9 0 2 Letters to the Editor The Journal of Thoracic and Cardiovascular Surgery April 1996 Suspecting an improperly applied aortic crossclamp to be the cause of backflow, we inspected the clamp and found it to be properly positioned. Because the profuse arterial return from the LCA persisted and a repeat dose of cardioplegic solution was similarly ineffective, we closed the LCA ostium from within the pulmonary artery with 5-0 Prolene sutures (Ethicon, Inc., Somerville, N.J.). Cardiopulmonary bypass was discontinued without prob- lems and the patient made an uneventful postoperative recovery. There was no evidence of ischemia on a post- operative stress electrocardiogram or residual shunt on an echocardiogram. Regarding the optimal surgical management, simple ligation of the anomalous LCA is a viable proposition in dealing with ALCAPA when enough collaterals from the right coronary artery exist to supply the left coronary system adequately, t However, as cardiac surgical tech- nique evolved and systemic-coronary connections could be surgically created with safety, the reconstruction of a double coronary system began to be advocated widely. The disadvantage claimed with simple LCA ligation is that the entire myocardium is left at the mercy of a single coronary artery. This risk is reduced if a systemic artery is connected to the LCA. Although theoretically attractive, no long-term comparative study with patients who have undergone the two-coronary system of reconstruction followed up for an equal period of time has been pub- lished to support this contention. The two widely quoted studies 2, 3 to condemn LCA ligation because of its high operative mortality and risk of sudden death after surgery have included observations on patients operated on in infancy also, usually as last resort procedures in desper- ately ill patients. Because these patients may not have had well-developed intercoronary collaterals at the time of the operation, LCA ligation is bound to produce sudden left ventricular ischemia and a poor outcome. Conclusions drawn from such a patient population cannot be extrapo- lated to the group with well-developed collateral flow and no ischaemia. In fact, other workers 4' 5 have reported good results after LCA ligation in patients of this type. Again, theoretically, any surgical conduit to the LCA, constructed as it is very early in the life of the patient, is subject to the same hemodynamic stresses and probably has an equal chance of atherosclerotic obstruction with aging as the right coronary artery. In fact, in all forms of two-coronary reconstructions, long-term patency of the grafts has varied on the basis on the choice of conduit. If grafts are patent for at least 18 months, the size of the right coronary artery collaterals return to normal. Should late occlusion occur, these young patients may be left with the equivalent of left main trunk disease! In their case, Chart, Hare, and Buxton had to provide an alternate channel because of the preoperative features of left ventricular ischemia, and their actions were proved right by the postoperative improvement in these parame- ters. Our contention, however, is that, in a patient such as ours, who has no symptoms, has no features of reduced myocardial perfusion, and has apparently excellent collat- eral blood supply to the anomalous LCA, there is no need at present for surgically creating an alternate conduit to the LCA. The fact that it is possible to do so safely does not justify its need or indicate that it should be done. Only periodic follow-up of our patient with investiga- tions to detect later development of left ventricular isch- emia will determine whether we are correct. S. Sivasubramanian, MS S. M. R. G. Krishnamurthy, MCh P. Thirumalai, D M R. Alagesan, DM S. Viswakumar, MCh A. Sukumar, MCh D. Muthukumar, DM G. Karthikeyan, MD Department of Cardiothoracic Surgery Department of Cardiology Madras Medical College and Government General Hospital Madras 600 003, India REFERENCES 1. Sabiston DC, Floyd WL, McIntosh HD. Anomalous origin of the left coronary artery from the pulmonary artery in adults: surgical management. Arch Surg 1968;97:963-8. 2. Bunton R, Jonas RA, Lang P, Rein JJT, Castaneda AR. Anomalous origin of left coroanary artery from puhnonary artery: ligation versus establishment of a two coronary artery system. J THORAC CARDIOVASC SURG 1987;93:103-8. 3. Wilson CL, Dlabal PW, McGuire SA. Surgical treatment of anomalous left coronary artery from pulmonary artery: follow up in teenagers and adults. Am Heart J 1979;98:440-6. 4, Wright NL, Baue AE, Baum S, Zinnser HF. Coronary artery steal due to an anomalous left coronary artery originating from the pulmonary artery. J THORAC CARDIOVASC SURG 1970;59:461. 5. Arciniegas E, Farooki ZQ, Hakimi M, Green EW. Management of anomalous left coronary artery from the pulmonary artery. Circulation 1980;62(Suppl):I180-9. 12/8/70595 Reply to the Editor. Dr. Sivasubramanian and colleagues rightly highlight the importance of collateral blood flow, especially from noncoronary vessels, in adult patients with an anomalous left main coronary artery arising from the pulmonary artery. It is probably this feature that allows these patients to survive beyond childhood. We believe that it is impor- tant to assess the adequacy of these collaterals objectively before embarking on reconstructive surgery. This can be done indirectly by assessing left ventricular size and function and myocardial perfusion during functional test- ing. Despite brisk noncoronary collateral blood flow, as observed during attempts at cardiopulmonary bypass dur- ing the operation, the patient described in our report 1 had evidence of myocardial ischemia before the operation. This was demonstrated by symptoms of fatigue and exer- tional dyspnea, left ventricular dilatation, reduced func- tional capacity, and the presence of reversible perfusion abnormality in the anterior wall. The time scale for the development of myocardial