Case Report
A two month old girl child weighing 3Kg presented with cyanosis,
breathlessness and failure to thrive. On examination, the child had
tachycardia and tachypnea with oxygen saturation of 77% on room air.
The precordium was hyper dynamic and a systolic murmur was auscultated.
The chest radiogram revealed cardiomegaly and pulmonary plethora. The
diagnosis of TBA with large sub-pulmonic ventricular septal defect (VSD)
and large patent ductus arteriosus (PDA) was confirmed on
echocardiogram. A single coronary artery arising from non-facing sinus
was reported. The surgery was performed through median sternotomy on
moderate hypothermic cardioplegic arrest. The great arteries were in
side by side relationship with aorta anterior and to the right of
pulmonary artery. A significant size discrepancy between the great
arteries was noted. A single coronary was arising from the non-facing
sinus and it soon divided into right coronary artery (RCA), left main
coronary artery (LMCA) and two prominent conal arteries. The RCA course
was usual in the right atrioventricular (AV) groove. The LMCA looped
posterior to the great arteries before bifurcating into circumflex (Cx)
coursing in the left AV groove and left anterior descending artery (LAD)
in the interventricular groove. An additional tiny conal artery was
arising from the facing sinus. (Figure 1,2). The Cardiopulmonary bypass
was instituted following aortobicaval cannulation. The PDA was divided
and antegrade Delnido’s cardioplegia was delivered. The VSD was repaired
with e-PTFE patch. Aorta was transected and coronary buttons were
harvested. The pulmonary artery was transected and LeCompte manoeuvre
was performed. The distance between the coronary button and the
neoaortic root was 25 mm. An autologous untreated pericardial tube was
constructed over 5mm Hegar’s dilator (Figure 3) and interposed between
the coronary button and the neoaorta. The pulmonary confluence was
shifted rightwards away from the pericardial tube. (Figure 4,5) The rest
of surgery was routine and postoperative course was uneventful. The
Echocardiogram at discharge demonstrated patent coronary artery and good
biventricular function. The child was diagnosed with sub-valvar right
ventricular outflow tract obstruction (RVOTO) after two years and she
underwent surgery for the RVOTO relief. The coronary artery was found
patent on the angiogram performed prior to re-operation. (Figure 6) The
child continues to do well at 30 months follow-up.