees caudocranial and 20 degrees-30 degrees left anterior oblique angles. SETTING--Tertiary referral centre. RESULTS--Ten of the 295 cases reviewed were shown to have a coronary vessel traversing the right ventricular outflow tract. In one case the diagnosis was suspected before operation but it was missed in the others. Even in retrospect we could not be certain of the precise anatomy with the use of standard angiographic views. In the prospective study the caudocranial aortogram showed the aortic valve face on in all the patients. The right ventricular outflow tract lay in a left and anterior (seen as superior) position in relation to the aortic root. Thus any vessel crossing the outflow tract could be identified. Identification of the aortic cusps allowed precise definition of the origin of the coronary arteries. All but four had normal origin and course of the coronary arteries. Four had paired left anterior descending arteries (including the restudied patient), in all cases with a large vessel originating from the right coronary artery passing across the right ventricular outflow tract. CONCLUSIONS--Important anomalies of the coronary arteries in tetralogy of Fallot may remain undiagnosed if standard angiographic projections are used. Aortography with > or = 45 degrees caudocranial and 20 degrees-30 degrees left anterior oblique angles allows precise definition of the anatomy and certainty as to whether any major vessel crosses the right ventricular outflow tract. Interpretation, however, can only be correct if the projection is technically adequate with a view of the aortic valve face on. Furthermore, a normal bifurcation of the left main stem does not exclude a second left anterior descending artery crossing the pulmonary outflow tract.

Institutional address: Department of Paediatric Cardiology Royal Brompton National Heart and Lung Hospital London.

(REFERENCE 27 OF 42) 94107654

Salzer-Muhar U Proll E Kronik G Intercoronary collateral flow detected by Doppler colour flow mapping is an additional diagnostic sign in children with anomalous origin of the left coronary artery from the pulmonary artery.

In: Br Heart J (1993 Dec) 70(6):558-9

ISSN: 0007-0769

Intercoronary collateral flow within septal collaterals was detected by colour-coded Doppler echocardiography in three children with anomalous origin of the left coronary artery from the pulmonary artery. In each of the three patients angiography confirmed the presence of septal collaterals.

Institutional address: Department of Paediatric Cardiology University of Vienna Austria.

*****CHEST*****

(REFERENCE 28 OF 42) 95079847

Chopra PS Reed WH Wilson AD Rao PS Delayed presentation of anomalous circumflex coronary artery arising from pulmonary artery following repair of aortopulmonary window in infancy.

In: Chest (1994 Dec) 106(6):1920-2

ISSN: 0012-3692

Anomalous origin of the circumflex coronary artery is extremely rare and may cause serious perioperative myocardial injury associated with correction of coexisting congenital malformations. We describe a 15- year-old female patient who underwent surgical correction of an aortopulmonary window at 13 months. Fourteen years later, she presented with dyspnea on exertion associated with angina. On cardiac catheterization, she was noted to have a step-up in oxygen saturation in the pulmonary artery and retrograde filling of the circumflex coronary artery from the left anterior descending coronary artery, with drainage into the pulmonary artery. The patient underwent surgical bypass of the anomalous circumflex coronary artery and ligation of its anomalous origin in the pulmonary artery. Her postoperative course was uneventful, with complete relief of symptoms. We have reviewed this rare congenital anomaly and its therapeutic options.

Institutional address: Department of Surgery University of Wisconsin Medical School Madison.

(REFERENCE 29 OF 42) 94008146

Machado C Bhasin S Soulen RL Confirmation of anomalous origin of the right coronary artery from the left sinus of Valsalva with magnetic resonance imaging.

In: Chest (1993 Oct) 104(4):1284-6

ISSN: 0012-3692

Anomalous origin of the right coronary artery from the left sinus of Valsalva is a rare but clinically significant congenital abnormality, difficult to diagnose angiographically. We describe a patient in whom magnetic resonance imaging was used to delineate the anomalous course of the right coronary artery following angiographic demonstration limited by technical considerations.

Institutional address: Wayne State University Department of Internal Medicine Detroit.

(REFERENCE 30 OF 42) 93251900

Alam M Brymer J Smith S Transesophageal echocardiographic diagnosis of anomalous left coronary artery from the right aortic sinus.

In: Chest (1993 May) 103(5):1617-8

ISSN: 0012-3692

Patients with anomalous left main coronary artery arising from the right sinus of Valsalva and coursing posteriorly between the aorta and the pulmonary artery are prone to sudden death. We present a patient with this entity in whom the diagnosis was made by

transesophageal two-dimensional echocardiography and coronary angiography.

Institutional address: Heart and Vascular Institute Henry Ford Hospital Detroit 48202.

*****CIRCULATION*****

(REFERENCE 31 OF 42) 97057378

Lambert V Touchot A Losay J Piot JD Henglein D Serraf A Lacour-Gayet F Planche C Midterm results after surgical repair of the anomalous origin of the coronary artery.

In: Circulation (1996 Nov 1) 94(9 Suppl):II38-43

ISSN: 0009-7322

BACKGROUND: Immediate results after surgical repair of the anomalous origin of the coronary artery are well known, but few studies reported midterm results in a relatively large population. METHODS AND RESULTS: Between 1980 and 1995, 39 consecutive patients with anomalous origin of the coronaries artery from the pulmonary artery had restoration of a two-coronary-artery system. Median age at surgery was 18.5 months (range, 2.7 months to 38 years). Left ventricular (LV) function was normal in 13 patients. Direct aortic implantation was performed in 34 patients (87%), associated with mitral valvuloplasty in 3 patients. Hospital death occurred in 5 patients (13%; 70% confidence limits [CL], 8 to 20). Two patients were lost to follow-up. Mean follow-up was 40 +/- 42 months. There was no late death after 1 month, and the survival rate was 84% (70% CL, 67 to 93). One patient had a mitral valvuloplasty 18 months after reimplantation. At the last follow-up, LV shortening fraction (SF) was normal in 86% (70% CL, 61 to 96), but LV dilation persisted in 73% of patients, and 12 of the survivors (39%) had abnormal regional wall motion of the left ventricle. A perfusion defect with incomplete redistribution was observed in 8 patients on thallium-201 imaging performed in 45% of survivors. Total mortality was related only to the preoperative SF: 12% versus 24.8% (P < .05). No factor was related to SF recovery. CONCLUSIONS: Despite no late deaths and SF recovery, LV dilation and ischemic segments of the left ventricle persisted at the long-term follow-up.

Institutional address: Centre Chirurgical Marie Lannelongue Le Plessis Robinson France.

*****HEART*****

(REFERENCE 32 OF 42) 99164432

Nightingale AK Burrell CJ Marshall AJ Anomalous origin of the left coronary artery from the pulmonary artery: natural history and normal pregnancies.

In: Heart (1998 Dec) 80(6):629-31

ISSN: 1355-6037

Two female patients are described with anomalous origin of the left coronary artery arising from the pulmonary artery who sustained an anterolateral myocardial infarction in infancy. Neither patient received surgical treatment although both have lived to middle age with minimal cardiovascular problems and have had uncomplicated pregnancies. Good exercise tolerance and long term survival may be possible even without surgery for patients with this anomaly.

Institutional address: South West Cardiothoracic Centre Plymouth Hospitals NHS Trust Derriford Hospital UK.

*****JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY*****

(REFERENCE 33 OF 42) 97390674

Schwartz ML Jonas RA Colan SD Anomalous origin of left coronary artery from pulmonary artery: recovery of left ventricular function after dual coronary repair.

In: J Am Coll Cardiol (1997 Aug) 30(2):547-53

ISSN: 0735-1097

OBJECTIVES: We reviewed our institutional experience with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) after dual coronary repair to assess preoperative variables predictive of outcome, the time course for postoperative recovery of cardiac function, the short- and long-term complications and our experience with left ventricular assist devices (LVAD) in these patients. BACKGROUND: Outcome after surgical repair of ALCAPA remains incompletely defined. METHODS: The surgical records and echocardiograms of 42 patients were reviewed. Left ventricular function was assessed by fractional shortening z-score (FSz) and stress-velocity index. RESULTS: The overall survival rate was 86%. All six patients who died were < 1 year old and died within 3 days of the operation. More severe preoperative mitral regurgitation (MR) was associated with increased mortality, but age, body surface area, preoperative FSz and end-diastolic dimension were not. We used an LVAD for 7 of 28 patients who underwent repair for ALCAPA since its introduction at our institution, with a survival of 5 of 7 patients. The degree of MR improved in 62% of patients and remained unchanged in 38%. Complications included supravalvar pulmonary stenosis (16 of 21 patients) and baffle leaks (11 of 21 patients) with the intrapulmonary baffling technique. Supravalvar pulmonary stenosis developed in 1 of 11 patients after direct coronary reimplantation. Left ventricular function became normalized in all 28 patients with follow-up past 1 year, regardless of preoperative FSz. Of 13 patients who underwent serial postoperative echocardiography, the average time to normalization of function was 2 to 7 months. CONCLUSIONS: The degree of preoperative MR was predictive of outcome, whereas the severity of preoperative cardiac dysfunction and ventricular dilation were not. Mild and moderate MR tended to improve without mitral valvuloplasty. Complete recovery from myocardial dysfunction is expected after dual coronary repair of ALCAPA.

Institutional address: Department of Cardiology Children's Hospital Boston Massachusetts 02115 USA.

(REFERENCE 34 OF 42) 98122422

Singh TP Di Carli MF Sullivan NM Leonen MF Morrow WR Myocardial flow reserve in long-term survivors of repair of anomalous left coronary artery from pulmonary artery.

In: J Am Coll Cardiol (1998 Feb) 31(2):437-43

ISSN: 0735-1097

OBJECTIVES: This study sought to evaluate regional myocardial flow reserve in long-term survivors of repair of anomalous left coronary artery from pulmonary artery (ALCAPA) and to relate the flow abnormalities to the patients' exercise performance. BACKGROUND: Patients with ALCAPA usually present during infancy with severe ischemic cardiomyopathy. The left ventricular function recovers after surgical repair. However, the extent of recovery of myocardial blood flow (MBF) and its potential physiologic significance in long-term survivors are unknown. METHODS: We evaluated MBF (ml/g per min) at baseline and during maximal coronary vasodilation by adenosine in 11 patients after ALCAPA repair (median age 17 years, range 7 to 22) using nitrogen-13 ammonia and dynamic positron emission tomographic imaging. Patients also underwent an incremental exercise test with metabolic monitoring. In each patient, MBF was quantified in the three major vascular territories: the left anterior descending and left circumflex coronary artery territories and the right coronary artery (control region) territory. RESULTS: Basal MBF was mildly reduced in the left coronary territories versus the control region (0.79 +/- 0.14 vs. 0.85 +/- 0.19, p = 0.05). During hyperemia, flow in the left coronary territories was significantly lower than that in the control region (2.1 +/- 0.5 vs. 2.6 +/- 0.5, p < 0.001). As a result, myocardial flow reserve was lower in the left coronary territories than in the control region (2.6 +/- 0.7 vs. 3.2 +/- 0.7, p < 0.001). Exercise performance was impaired in patients when compared with age-matched control subjects. Maximal oxygen consumption correlated linearly with maximal hyperemic flows in the left coronary artery territories (r = 0.73, p = 0.03). CONCLUSIONS: Long-term survivors of ALCAPA repair demonstrate regional impairment of myocardial flow reserve. This may contribute to impaired exercise performance by limiting cardiac output reserve.

Registry Numbers: 124-38-9 (Carbon Dioxide) 58-61-7 (Adenosine) 7664-41-7 (Ammonia)

Institutional address: Department of Pediatrics Wayne State University School of Medicine Detroit Michigan USA.

*****JOURNAL OF PEDIATRICS*****

(REFERENCE 35 OF 42) 93274439

Bensky AS Meyer RA An unusual coronary artery origin in a patient with anomalous left coronary artery.

In: J Pediatr (1993 Jun) 122(6):S100-3

ISSN: 0022-3476

In the typical patient with anomalous left coronary artery (ALCA) arising from the pulmonary artery, the left coronary artery arises from within the left or posterior pulmonary sinus. We report a case of ALCA in which the left coronary arose medially from the pulmonary artery above the commissure separating the right and posterior pulmonary sinuses. This unusual origin highlighted some of the problems with the noninvasive diagnosis of ALCA.

Institutional address: Division of Pediatric Cardiology Children's Hospital Medical Center Cincinnati Ohio.

*****JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY*****

(REFERENCE 36 OF 42) 95182612

Laks H Ardehali A Grant PW Allada V Aortic implantation of anomalous left coronary artery. An improved surgical approach.

In: J Thorac Cardiovasc Surg (1995 Mar) 109(3):519-23

ISSN: 0022-5223

Anomalous origin of the left coronary artery from the pulmonary artery may present a technical challenge. Direct implantation of the

anomalous left coronary artery into the aorta to provide a two coronary artery system is the preferred surgical approach. We describe a modification of this technique to allow anastomosis of the anomalous left coronary artery with the excised button of pulmonary artery from within the lumen of the aorta. We have used this procedure in six children and one adult with anomalous left coronary artery with favorable outcome. The potential benefits of this modified technique are (1) improved operative exposure, (2) ability to implant the anomalous left coronary artery in the appropriate sinus, (3) avoidance of aortic valve damage or distortion because of improved exposure, and (4) applicability to patients of all ages.

Institutional address: Department of Surgery University of California Los Angeles School of Medicine.

(REFERENCE 37 OF 42) 94315938

Alexi-Meskishvili V Hetzer R Weng Y Lange PE Jin Z Berger F Loebe M Anomalous origin of the left coronary artery from the pulmonary artery. Early results with direct aortic reimplantation.

In: J Thorac Cardiovasc Surg (1994 Aug) 108(2):354-62

ISSN: 0022-5223

Between January 1991 and June 1993, eleven children with anomalous origin of the left coronary artery from the pulmonary artery underwent direct aortic reimplantation of the left coronary artery at the German Heart Institute Berlin. The patients' ages ranged from 2.5 months to 10.5 years; six were infants. Three infants were intubated and their lungs ventilated before the operation, and one was resuscitated 2 days before the operation. The electrocardiograms of eight patients indicated deep Q waves. All but three of these patients had insufficient collaterals between the right and left coronary arteries. The entire group exhibited reduced left ventricular ejection fraction (minimum 15%) including mitral valve incompetence, which was moderate in six patients and severe in three. All six infants underwent emergency operations, and the remaining children, who were older, underwent elective operations involving moderate hypothermic perfusion and cold crystalloid cardioplegia. Aortic cross-clamping time ranged from 22 to 79 minutes (mean 54 minutes). A two-coronary artery system was established in all patients by direct reimplantation of the anomalous left coronary artery into the ascending aorta. Three patients who also exhibited severe mitral valve incompetence underwent modified Kay mitral valve annuloplasty. A delayed sternal closure procedure (closure performed 1 to 10 days after the operation) was used on eight patients. A 10- month-old patient was successfully treated after the operation with a centrifugal left heart assist device and a 9-year-old patient received extracorporeal membrane oxygenation because of severe heart failure. No postoperative deaths occurred. Left ventricular end- diastolic volume decreased dramatically after the operation and returned to near normal values 1 to 9 months postoperatively. At the same time, the preoperatively depressed left ventricular ejection fraction returned to normal and mitral valve incompetence decreased or vanished in eight patients. Color Doppler echocardiograms (eleven patients) and coronary angiograms (three patients) indicated that the reimplanted left coronary artery was patent in all eleven patients during the follow-up period. Reimplantation of the left coronary artery into the ascending aorta is an effective method of establishing a two-coronary artery system in children with anomalous origin of the left coronary artery from the pulmonary artery. Mitral

valve annuloplasty is recommended for patients who also have severe mitral valve incompetence. Prolonged assisted circulation must be used in cases of severe postoperative heart failure.

Institutional address: Department of Thoracic and Cardiovascular Surgery German Heart Institute Berlin.

(REFERENCE 38 OF 42) 94301003

Berdjis F Takahashi M Wells WJ Stiles QR Lindesmith GG Anomalous left coronary artery from the pulmonary artery. Significance of intercoronary collaterals.

In: J Thorac Cardiovasc Surg (1994 Jul) 108(1):17-20

ISSN: 0022-5223

Seventeen patients with an anomalous left coronary artery from the pulmonary trunk underwent surgical treatment and were evaluated, with a mean follow-up of 9.5 years. Analysis has included clinical symptoms cardiac laboratory tests, angiographic grading of intercoronary collaterals, echocardiographic and angiographic measurement of left ventricular function, surgical methods, and the postoperative outcome. Ten patients (59%) survived, and there were seven early deaths. The only significant variable relating to survival was the extent of preoperative intercoronary connections. In survivors, the postoperative left ventricular ejection fraction increased from 45% +/- 25% to 64% +/- 14% (p < 0.01). Nine of ten survivors are free of symptoms and have normal left ventricular function. Nevertheless, half of all created anastomoses were occluded within 2 years of the operation. We speculate that even if temporarily constructed, a dual coronary supply allows for left ventricular recovery and normalization of function.

Institutional address: Division of Pediatric Cardiology Childrens Hospital Los Angeles University of Southern California School of Medicine.

(REFERENCE 39 OF 42) 94133737

Killen DA Wathanacharoen S Proximal bypass to anomalous circumflex coronary artery.

In: J Thorac Cardiovasc Surg (1994 Feb) 107(2):447-9

ISSN: 0022-5223

A technique for coronary artery bypass to the proximal segment of an anomalous circumflex coronary artery is described. This technique has been used in four patients. It is suggested that in some situations this would be the preferable approach for bypassing an anomalous circumflex coronary artery obstruction.

Institutional address: MidAmerica Heart Institute of Saint Luke's Hospital Kansas City Mo.

(REFERENCE 40 OF 42) 94017908

Stern H Sauer U Locher D Bauer R Meisner H Sebening F Buhlmeyer K Left ventricular function assessed with echocardiography and myocardial perfusion assessed with scintigraphy under dipyridamole stress in pediatric patients after repair for anomalous origin of the left coronary artery from the pulmonary artery.

In: J Thorac Cardiovasc Surg (1993 Oct) 106(4):723-32

ISSN: 0022-5223

Twenty-three patients who underwent operation for anomalous origin of

the left coronary artery from the pulmonary artery were reexamined with two-dimensional echocardiography and thallium 201 perfusion imaging. Follow-up studies were performed 0.6 to 16.2 years (median 2.9 years) after operation. In 22 of 23 patients, a two coronary artery system had been established by implantation of the left coronary artery into the aorta (n = 8) or by anastomosis of the left subclavian artery with the left coronary artery (n = 14). The left coronary artery had been ligated in only one patient. For stress testing, 0.8 mg dipyridamole per kilogram body weight was infused in a 10-minute period in 20 of the 23 patients. High-dose dipyridamole infusion increased mean heart rate (98.1 +/- 27.1 to 122.3 +/- 19.2 beats/min, p < 0.001) and mean left ventricular ejection fraction (54.8% +/- 11.8% to 61.3% +/- 12.5%, p < 0.05) and decreased left ventricular end-diastolic volume index (38.8 +/- 26.7 to 29.9 +/- 8.3 ml/m2, p < 0.005). At rest, left ventricular dimensions were abnormal in only one patient, in whom the anastomosis with the left coronary artery proved to be occluded, as seen with subsequent angiography. Left ventricular function seen with two-dimensional echocardiography was normal in 19 patients and was compromised in 3 (all of whom had major structural anomalies of the left ventricle, such as left ventricular aneurysm, occlusion of the anastomosis, or mitral valve prosthesis). Patients with R-wave loss as seen with preoperative electrocardiography tended to have larger left ventricular volumes at follow-up (69.2 +/- 56.5 ml/m2 versus 32.4 +/- 9.6 ml/m2, p < 0.07). Ten of 20 patients had normal thallium 201-perfusion scans. In 9 of 20 patients defects revealed by permanent thallium 201-perfusion were observed and determined to be myocardial scars. Transient perfusion defects under dipyridamole stress with redistribution at rest occurred in three children, two of whom also had permanent thallium 201 defects. None of the three patients had angina-like symptoms or S- T segment changes during dipyridamole stress. Left ventricular ejection fraction, however, decreased severely during dipyridamole infusion in the single patient with ligature of the left coronary artery. The two remaining patients had normal echocardiographic left ventricular function under stress, and the diagnosis of myocardial ischemia as seen with scintigraphy must be questioned.(ABSTRACT TRUNCATED AT 400 WORDS)

Registry Numbers: 58-32-2 (Dipyridamole)

Institutional address: Division of Pediatric Cardiology Deutsches Herzzentrum Munich Germany.

(REFERENCE 41 OF 42) 94017907

Tashiro T Todo K Haruta Y Yasunaga H Nagata M Nakamura M Anomalous origin of the left coronary artery from the pulmonary artery. New operative technique [see comments]

In: J Thorac Cardiovasc Surg (1993 Oct) 106(4):718-22

ISSN: 0022-5223

We report a new operative technique for repair of anomalous origin of the left coronary artery from the pulmonary artery. The principles of the proposed technique are left main coronary angioplasty using a transected main pulmonary artery, side-to-side anastomosis of the aorta and newly created left coronary artery, and direct anastomosis of the transected pulmonary artery. No prosthetic material is used in this procedure. Our experience in two adults (a 35-year-old man and a

68-year-old woman) indicated that this technique permits two coronary system repair for any anatomic variation of the left coronary artery without the use of prosthetic material. This is more advantageous in infants.

Comment in: J Thorac Cardiovasc Surg 1994 Dec;108(6):1147-8

Comment in: J Thorac Cardiovasc Surg 1995 Feb;109(2):398-9

Institutional address: Department of Thoracic and Cardiovascular Surgery St. Mary's Hospital Kurume Japan.

*****MAYO CLINIC PROCEEDINGS*****

(REFERENCE 42 OF 42) 98327699

Izhar U Lerman A Olney BA Schaff HV Minimally invasive direct coronary artery bypass--a surgical approach for anomalous right coronary artery from left aortic sinus of Valsalva.

In: Mayo Clin Proc (1998 Jul) 73(7):661-4

ISSN: 0025-6196

Anomalous origin of the right coronary artery from the left aortic sinus of Valsalva, although rare, has been associated with myocardial ischemia and sudden death. Methods of surgical correction include

ostial reconstruction, excision and translocation of the vessel origin, and coronary artery bypass grafting. We describe a 39-year- old man with symptoms of myocardial ischemia and an anomalous right coronary artery in whom we performed the new, minimally invasive direct coronary artery bypass procedure with use of the right internal mammary artery.

Institutional address: Division of Thoracic and Cardiovascular Surgery Mayo Clinic Rochester MN 55905 USA.