Name: direct re-implantation of left coronary artery into the aorta in adults with anomalous origin of left coronary artery from the pulmonary artery (alcapa)
Uploaded: 2017-04-24T15:00:00
Description: Watch this Scientific Journal Video about Direct Re-implantation of Left Coronary Artery into the Aorta in Adults with Anomalous Origin of Left Coronary Artery from the Pulmonary Artery ALCAPA at JoVE

This work was supported by a grant of the Swiss Cardiovascular Foundation to RT.

The protocol follows the institutional guidelines of the human research ethics committee of the University of Zurich.
1. Preparation for Surgery
<ol>
	<li>Clean and prepare the surgical suite in a typical manner. To facilitate communication between the surgeon and the perfusionist, place the heart-lung machine to the left of the patient, opposite to the surgeon.</li>
	<li>Pre-medicate the patient by the oral administration of 5 mg of midazolam, 30 - 60 min prior to the induction of anesthesi...

<ol>
	<li>Dodge-Khatami, A., Mavroudis, C., Backer, C. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anomalous+origin+of+the+left+coronary+artery+from+the+pulmonary+artery:+collective+review+of+surgical+therapy.">Anomalous origin of the left coronary artery from the pulmonary artery: collective review of surgical therapy.</a> Ann. Thorac. Surg. 74 (3), 946-955 (2002).</li><li>Keith, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+anomalous+origin+of+the+left+coronary+artery+from+the+pulmonary+artery.">The anomalous origin of the left coronary artery from the pulmonary artery.</a> Br. Heart J. 21 (2), 149-161 (1959).</li><li>Hauser, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Congenital+anomalies+of+the+coronary+arteries.">Congenital anomalies of the coronary arteries.</a> Heart. 91 (9), 1240-1245 (2005).</li><li>Wesselhoeft, H., Fawcett, J. S., Johnson, A. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anomalous+origin+of+the+left+coronary+artery+from+the+pulmonary+trunk.+Its+clinical+spectrum,+pathology,+and+pathophysiology,+based+on+a+review+of+140+cases+with+seven+further+cases.">Anomalous origin of the left coronary artery from the pulmonary trunk. Its clinical spectrum, pathology, and pathophysiology, based on a review of 140 cases with seven further cases.</a> Circulation. 38 (2), 403-425 (1968).</li><li>Edwards, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+direction+of+blood+flow+in+coronary+arteries+arising+from+the+pulmonary+trunk.">The direction of blood flow in coronary arteries arising from the pulmonary trunk.</a> Circulation. 29 (2), 163-166 (1964).</li><li>Agustsson, M. H., Gasul, B. M., Fell, H., Graettinger, J. S., Bicoff, J. P., Waterman, D. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anomalous+origin+of+the+left+coronary+artery+from+the+pulmonary+artery+diagnosis+and+treatment+of+infantile+and+adult+types.">Anomalous origin of the left coronary artery from the pulmonary artery diagnosis and treatment of infantile and adult types.</a> JAMA. 180 (1), 15-21 (1962).</li><li>Roberts, S. M., Banbury, T., Mehta, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+rare+case+of+anomalous+left+coronary+artery+from+the+pulmonary+artery+(Bland-White-Garland+Syndrome)+in+a+68-year-old+woman.">A rare case of anomalous left coronary artery from the pulmonary artery (Bland-White-Garland Syndrome) in a 68-year-old woman.</a> Semin. Cardiothorac. Vasc. Anesth. , (2016).</li><li>Yau, J. M., Singh, R., Halpern, E. J., Fischman, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anomalous+origin+of+the+left+coronary+artery+from+the+pulmonary+artery+in+adults:+a+comprehensive+review+of+151+adult+cases+and+a+new+diagnosis+in+a+53-year-old+woman.">Anomalous origin of the left coronary artery from the pulmonary artery in adults: a comprehensive review of 151 adult cases and a new diagnosis in a 53-year-old woman.</a> Clin. Cardiol. 34 (4), 204-210 (2011).</li><li>Michielon, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anomalous+coronary+artery+origin+from+the+pulmonary+artery:+correlation+between+surgical+timing+and+left+ventricular+function+recovery.">Anomalous coronary artery origin from the pulmonary artery: correlation between surgical timing and left ventricular function recovery.</a> Ann. Thorac. Surg. 76 (2), 581-588 (2003).</li><li>Dodge-Khatami, A., Mavroudis, C., Backer, C. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Congenital+Heart+Surgery+Nomenclature+and+Database+Project:+anomalies+of+the+coronary+arteries.">Congenital Heart Surgery Nomenclature and Database Project: anomalies of the coronary arteries.</a> Ann. Thorac. Surg. 69 (4 Suppl), S270-S297 (2000).</li><li>Talwar, S., Jha, A. J., Choudhary, S. K., Gupta, S. K., Airan, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Repair+of+anomalous+left+coronary+artery+from+pulmonary+artery+(ALCAPA)+beyond+infancy.">Repair of anomalous left coronary artery from pulmonary artery (ALCAPA) beyond infancy.</a> Heart Surg. Forum. 16 (4), E210-E215 (2013).</li><li>Toumpourleka, M., Belitsis, G., Alonso, R., Rubens, M., Moat, N., Gatzoulis, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Late+presentation+and+surgical+repair+of+ALCAPA.">Late presentation and surgical repair of ALCAPA.</a> Int. J. Cardiol. 186, 207-209 (2015).</li><li>Quah, J. X., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+management+of+the+older+adult+patient+with+anomalous+left+coronary+artery+from+the+pulmonary+artery+syndrome:+a+presentation+of+two+cases+and+review+of+the+literature.">The management of the older adult patient with anomalous left coronary artery from the pulmonary artery syndrome: a presentation of two cases and review of the literature.</a> Congenit. Heart Dis. 9 (6), E185-E194 (2014).</li><li>Kottayil, B. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anomalous+origin+of+left+coronary+artery+from+pulmonary+artery+in+older+children+and+adults:+direct+aortic+implantation.">Anomalous origin of left coronary artery from pulmonary artery in older children and adults: direct aortic implantation.</a> Ann. Thorac. Surg. 91 (2), 549-553 (2011).</li><li>Rajbanshi, B. G., Burkhart, H. M., Schaff, H. V., Daly, R. C., Phillips, S. D., Dearani, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+strategies+for+anomalous+origin+of+coronary+artery+from+pulmonary+artery+in+adults.">Surgical strategies for anomalous origin of coronary artery from pulmonary artery in adults.</a> J. Thorac. Cardiovasc. Surg. 148 (1), 220-224 (2014).</li><li>Neumann, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+results+after+repair+of+anomalous+origin+of+left+coronary+artery+from+the+pulmonary+artery:+Takeuchi+repair+versus+coronary+transfer.">Long-term results after repair of anomalous origin of left coronary artery from the pulmonary artery: Takeuchi repair versus coronary transfer.</a> Eur. J. Cardio-Thorac. Surg. , (2016).</li><li>Pe&#241;a, E., Nguyen, E. T., Merchant, N., Dennie, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ALCAPA+syndrome:+not+just+a+pediatric+disease.">ALCAPA syndrome: not just a pediatric disease.</a> Radiographics. 29 (2), 553-565 (2009).</li></ol>

This protocol describes a detailed technique for the direct re-implantation of the ALCAPA into the aorta in an adult patient with the origin of main left coronary artery from the right-facing sinus of the pulmonary artery according to the Dodge-Khatami classification10. The myocardial protection strategy and the reconstruction of the pulmonary artery are clearly demonstrated. The major critical step of this technique is represented by the generous mobilization of the left coronary artery to achiev...

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly usually seen as an isolated lesion1. The incidence of ALCAPA is estimated at 1 in 300,000 live births, comprising between 0.24% and 0.46% of congenital cardiac diseases2,3. It is one of the most common causes of myocardial ischemia and infarction in children and, if left untreated, results in a 90% mortality rate in the first year of life4. Only 10 - 15% of infants survive to adulthood due to the rapid development of a large dominant right coronary artery (RCA) with extensive intercoronary collaterals4. During the neonatal period, high pulmonary vascular resistance and the resultant pulmonary artery (PA) pressures ensure that antegrade flow is&#160;maintained from the PA into the anomalous left coronary artery. As the pulmonary vascular resistance gradually decreases, antegrade flow to the left coronary artery reduces. This eventually leads to reversal of flow, and left-to-right shunting into the PA, thus resulting in a &#34;coronary steal5.&#34; Thus, left ventricular (LV) myocardial perfusion depends on intercoronary collaterals from an RCA5,6.
The coronary steal phenomenon and retrograde left-sided coronary flow provide a substrate for chronic subendocardial ischemia, which may lead to left ventricular dysfunction, ischemic mitral regurgitation, and malignant ventricular arrhythmias precipitated by acute myocardial ischemia7. In a subset of adult patients, the mean age at presentation is 41 years, with a shift in sex distribution toward female patients (Female-to-male ratio: 2:1)8. In this patient population, 14% are asymptomatic; 66% present with symptoms of angina, dyspnea, palpitations, or fatigue; and 17% present with life-threatening symptoms, including ventricular arrhythmias, syncope, and sudden cardiac death8. The average age of life-threatening presentation is 33 years and of sudden cardiac death 31 years8. Therefore, surgical correction is highly recommended as soon as the diagnosis is made, regardless of age or the degree of intercoronary collateralization1,9.
Depending on the origin of the anomalous left coronary artery, direct re-implantation of the ALCAPA into the aorta is the more physiologically sound repair technique to reestablish the dual-coronary perfusion system. Most commonly, ALCAPA takes off from the right-hand pulmonary sinus (sinus 1 of the PA), which faces the aortic sinus where the main left coronary artery usually originates (sinus 2 of the aorta)10. This coronary anatomy is most suited to the direct re-implantation technique. The aim of this report is to describe, in detail, the technique for the direct re-implantation of the left coronary artery in ALCAPA in adult patients. The rationale behind direct re-implantation is the advantage-the physiological reestablishment of dual-coronary perfusion-it offers over the ligation of the anomalous left coronary combined with coronary artery bypass grafting11,12,13.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Heart surgery infrastructure:</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Heart Lung Machine</td>
			<td>Stockert</td>
			<td>SIII</td>
		</tr>
		<tr>
			<td>EOPA 24Fr. arterial cannula</td>
			<td>Medtronic</td>
			<td>77624</td>
		</tr>
		<tr>
			<td>Quickdraw 25Fr. femoral venous cannula</td>
			<td>Edwards</td>
			<td>QD25</td>
		</tr>
		<tr>
			<td>LV vent catheter 17Fr.</td>
			<td>Edwards</td>
			<td>E061</td>
		</tr>
		<tr>
			<td>Antegrade 9Fr. cardioplegia cannula</td>
			<td>Edwards</td>
			<td>AR012V</td>
		</tr>
		<tr>
			<td>Retrograde 14Fr. cardioplegia cannula&#160;</td>
			<td>Edwards</td>
			<td>NPC014&#160;</td>
		</tr>
		<tr>
			<td>Electrocautery</td>
			<td>Covidien</td>
			<td>Force FX</td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog number</td>
		</tr>
		<tr>
			<td>Sutures:</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Polypropylene 4/0</td>
			<td>Ethicon</td>
			<td>8871H</td>
		</tr>
		<tr>
			<td>Polypropylene 5/0</td>
			<td>Ethicon</td>
			<td>8870H</td>
		</tr>
		<tr>
			<td>Polypropylene 6/0</td>
			<td>Ethicon</td>
			<td>EH7400H</td>
		</tr>
		<tr>
			<td>Braided polyesther 2/0 ligature with polybutylate coating&#160;</td>
			<td>Ethicon</td>
			<td>X305H</td>
		</tr>
		<tr>
			<td>Intergard dacron graft 8 mm</td>
			<td>Maquet</td>
			<td>IGW0008-30</td>
		</tr>
		<tr>
			<td>Micro knife Sharpoint&#160;</td>
			<td>TYCO Healthcare PTY&#160;</td>
			<td>78-6900</td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog number</td>
		</tr>
		<tr>
			<td>Drugs:</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Midazolam</td>
			<td>Roche Pharma</td>
			<td>N05CD08</td>
		</tr>
		<tr>
			<td>Rocuronium</td>
			<td><a href="https://www.compendium.ch/comp/mnr/22695/de">MSD Merck Sharp &#38; Dohme&#160;</a></td>
			<td>M03AC09</td>
		</tr>
		<tr>
			<td>Propofol</td>
			<td>Fresenius Kabi</td>
			<td>N01AX10</td>
		</tr>
		<tr>
			<td>Fentanil</td>
			<td>Actavis</td>
			<td>N01AH01</td>
		</tr>
		<tr>
			<td>Name</td>
			<td>Company</td>
			<td>Catalog number</td>
		</tr>
		<tr>
			<td>Instruments:</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Cooley Derra anastomosis clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>DC40810-16</td>
		</tr>
		<tr>
			<td>Cooley vascular clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>DC40810-16</td>
		</tr>
		<tr>
			<td>Dissection forceps Carpentier</td>
			<td>Delacroix-Chevalier</td>
			<td>DC13110-28&#160;</td>
		</tr>
		<tr>
			<td>Scissors Metzenbaum</td>
			<td>Delacroix-Chevalier</td>
			<td>B351751</td>
		</tr>
		<tr>
			<td>Needle holder Ryder</td>
			<td>Delacroix-Chevalier</td>
			<td>DC51130-20&#160;</td>
		</tr>
		<tr>
			<td>Dissection forceps DeBakey</td>
			<td>Delacroix-Chevalier</td>
			<td>DC12000-21&#160;</td>
		</tr>
		<tr>
			<td>Micro needle holder Jacobson</td>
			<td>Delacroix-Chevalier</td>
			<td>DC50002-21&#160;</td>
		</tr>
		<tr>
			<td>Micro scisors Jacobson</td>
			<td>Delacroix-Chevalier</td>
			<td>DC20057-21&#160;</td>
		</tr>
		<tr>
			<td>Lung retractor</td>
			<td>Delacroix-Chevalier</td>
			<td>B803990</td>
		</tr>
		<tr>
			<td>Allis clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>DC45907-25&#160;</td>
		</tr>
		<tr>
			<td>O&#8217;Shaugnessy Dissector</td>
			<td>Delacroix-Chevalier</td>
			<td>B60650</td>
		</tr>
		<tr>
			<td>Vessel loop</td>
			<td>Medline</td>
			<td>VLMINY</td>
		</tr>
		<tr>
			<td>18 blade knife</td>
			<td>Delacroix-Chevalier</td>
			<td>B130180</td>
		</tr>
		<tr>
			<td>Leriche haemostatic clamp</td>
			<td>Delacroix-Chevalier</td>
			<td>B86555</td>
		</tr>
	</tbody>
</table>

direct re-implantation of left coronary artery into the aorta in adults with anomalous origin of left coronary artery from the pulmonary artery (alcapa)

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly which is one of leading causes of myocardial ischemia and infarction in children. If left untreated, it results in a 90% mortality rate in the first year of life. In patients who survive to the adulthood, the coronary steal phenomenon and retrograde left-sided coronary flow provide a substrate for chronic subendocardial ischemia, which may lead to left ventricular dysfunction, ischemic mitral regurgitation, malignant ventricular arrhythmias, and sudden cardiac death. The average age of life-threatening presentation is 33 years and of sudden cardiac death 31 years. Therefore, surgical correction is highly recommended as soon as the diagnosis is made, regardless of age. In adult-type ALCAPA originating from the right-facing sinus of the pulmonary artery, direct re-implantation of the ALCAPA into the aorta is the more physiologically sound repair technique to re-establish the dual-coronary perfusion system and is recommended. This protocol describes the technique of direct re-implantation of adult-type ALCAPA into the aorta.

Presentation
The patient was a 48-year-old woman presenting with the recent onset of angina Canadian Cardiovascular Society (CCS) grad III and occasional palpitations. She reported three uneventful pregnancies. Moderate smoking was the main cardiovascular risk factor. Trans-thoracic echocardiography showed a moderately impaired (45%) left ventricular ejection fraction and no mitral regurgitation. A coronary angiography was then per...

Watch this Scientific Journal Video about Direct Re-implantation of Left Coronary Artery into the Aorta in Adults with Anomalous Origin of Left Coronary Artery from the Pulmonary Artery ALCAPA at JoVE

Direct Re-implantation of Left Coronary Artery into the Aorta in Adults with Anomalous Origin of Left Coronary Artery from the Pulmonary Artery ALCAPA

Surgical correction of ALCAPA is highly recommended, regardless of age or the degree of intercoronary collateralization. This protocol presents a technique for the direct re-implantation of adult-type ALCAPA into the aorta to re-establish the dual-coronary perfusion. Whenever feasible, direct re-implantation is preferred to other surgical correction techniques.

Direct Re-implantation of Left Coronary Artery into the Aorta in Adults with Anomalous Origin of Left Coronary Artery from the Pulmonary Artery (ALCAPA)

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly which is one of leading causes of myocardial ...

The overall goal of this surgical procedure is to reconnect the anomalous left coronary artery from the pulmonary artery directly into the aorta. This method improves on the surgical correction of the ALCAPA, such as by relieving tension on the coronary anastomosis. But the main advantage of this technique is that it provides a great physiological restitution of the dual coronary perfusion.Though this method can be applied to surgical correction of ALCAPA, it can also provide insight for other surgical procedures such as reimplantation of coronaries during aortic roots surgery. After preparing the patient for surgery and opening the sternum, incise the pericardium over the aorta to uncover the massively dilated and tortuous right coronary artery. Grab the pericardium and cut up to its reflection line over the ascending aorta.Use electrocautery as needed. Then dissect the aorta circumferentially. Gently push the ascending aorta to the left using a lung retractor and grip the soft tissue behind the ascending aorta.Separate the posterior wall of the ascending aorta from the surrounding tissue using electrocautery. Continue to dissect cautery behind the ascending aorta, being careful to avoid injury to the right pulmonary artery. Next, gently push aside the main pulmonary artery and separate the attached ascending aorta using electrocautery.Then dissect the main pulmonary artery. First, push aside the ascending aorta with a clamped piece of gauze. Then with new gauze, dissect the posterior wall of the main pulmonary artery without injuring the adjacent main left coronary artery.Now pass the dissector under the main pulmonary artery and gently open it to make a tunnel. Then grip an open loop in jaws of the dissector. Finally, grab the adventitia of the ascending aorta and pull the vessel loop held by the dissector to encircle the main pulmonary artery.Continue by placing a left ventricular vent. After placing a pursestring on the right upper pulmonary vein, gently push the superior vena cava towards the left side and make a small cut in the middle of the pursestring. Then gently open the clamp.Next, insert a vent through the right upper pulmonary vein and mitral valve into the left ventricle to unload the left heart. After securing the vent with ligature, gently dilate the opening in the pulmonary artery. And insert an antegrade cardioplegia cannula in the main pulmonary artery.Now insert an antegrade cardioplegia cannula into the ascending aorta. Secure it with a braided polyester two over zero ligature with a polybutylene coating. Before proceeding, verify the correct placement of the antegrade cardioplegia cannulas in the main pulmonary artery and ascending aorta.Once the heart is made ready to open, transect the aorta. Remove the cardioplegia cannula and grab the ascending aorta with forceps on each side of the opening. Then enlarge the opening with an 18 blade knife and finish with scissors.Now verify the absence of the left coronary ostium inside the aorta in the left sinus of valsalva. To proceed, transect the main pulmonary artery. Remove the cardioplegia cannula and grab the main pulmonary artery on each side of the opening.Enlarge the opening with an 18 blade knife and finish with scissors. Then confirm the presence of the left coronary ostium originating from the right facing sinus one of the pulmonary artery. After preparing the pulmonary artery, grab a large surrounding patch of the proximal main pulmonary root wall and cut the left coronary ostium from the right facing sinus one.Take care to not injure the pulmonary valve. Before proceeding, mobilize the main left coronary artery up to its bifurcation. To begin, prepare for the reimplantation of the left coronary ostium.Grip the proximal ascending aorta and use a straight blade to create a neo-ostium in the left sinus two of the aorta. Leave a 10 millimeter margin of aortic root wall around the neo-ostium towards the commissure between the left sinus two and the right coronary sinus. Also, leave a 10 millimeter margin towards the aortic annulus.Next, connect the main left coronary ostium end to end to the neo-ostium in the left sinus two of the aorta using a running six over zero propylene monofilament suture. Start the anastomosis at the deepest point of the main left coronary ostium and allow it to come up on the right hand side of the anastomosis. To relieve suture tension on the tissue, manually bring the aorta and the main left coronary ostium together when pulling sutures.Complete the anastomosis by running the left hand side of the suture to meet the other end. Now repair the defect in the pulmonary artery root using a non-treated autologous pericardial patch. Connect the patch at the deepest point of the right facing sinus one of the pulmonary artery using a running six over zero propylene monofilament suture.First, run up the left end of the suture to mid height of the defect. Then do the same with the right end of the suture. Keep the two suture ends under tension.Now reestablish the continuity of the great vessel. Reconnect the proximal party of the aorta to its distal part using an end to end anastomosis with running five over zero propylene monofilament suture. Start at the deepest point and come up on the right hand side.Complete the anastomosis by running the left hand side of the suture to meet the other end. Now de-air the aorta by removing the aortic cross clamp. At this point, start rewarming the patient.Next reconnect the pulmonary artery. First, place a pump sucker into the distal pulmonary artery to remove the site of the operative field. Then from the patched defect, continue a running suture from the left end to complete the posterior and left aspects of the anastomosis.Then from the right end of the patch, continue the suture to complete the posterior and right aspects of the anastomosis. Tie the two ends of the suture to finish the connection. A 48 year old woman presented with recent onset of angina grad three and occasional palpitations.Transthoracic echocardiography showed a moderately impaired left ventricular ejection fraction and no mitral regurgitation. Coronary angiography demonstrated the absence of the left main coronary artery, LCA, arising from the aorta. The right coronary artery, RCA, was considerably enlarged and perfused the main left coronary artery via intraseptal collaterals.Thus the diagnosis of ALCAPA was made. The anatomical type of ALCAPA was further defined by biplane and three dimensional CT scans. The described surgical procedure was then performed.Post operatively the patient was separated from the cardiopulmonary bypass at a core temperature of 37 degrees celsius. No myocardial ischemia occurred. Bleeding from the chest tube drain was less than 30 milliliters per hour and the patient was weaned from the ventilator and extubated within six hours.A year later the patient was leading a productive life. A CT scan showed the re-implanted ALCAPA was widely patent at the site of anastomosis to the aorta. The pulmonary artery did not present any narrowing at the site of reconstruction.With the autologous pericardial patch used to repair the defect in the right facing sinus of the PA.Once mastered, this technique can be done in five hours if it is performed properly. While attempting this procedure, it is important to remember to achieve a good immobilization of the left coronary artery. After its development, this technique paved the way for researchers in the field of cardiac surgery to explore a direct re-implantation of anomalous left coronary artery from pulmonary artery in adults.Don't forget that working with coronary ostia can be extremely hazardous and precautions such as gentle handling and enough immobilization of the left coronary ostium should always be taken while performing this procedure.

direct-re-implantation-left-coronary-artery-into-aorta-adults-with

Research

JoVE Journal

Medicine

Use of a Hanging Weight System for Coronary Artery Occlusion in Mice

Murine studies of acute injury are an area of intense investigation, as knockout mice for different genes are becoming increasingly available 1-38. Cardioprotection by ischemic preconditioning (IP) remains an area of intense investigation. To further elucidate its molecular basis, the use of knockout mouse studies is particularly important 7, 14, 30, 39. Despite the fact that previous studies have already successfully performed cardiac ischemia and reperfusion in mice, this model is technically very challenging. Particularly, visual identification of the coronary artery, placement of the suture around the vessel and coronary occlusion by tying off the vessel with a supported knot is technically difficult. In addition, re-opening the knot for intermittent reperfusion of the coronary artery during IP without causing surgical trauma adds additional challenge. Moreover, if the knot is not tied down strong enough, inadvertent reperfusion due to imperfect occlusion of the coronary may affect the results. In fact, this can easily occur due to the movement of the beating heart.
Based on potential problems associated with using a knotted coronary occlusion system, we adopted a previously published model of chronic cardiomyopathy based on a hanging weight system for intermittent coronary artery occlusion during IP 39. In fact, coronary artery occlusion can thus be achieved without having to occlude the coronary by a knot. Moreover, reperfusion of the vessel can be easily achieved by supporting the hanging weights which are in a remote localization from cardiac tissues.
We tested this system systematically, including variation of ischemia and reperfusion times, preconditioning regiments, body temperature and genetic backgrounds39. In addition to infarct staining, we tested cardiac troponin I (cTnI)
as a marker of myocardial infarction in this model. In fact, plasma levels of cTnI correlated with infarct sizes (R2=0.8). Finally, we could show in several studies that this technique yields highly reproducible infarct sizes during murine IP and myocardial infarction6, 8, 30, 40, 41. Therefore, this technique may be helpful for researchers who pursue molecular mechanisms involved in cardioprotection by IP using a genetic approach in mice with targeted gene deletion. Further studies on cardiac IP using transgenic mice may consider this technique.

A murine model for myocardial ischemia and ischemic preconditioning is an important tool study cardioprotective mechanisms in vivo. Here, we report an easy applicable in situ model for cardiac IP using a hanging-weight system for coronary artery occlusion.

Murine studies of acute injury are an area of intense investigation, as knockout mice for different genes are becoming increasingly available 1-38. ...

Coronary Artery Ligation and Intramyocardial Injection in a Murine Model of Infarction

Mouse models are a valuable tool for studying acute injury and chronic remodeling of the myocardium in vivo. With the advent of genetic modifications to the whole organism or the myocardium and an array of biological and/or synthetic materials, there is great potential for any combination of these to assuage the extent of acute ischemic injury and impede the onset of heart failure pursuant to myocardial remodeling. 
Here we present the methods and materials used to reliably perform this microsurgery and the modifications involved for temporary (with reperfusion) or permanent coronary artery occlusion studies as well as intramyocardial injections. The effects on the heart that can be seen during the procedure and at the termination of the experiment in addition to histological evaluation will verify efficacy. 
Briefly, surgical preparation involves anesthetizing the mice, removing the fur on the chest, and then disinfecting the surgical area. Intratracheal intubation is achieved by transesophageal illumination using a fiber optic light. The tubing is then connected to a ventilator. An incision made on the chest exposes the pectoral muscles which will be cut to view the ribs. For ischemia/reperfusion studies, a 1 cm piece of PE tubing placed over the heart is used to tie the ligature to so that occlusion/reperfusion can be customized. For intramyocardial injections, a Hamilton syringe with sterile 30gauge beveled needle is used. When the myocardial manipulations are complete, the rib cage, the pectoral muscles, and the skin are closed sequentially. Line block analgesia is effected by 0.25% marcaine in sterile saline which is applied to muscle layer prior to closure of the skin. The mice are given a subcutaneous injection of saline and placed in a warming chamber until they are sternally recumbent. They are then returned to the vivarium and housed under standard conditions until the time of tissue collection. At the time of sacrifice, the mice are anesthetized, the heart is arrested in diastole with KCl or BDM, rinsed with saline, and immersed in fixative. Subsequently, routine procedures for processing, embedding, sectioning, and histological staining are performed. 
Nonsurgical intubation of a mouse and the microsurgical manipulations described make this a technically challenging model to learn and achieve reproducibility. These procedures, combined with the difficulty in performing consistent manipulations of the ligature for timed occlusion(s) and reperfusion or intramyocardial injections, can also affect the survival rate so optimization and consistency are critical.

Numerous genetic manipulations and/or intramyocardial injections of genes, proteins, cells, and/or biomaterials are superimposed upon the dimension of time in studies of acute ischemia/ reperfusion injury and chronic remodeling in mice. This video illustrates the microsurgical procedures for ischemia/reperfusion, permanent coronary artery ligation, and intramyocardial injection studies.

Mouse models are a valuable tool for studying acute injury and chronic remodeling of the myocardium in vivo.  With the advent of genetic modifications to ...

Modified Technique for Coronary Artery Ligation in Mice

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI we need better knowledge about pathophysiology of myocardial ischemia. This knowledge may be valuable to define new therapeutic targets for innovative cardiovascular therapies4. Experimental MI model in mice is an increasingly popular small-animal model in preclinical research in which MI is induced by means of permanent or temporary ligation of left coronary artery (LCA)5. In this video, we describe the step-by-step method of how to induce experimental MI in mice.
The animal is first anesthetized with 2% isoflurane. The unconscious mouse is then intubated and connected to a ventilator for artificial ventilation. The left chest is shaved and 1.5 cm incision along mid-axillary line is made in the skin. The left pectoralis major muscle is bluntly dissociated until the ribs are exposed. The muscle layers are pulled aside and fixed with an eyelid-retractor. After these preparations, left thoracotomy is performed between the third and fourth ribs in order to visualize the anterior surface of the heart and left lung. The proximal segment of LCA artery is then ligated with a 7-0 ethilon suture which typically induces an infarct size ~40% of left ventricle. At the end, the chest is closed and the animals receive postoperative analgesia (Temgesic, 0.3 mg/50 ml, ip). The animals are kept in a warm cage until spontaneous recovery.

The surgical procedure used to induce experimental myocardial infarction in mice begins with left thoracotomy between the third and the fourth ribs in order to visualize the anterior surface of the heart and left lung. The left coronary artery is ligated, the chest is closed and the mouse is allowed to recover spontaneously.

Myocardial infarction (MI) is one of the most important causes of mortality in humans1-3. In order to improve morbidity and mortality in patients with MI ...

A Murine Model of Myocardial Ischemia-reperfusion Injury through Ligation of the Left Anterior Descending Artery

Acute or chronic myocardial infarction (MI) are cardiovascular events resulting in high morbidity and mortality. Establishing the pathological mechanisms at work during MI and developing effective therapeutic approaches requires methodology to reproducibly simulate the clinical incidence and reflect the pathophysiological changes associated with MI. Here, we describe a surgical method to induce MI in mouse models that can be used for short-term ischemia-reperfusion (I/R) injury as well as permanent ligation. The major advantage of this method is to facilitate location of the left anterior descending artery (LAD) to allow for accurate ligation of this artery to induce ischemia in the left ventricle of the mouse heart. Accurate positioning of the ligature on the LAD increases reproducibility of infarct size and thus produces more reliable results. Greater precision in placement of the ligature will improve the standard surgical approaches to simulate MI in mice, thus reducing the number of experimental animals necessary for statistically relevant studies and improving our understanding of the mechanisms producing cardiac dysfunction following MI. This mouse model of MI is also useful for the preclinical testing of treatments targeting myocardial damage following MI.

We introduce a surgical method to induce experimental ischemia/reperfusion (I/R) injury to simulate myocardial infarction (MI) in mouse models that allows for more clarity in positioning of the ligation on the left anterior descending artery (LAD) to increase the reproducibility of MI experiments in mice.

Acute or chronic myocardial infarction (MI) are cardiovascular events resulting in high morbidity and mortality. Establishing the pathological mechanisms ...

Permanent Ligation of the Left Anterior Descending Coronary Artery in Mice: A Model of Post-myocardial Infarction Remodelling and Heart Failure

Heart failure is a syndrome in which the heart fails to pump blood at a rate commensurate with cellular oxygen requirements at rest or during stress. It is characterized by fluid retention, shortness of breath, and fatigue, in particular on exertion. Heart failure is a growing public health problem, the leading cause of hospitalization, and a major cause of mortality. Ischemic heart disease is the main cause of heart failure.
Ventricular remodelling refers to changes in structure, size, and shape of the left ventricle. This architectural remodelling of the left ventricle is induced by injury (e.g., myocardial infarction), by pressure overload (e.g., systemic arterial hypertension or aortic stenosis), or by volume overload. Since ventricular remodelling affects wall stress, it has a profound impact on cardiac function and on the development of heart failure. A model of permanent ligation of the left anterior descending coronary artery in mice is used to investigate ventricular remodelling and cardiac function post-myocardial infarction. This model is fundamentally different in terms of objectives and pathophysiological relevance compared to the model of transient ligation of the left anterior descending coronary artery. In this latter model of ischemia/reperfusion injury, the initial extent of the infarct may be modulated by factors that affect myocardial salvage following reperfusion. In contrast, the infarct area at 24 hr after permanent ligation of the left anterior descending coronary artery is fixed. Cardiac function in this model will be affected by 1) the process of infarct expansion, infarct healing, and scar formation; and 2) the concomitant development of left ventricular dilatation, cardiac hypertrophy, and ventricular remodelling.
Besides the model of permanent ligation of the left anterior descending coronary artery, the technique of invasive hemodynamic measurements in mice is presented in detail.

Heart failure is the leading cause of hospitalization and a major cause of mortality. A model of permanent ligation of the left anterior descending coronary artery in mice is applied to investigate ventricular remodelling and cardiac dysfunction post-myocardial infarction. The technique of invasive hemodynamic measurements in mice is presented.

Heart failure is a syndrome in which the heart fails to pump blood at a rate commensurate with cellular oxygen requirements at rest or during stress. It ...

Ultrasound Based Assessment of Coronary Artery Flow and Coronary Flow Reserve Using the Pressure Overload Model in Mice

Transthoracic Doppler echocardiography (TTDE) is a clinically useful, noninvasive tool for studying coronary artery flow velocity and coronary flow reserve (CFR) in humans. Reduced CFR is accompanied by marked intramyocardial and pericoronary fibrosis and is used as an indication of the severity of dysfunction. This study explores, step-by-step, the real-time changes measured in the coronary flow velocity, CFR and systolic to diastolic peak velocity (S/D) ratio in the setting of an aortic banding model in mice. By using a Doppler transthoracic imaging technique that yields reproducible and reliable data, the method assesses changes in flow in the septal coronary artery (SCA), for a period of over two weeks in mice, that previously either underwent aortic banding or thoracotomy. 
During imaging, hyperemia in all mice was induced by isoflurane, an anesthetic that increased coronary flow velocity when compared with resting flow. All images were acquired by a single imager. Two ratios, (1) CFR, the ratio between hyperemic and baseline flow velocities, and (2) systolic (S) to diastolic (D) flow were determined, using a proprietary software and by two independent observers. Importantly, the observed changes in coronary flow preceded LV dysfunction as evidenced by normal LV mass and fractional shortening (FS). 
The method was benchmarked against the current gold standard of coronary assessment, histopathology. The latter technique showed clear pathologic changes in the coronary artery in the form of peri-coronary fibrosis that correlated to the flow changes as assessed by echocardiography. 
The study underscores the value of using a non-invasive technique to monitor coronary circulation in mouse hearts. The method minimizes redundant use of research animals and demonstrates that advanced ultrasound-based indices, such as CFR and S/D ratios, can serve as viable diagnostic tools in a variety of investigational protocols including drug studies and the study of genetically modified strains.

Coronary flow reserve (CFR) is useful for assessment of myocardial oxygen demand and evaluation of cardiovascular risk. This study establishes a step-by-step transthoracic Doppler echocardiographic (TTDE) method for longitudinal monitoring of the changes in CFR, as measured from coronary artery in mice, under the experimental pressure overload of aortic banding.

Transthoracic Doppler echocardiography (TTDE) is a clinically useful, noninvasive tool for studying coronary artery flow velocity and coronary flow ...

Murine Echocardiography of Left Atrium, Aorta, and Pulmonary Artery

The present methodology teaches the investigator how to measure and use the LAV as a surrogate of chronic elevations in Left Ventricular diastolic pressure through echocardiography, as well as to obtain measurements of the Aorta and PA diameter in mice.
Mice older than 10 d of age can be analyzed using the present technique. The technique is composed of 3 main steps: set-up, image acquisition, and image analysis. The set-up step consists of getting the mouse anesthetized with 1% isoflurane, shaving it, and taping it in a supine position to a heated EKG board where the image acquisition will take place. The image acquisition step consists of learning to identify the cardiac structures and obtaining all the required images with its correspondent probe and axis in order to be able to calculate volumes and diameters. The image analysis step consists of measuring the previously acquired images with the aid of computer software.
Advantages of the proposed technique include a fast (15 min) procedure that would allow the researcher to evaluate interventions in a non-invasive, non-terminal approach and therefore follow the same mouse over time; each mouse can be used as its own control. This fact plus having the same operator perform all the acquisition and analysis for the entire experiment minimizes the limitation of operator-dependency. The present methodology is useful for mouse researchers in cardiovascular and pulmonary medicine.

The following protocol describes the methodology for the acquisition and analysis of echocardiographic images used to obtain the Left Atrial Volume (LAV), Aorta (Ao) diameter, and Pulmonary Artery (PA) diameter in mice. This technique is a non-invasive, non-terminal procedure that allows assessment of the cardiopulmonary function.

The present methodology teaches the investigator how to measure and use the LAV as a surrogate of chronic elevations in Left Ventricular diastolic ...

Murine Left Anterior Descending (LAD) Coronary Artery Ligation: An Improved and Simplified Model for Myocardial Infarction

Ischemic heart disease (IHD), or acute coronary syndrome (ACS), is one of the leading causes of death in the United States. IHD is characterized by reduced blood supply to the heart, resulting in the loss of oxygen to and the ensuing necrosis of the heart muscle. The MI model has gained popularity for its use as a short-term ischemia-reperfusion model and a long-term permanent ligation model. Below, we describe a reliable method for the permanent ligation of the LAD. With mouse genetic engineering technology becoming more advanced, and with an increasing availability of quality murine surgical instruments, the mouse has become a popular model for MI surgeries. Our surgical model incorporates the use of an easily reversible anesthetic for the rapid recovery of the mouse; a minimally invasive endotracheal intubation without involving a tracheotomy; and a thoracentesis through the original thoracotomy site without creating an additional incision in the chest, as is done in some other methods, to effectively remove excess blood and air from the chest cavity. This method is comparatively less invasive than other methods, which dramatically reduces surgical and post-surgical complications and mortality and improves reproducibility.

Murine Left Anterior Descending LAD Coronary Artery Ligation: An Improved and Simplified Model for Myocardial Infarction

We provide a reliable method for left anterior descending artery (LAD) ligation in a mouse model. This method is comparatively less invasive than other methods, involving endotracheal intubation, a left-sided thoracotomy approach, and thoracentesis. This method can be used as a model for both acute and chronic myocardial infarction (MI).

Ischemic heart disease (IHD), or acute coronary syndrome (ACS), is one of the leading causes of death in the United States. IHD is characterized by ...

Identifying Coronary Artery Calcification on Non-gated Computed Tomography Scans

Coronary artery calcification (CAC) provides an objective measure of coronary artery disease and can readily be identified on non-gated computed tomography (CT) scans with a high correlation with gated cardiac CT scans. This standardized protocol takes a step-wise approach to not only optimizing an image for the identification of calcification but also to distinguishing CAC from other common causes of calcification in the cardiac silhouette. Recognition of CAC on non-gated CT scans helps to identify a very powerful prognostic factor that can influence therapeutic interventions or downstream diagnostic testing without requiring a gated cardiac scan. These non-gated CT scans are often acquired as part of the routine care of the patient, and this data is readily available without another dose of&#160;ionizing radiation. This protocol allows for the precise and accurate extraction of this data for the purposes of retrospective data analysis in clinical research studies, but also in the clinical evaluation and management of patients.

Here, we present a protocol to reliably and systematically identify coronary artery calcification (CAC) on non-gated computed tomography (CT) scans of the chest or abdomen. CAC provides an objective measure of coronary artery disease for both research and clinical purposes.

Coronary artery calcification (CAC) provides an objective measure of coronary artery disease and can readily be identified on non-gated computed ...

Murine Myocardial Infarction Model using Permanent Ligation of Left Anterior Descending Coronary Artery

Myocardial infarction (MI) and acute coronary diseases are among the most prominent causes of death in population with western lifestyle. The murine models of MI with permanent ligation of left-anterior descending (LAD) coronary artery closely mimics MI in humans. Murine models benefit from the extensive genetic engineering available nowadays. Here we propose a reproducible murine surgical model of myocardial infarction by permanent LAD coronary ligation. Our technique comprises anesthesia with ketamine/xylazine that can be rapidly reversed by administration of an antagonist, intubation without tracheotomy for mechanical-assisted ventilation, ventilation with application of extrinsic positive end-expiratory pressure (PEEP) to avoid alveolar collapse, a thoracotomy method limiting to the minimum surgical lesions made to skeletal muscles, and lung inflation without thoracentesis. This method is sparsely invasive, reproducible and reduces post-surgery mortality and complications.

Herein we describe a surgical procedure showing how to achieve permanent ligation of the left-anterior descending coronary artery in mice. This model is of high relevance to investigate the pathophysiology of myocardial infarction and the concomitant biological processes.

Myocardial infarction (MI) and acute coronary diseases are among the most prominent causes of death in population with western lifestyle. The murine ...