Dual Aortic-Pulmonary Flap for Nonfacing Sinus Left Coronary Artery Origin From the Pulmonary Artery

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) arising from the nonfacing sinus presents a significant technical challenge because direct reimplantation may not be feasible due to insufficient coronary length. We describe a dual aortic-pulmonary flap technique enabling anterior tension-free reimplantation. A 6-month-old infant with mildly reduced left ventricular systolic function secondary to ALCAPA originating from the anterior nonfacing pulmonary sinus underwent surgical repair. Following maximal coronary mobilization, a large anterior pulmonary artery flap and a posterior-based aortic flap were constructed and sutured together to create a tubular native arterial extension, permitting tension-free anterior implantation. The anterior pulmonary valve commissure was temporarily detached and subsequently resuspended. Following reimplantation, left ventricular ejection fraction improved from 54% preoperatively to 62% at discharge and mitral regurgitation regressed from moderate to trivial at 1-year follow up. Good coronary artery flow was demonstrated on echocardiogram and the patient remains asymptomatic at 1-year follow up. The dual-flap technique provides additional coronary length using exclusively native arterial tissue and facilitates anterior tension-free reimplantation in selected cases of nonfacing sinus ALCAPA. Further follow up is required to determine long-term durability.