Case Report
A two month old girl child weighing 3Kg presented with cyanosis, breathlessness and failure to thrive. On examination, the child had tachycardia and tachypnea with oxygen saturation of 77% on room air. The precordium was hyper dynamic and a systolic murmur was auscultated. The chest radiogram revealed cardiomegaly and pulmonary plethora. The diagnosis of TBA with large sub-pulmonic ventricular septal defect (VSD) and large patent ductus arteriosus (PDA) was confirmed on echocardiogram. A single coronary artery arising from non-facing sinus was reported. The surgery was performed through median sternotomy on moderate hypothermic cardioplegic arrest. The great arteries were in side by side relationship with aorta anterior and to the right of pulmonary artery. A significant size discrepancy between the great arteries was noted. A single coronary was arising from the non-facing sinus and it soon divided into right coronary artery (RCA), left main coronary artery (LMCA) and two prominent conal arteries. The RCA course was usual in the right atrioventricular (AV) groove. The LMCA looped posterior to the great arteries before bifurcating into circumflex (Cx) coursing in the left AV groove and left anterior descending artery (LAD) in the interventricular groove. An additional tiny conal artery was arising from the facing sinus. (Figure 1,2). The Cardiopulmonary bypass was instituted following aortobicaval cannulation. The PDA was divided and antegrade Delnido’s cardioplegia was delivered. The VSD was repaired with e-PTFE patch. Aorta was transected and coronary buttons were harvested. The pulmonary artery was transected and LeCompte manoeuvre was performed. The distance between the coronary button and the neoaortic root was 25 mm. An autologous untreated pericardial tube was constructed over 5mm Hegar’s dilator (Figure 3) and interposed between the coronary button and the neoaorta. The pulmonary confluence was shifted rightwards away from the pericardial tube. (Figure 4,5) The rest of surgery was routine and postoperative course was uneventful. The Echocardiogram at discharge demonstrated patent coronary artery and good biventricular function. The child was diagnosed with sub-valvar right ventricular outflow tract obstruction (RVOTO) after two years and she underwent surgery for the RVOTO relief. The coronary artery was found patent on the angiogram performed prior to re-operation. (Figure 6) The child continues to do well at 30 months follow-up.