New surgical technique for repairing ALCAPA originating from the non-facing pulmonary sinus: The Aswan Drawbridge technique

Abstract

Background: Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly in which coronary steal causes progressive left ventricular ischemia, dysfunction, and secondary mitral regurgitation. Direct reimplantation into the aorta is the gold standard. However, it is technically hazardous when the left coronary artery (LCA) arises from the distant non-facing pulmonary sinus, because tension on the transferred vessel risks occluding it. The Takeuchi procedure is an established alternative, but it has limitations, particularly when the anomalous ostium lies close to a pulmonary valve commissure.
Technique: We describe the “Aswan Drawbridge” technique in an asymptomatic 8-year-old girl whose anomalous LCA ostium lay immediately adjacent to a pulmonary valve commissure. The commissure was partially detached to maximize the harvested coronary button. A long aortic flap was then created in the left coronary sinus and reflected inferiorly, like a drawbridge, to form the floor of the tunnel. The lateral flaps of the button were sutured to this aortic flap, creating a tension-free tunnel of autologous arterial tissue between the LCA and the aorta. The pulmonary artery defect was reconstructed with an autologous pericardial patch, and the detached commissure was resuspended to it.
Outcome: The postoperative course was uneventful, and the patient was discharged on postoperative day 7. Cardiac computed tomography at 1 month showed a patent 5-mm tunnel without kinking, stenosis, or compression. At 3 years, the patient remained asymptomatic, with normal biventricular function and regression of mitral regurgitation from moderate to mild, consistent with left ventricular reverse remodeling.
Conclusion: The Aswan Drawbridge technique is a feasible option for ALCAPA arising from the non-facing pulmonary sinus. Longer follow-up is needed to establish the tunnel’s durability.