Repair of Anomalous Left Coronary Artery From the Pulmonary Artery via Direct Coronary Transfer

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare but critical congenital anomaly that typically presents in infancy with myocardial ischemia and left ventricular dysfunction. Early surgical correction is essential and aims to establish a dual coronary system. In this video, the authors demonstrate the repair through direct aortic implantation (1, 2, 3).

The aim of this video is to highlight the key technical aspects of repairing the ALCAPA via direct coronary transfer, with particular emphasis on operative sequencing, anatomical landmarks, and safe surgical principles, making it suitable for experienced surgeons.

Steps

Following the induction of general anesthesia, standard arterial and central venous monitoring lines were established. Measures that reduce pulmonary vascular resistance were avoided.

A median sternotomy was performed, the thymus was excised, and the pericardium was opened. A pericardial patch was harvested for later use.

After systemic heparinization, purse-string sutures were placed in the distal ascending aorta and both venae cavae. The pulmonary arteries were dissected and encircled.

Ascending aortic and bicaval cannulation were performed, and cardiopulmonary bypass was initiated with mild to moderate hypothermia.

The aorta was cross-clamped early after initiation of bypass to prevent coronary steal into the pulmonary artery after snugging both branch pulmonary artery.

Del Nido cardioplegia was administered through the aortic root, with pulmonary artery snares tightened to prevent runoff.

The main pulmonary artery was transected proximal to its bifurcation.

The anomalous left coronary artery origin, typically arising from the posterior sinus of the pulmonary artery, was identified.

A generous coronary button was excised, and the proximal coronary artery was carefully mobilized to allow for a tension-free transfer.

An anterior aortotomy was performed to allow optimal visualization.

A medially based trapdoor incision was created in the aortic root at the chosen implantation site.

The coronary artery was reimplanted into the aorta with minimal rotation and without tension, ensuring an unobstructed course.

The aortotomy was closed using continuous polypropylene sutures.

A pericardial patch was used to augment the pulmonary artery and reduce tension on the repair.

The aortic root was de-aired, and the patient was weaned from cardiopulmonary bypass.

Following reimplantation, a dual coronary system was restored.

In the current era, this technique is associated with excellent early and long-term outcomes, with survival exceeding 95 percent. Recovery of ventricular function is expected, even in patients with significant preoperative dysfunction. Timely recognition and anatomical repair of ALCAPA can transform a life-threatening condition into one with excellent long-term prognosis.

This step-by-step demonstration highlights the fundamental surgical principles of ALCAPA repair, including the harvesting of the coronary button and transfer to the aorta using a medial trapdoor-based incision, providing a practical learning resource for surgeons.

This video submission is from the 2026 CTSNet Instructional Video Competition. Stay tuned to CTSNet.org and the CTSNet YouTube channel in the coming weeks to watch all entries from the competition, including the winning videos.  

References

1. Azakie A, Russell JL, McCrindle BW, et al: Anatomic repair of anomalous left coronary artery from the pulmonary artery by aortic reimplantation: early survival, patterns of ventricular recovery and late outcome. Ann Thorac Surg,20023.75(5):1535–1541, 2003
2. Azakie A. Repair of anomalous coronary artery from the pulmonary artery by aortic implantation. Oper Tech Thorac Cardiovasc Surg. 2015;20(2):135–147.
3. Carrel T.Surgical Treatment of Anomalous Aortic Origin of Coronary Arteries: The Reimplantation Technique and Its Modifications.Operative Techniques in Thoracic and Cardiovascular Surgery, 2017; 21, 178-201

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