ALCAPA Repair via Left Anterior Minithoracotomy

In this video, we are presenting the case of minimally invasive repair of the anomalous left coronary artery from the pulmonary artery in adult. A 29-year-old man has presented with ventricular fibrillation after physical training in the gym and was resuscitated with defibrillation.

Echocardiography showed moderately depressed left ventricular function - 35% and mild mitral insufficiency.

Angiography showed only one right coronary artery arising from the aorta and good collateral flow to the left coronary artery. CT scan confirmed that the left coronary artery arising from the main pulmonary artery.

Operation plan consisted of: peripheral cannulation for cardiopulmonary bypass, left anterior minithoracotomy in the 4th ICS, LITA harvesting, aortic cross-clamp and cardioplegia administration, LCA to PA disconnection and LITA to LAD anastomosis.

In this case for peripheral cannulation we used the right femoral approach. Femoral artery and vein was cannulated for cardiopulmonary bypass. Then left anterior thoracotomy in the 4th intercostal space was performed using pectoral muscle sparing technique. Left internal thoracic artery was clipped and divided in the same intercostal space. With the help of the special retractor, left internal thoracic artery was harvested under direct vision.

The main pulmonary artery was occluded in order to eliminate coronary steal from the left coronary artery to the PA during cardiopledia.

The cardioplegia catheter was inserted in the aortic root. The Chitwood cross-clamp was inserted in the 2nd ICS. After the aortic cross-clamp had been applied, the cold blood cardioplegic solution was administered with repeat doses at 20–30 minute intervals.

The left main coronary artery was identified and dissected near the origin from the pulmonary artery.

Coronary artery bypass grafting using LITA to LAD was performed side-to-side in a standard fashion.

After that aorta had been declamped, the heart restored its sinus rhythm. Hemostasis was checked and CPB was disconnected in the usual manner.

The duration of the operation time was 225 min, CPB time - 107 min. Aorta had been cross-clamped for 45 min.

Patient was discharged from the hospital on the 4th postoperative day with nice cosmetic results.

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