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Education  |   June 2017
Images in Anesthesiology: Anomalous Single Coronary Artery from the Pulmonary Artery
Author Notes
  • From the Division of Pediatric Anesthesiology, Department of Anesthesiology (K.A.M.), Division of Pediatric Anesthesiology, Department of Anesthesiology, School of Medicine (B.T.), Division of Cardiovascular and Thoracic Surgery, Department of Surgery (R.D.B.J.), and Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine (K.D.H.), Duke University Medical Center, Durham, North Carolina.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Address correspondence to Dr. Machovec: kelly.machovec@gmail.com
Article Information
Education / Images in Anesthesiology / Cardiovascular Anesthesia / Pediatric Anesthesia
Education   |   June 2017
Images in Anesthesiology: Anomalous Single Coronary Artery from the Pulmonary Artery
Anesthesiology 6 2017, Vol.126, 1169. doi:10.1097/ALN.0000000000001532
Anesthesiology 6 2017, Vol.126, 1169. doi:10.1097/ALN.0000000000001532
ANOMALOUS single coronary artery from the pulmonary artery (ASCAPA) is a rare congenital anomaly with high mortality. The images illustrate coronary anatomy of an 8-week-old, 3.5-kg infant who experienced cardiac arrest immediately after an uneventful ophthalmologic procedure under general anesthesia. Panel A of the figure demonstrates an aortogram with no coronary ostia (Supplemental Digital Content 1, Video, http://links.lww.com/ALN/B372). Panel B shows coronary filling after injection of the pulmonary artery, revealing a short single coronary (1) bifurcating into right (2) and left (3) branches (Supplemental Digital Content 2, Video, http://links.lww.com/ALN/B373).
ASCAPA is described in case reports, rarely with good surgical outcome.1  Survival correlates with early diagnosis, heralded by symptoms of myocardial ischemia including poor feeding and weight gain. Electrocardiogram may show ischemia; echocardiography may reveal ventricular dysfunction and mitral regurgitation but not coronary abnormalities. Cardiac catheterization provides definitive diagnosis. ASCAPA is fatal without surgical palliation consisting of aortic reimplantation of the coronary artery.
Blood delivered to the coronaries in ASCAPA originates from the pulmonary artery, explaining its reduced oxygen content and lower perfusion pressure.2  Coronary perfusion depends on elevated pulmonary vascular resistance (PVR); as PVR falls in the neonatal period, blood flow increases to the lungs, creating coronary steal and resultant ischemia. Anesthetic goals include maintaining coronary perfusion pressure by maintaining PVR and myocardial contractility.3  A ductus arteriosus maintained with prostaglandin may be the only supply of oxygenated blood to the coronaries.1  The baby depicted in these images had elevated pulmonary pressures of unclear etiology, which allowed survival to 8 weeks of age.
Competing Interests
The authors declare no competing interests.
References
Ochoa-Ramírez, E, Valdez-Garza, HE, Reyes-González, R, Mateos-Corral, D, Sánchez-Sigel, D, González-López, V . Double anomalous coronary origin from the pulmonary artery: successful surgical correction in an infant. Tex Heart Inst J 2005; 32:348–50 [PubMed]
Nicholson, WJ, Schuler, B, Lerakis, S, Helmy, T . Anomalous origin of the coronary arteries from the pulmonary trunk in two separate patients with a review of the clinical implications and current treatment recommendations. Am J Med Sci 2004; 328:112–5 [Article] [PubMed]
Fahy, CJ, Ing, RJ, Kern, FH, O’Hare, B, Redmond, JM, Jaggers, J . The anesthetic management and physiologic implications in infants with anomalous left coronary artery arising from the pulmonary artery. J Cardiothorac Vasc Anesth 2012; 26:286–90 [Article] [PubMed]