Sir,

In the pictorial essay published in March 2009, Goo et al. [1] shared their comprehensive experience in identifying coronary artery anomalies in patients with congenital heart diseases using current multislice CT techniques. The authors showed us that haemodynamically benign anomalies may have clinical significance. For example, in patients with high-take-off coronary artery, reckless aortic clamping during cardiopulmonary bypass may reduce coronary artery flow. In our hospital, high-take-off of coronary artery is considered to be the most-easily-overlooked surgically important coronary anomaly. We would like to share our experience to emphasize the importance of this to readers.

A 7-year-old boy was diagnosed with polysplenia syndrome and levotransposition of the great arteries, double outlet right ventricle, pulmonary stenosis, bilateral superior vena cava and interrupted inferior vena cava with azygous continuation after birth. Due to progressive symptoms of poor exercise tolerance and cyanosis, he was admitted for bidirectional Glenn shunt. Before surgery, MDCT was arranged. MDCT not only confirmed the diagnosis, but also revealed high-take-off of the left anterior descending coronary artery that was positioned beside the main pulmonary artery and passed anterior to the right ventricular outflow tract (Fig. 1). Since high-take-off of a coronary artery is a haemodynamically benign coronary anomaly and usually considered a normal variant [2], the operator focused on the major cardiac structures during operation. After cavopulmonary anastomoses, while attempting to close the main pulmonary artery stump, the dissection procedure resulted in transection of the left anterior descending coronary artery. In order to preserve left ventricular anterior wall perfusion, emergency coronary artery bypass graft surgery was performed using the right internal mammary artery to anastomose the middle left anterior descending coronary artery. Fortunately, the operation ran smoothly, and the patient was discharged uneventfully. No wall motion impairment was identified on follow-up echocardiography.

Fig. 1
figure 1

MDCT. a Volume-rendered and b oblique axial multiplanar reformatted images show the aortic valve (arrowhead) and high take-off of the left anterior descending coronary artery (arrows) located between the ascending aorta (AAo) and main pulmonary artery (MPA) and coursing anterior to the right ventricular outflow tract (asterisk). (Azy azygous vein, DAo descending aorta, LPA left pulmonary artery, LSVC left superior vena cava, RPA right pulmonary artery, RSVC right superior vena cava)

Full size image

This case highlights that high-take-off of coronary artery, considered to be a minor coronary anomaly or normal variant [2], can have critical surgical importance. The surgical implications of coronary artery anomalies can be different in different operations. For example, if the patient underwent a Blalock-Taussig shunt, the high take-off would not be a problem. We suggest that cardiac surgeons should review the high-resolution axial, coronal and sagittal thin-section images that are provided by ECG-gated MDCT [3] to simulate the surgical procedure before congenital heart operation to avoid coronary artery injury.