Myocardial protection during repair of anomalous left coronary artery from the pulmonary artery (ALCAPA) depends on where cardioplegia reaches the myocardium, not simply which solution is selected. The abnormal coronary origin and right-to-left collateral circulation can complicate distribution, washout, and maintenance of arrest.
Youssef El Dsouki, Gopikrishnan Thalapathy, and Ignazio Condello review three approaches: simultaneous aortic- and pulmonary-root Custodiol delivery, cold blood cardioplegia with selective left coronary ostial supplementation, and a repeated-dose warm blood protocol. Their article provides a technical comparison rather than a clinical effectiveness study.
Why Coronary Anatomy Changes the Protection Strategy
In ALCAPA, the left coronary artery arises from the pulmonary artery rather than the aorta. A conventional aortic-root infusion may therefore fail to provide adequate direct delivery to the left coronary territory before reconstruction. Collateral flow from the right coronary system further complicates the relationship between infusion, myocardial distribution, and sustained arrest.
The review centres on ensuring delivery to both coronary beds while managing collateral-related return of electrical activity and avoiding ventricular distension. Surgical stage matters: access to the anomalous left coronary ostium changes after pulmonary artery opening or transection.
Scope and Evidence Base
The authors report a targeted PubMed/MEDLINE search covering English-language publications from 2000 through 2024. Of 43 records retrieved, 15 sources were selected for technical detail. The synthesis draws on pediatric cardioplegia literature, operative tutorials, technical reports, and case-based experience.
Clinical outcomes were not systematically extracted or analysed. There is no pooled comparison of ventricular recovery, myocardial injury, inotropic support, postoperative ECMO, or survival. Broader congenital and adult cardiac surgery findings inform parts of the discussion, but they should not be interpreted as direct ALCAPA-specific comparative evidence.
Three Approaches Compared
| Approach | Delivery concept | Potential practical advantage | Main trade-off |
|---|---|---|---|
| Dual-root Custodiol (HTK) | Simultaneous infusion through the aortic and pulmonary roots | Access to both coronary systems with a prolonged single-dose strategy | Pressure control, ventricular distension, crystalloid volume, and electrolyte effects require attention |
| Cold blood with selective ostial supplementation | Initial aortic-root delivery followed by targeted left coronary ostial infusion after pulmonary artery transection | Staged, targeted protection during longer reconstruction | Accurate ostial cannulation and coordination of delivery and redosing |
| Warm blood protocol | Repeated root doses with supplemental left coronary ostial delivery after pulmonary artery opening | Flexibility to adjust composition and delivery during the operation | More frequent dosing, rhythm surveillance, and workload; collateral flow may contribute to early electrical return |
These are the three strategies selected by the review, not an exhaustive list or a ranked treatment hierarchy. The authors also acknowledge other crystalloid formulations and institution-specific approaches.
Dual-Root Crystalloid Delivery
The dual-root concept addresses the separate origins of the two coronary systems before repair. The review presents Custodiol as a way to provide sustained arrest with fewer interruptions for redosing. It also emphasises the need to control infusion pressure and watch for ventricular distension.
For small pediatric patients, the systemic consequences of crystalloid administration are relevant to perfusion planning. The authors discuss hemodilution and electrolyte disturbances, including hyponatremia. A long proposed protection window should not be read as a guarantee of uniform delivery or adequate protection throughout a particular repair.
Cold Blood and Selective Left Coronary Perfusion
The staged cold blood approach adds direct access to the left coronary territory after pulmonary artery transection. Its practical appeal is the ability to target delivery and repeat protection during a prolonged or complex reconstruction.
The trade-off is coordination. Ostial cannula placement, timing, and communication between the operative and perfusion teams become central to avoiding under-perfusion or washout. The review describes these technical considerations but does not demonstrate superior clinical outcomes for this approach in an ALCAPA-specific comparison.
Repeated-Dose Warm Blood Cardioplegia
The third strategy emphasises repeated delivery and intraoperative adjustment of metabolic conditions. The authors describe warm blood protocols as requiring particularly close rhythm surveillance because collateral circulation may contribute to premature electrical activity.
They also discuss terminal warm reperfusion, or a “hot shot,” while acknowledging that its proposed benefit is largely extrapolated from broader surgical literature. The article does not establish a distinct protective advantage for hot-shot administration in ALCAPA.
What Perfusion Teams Can Take From the Review
The most transferable lesson is to plan delivery around coronary anatomy and the sequence of repair. Relevant considerations include access to both coronary beds, the anticipated duration of crossclamping, collateral flow, ventricular distension, cumulative cardioplegia volume, and the logistics of redosing.
The published article includes detailed pressures, temperatures, and dosing schedules. Those values represent the protocols assembled by the authors rather than prospectively validated universal targets. Its narrative and comparison table also describe differing protection windows, reinforcing the need to interpret numerical schedules in their original context.
The article’s use of “normothermic” or “warm” blood cardioplegia likewise requires attention to the actual protocol: the comparison table lists delivery at 32–34°C with systemic temperature at 28°C. The label alone does not fully describe the temperature strategy.
Limitations and Interpretation
The evidence is predominantly observational, technical, and case-based. The search used one database, protocols were reported inconsistently, and institutional practices may influence which strategies appear most common. No randomised or comparative trials specifically establish the best ALCAPA cardioplegia approach in this review.
Accordingly, the article is most useful as a framework for discussing delivery routes and operational trade-offs. It does not justify claims that one solution, temperature, or dosing schedule improves survival or ventricular recovery relative to the alternatives. Prospective multicentre comparisons with consistent outcome reporting remain needed.
Original IPA educational summary of the review by El Dsouki, Thalapathy, and Condello. The source article is published under the Creative Commons Attribution 4.0 licence. The cover is a conceptual illustration, not a diagram of anomalous coronary anatomy.
Original Article
El Dsouki Y, Thalapathy G, Condello I. Cardioplegia strategies in ALCAPA surgery: A narrative review on practical comparison of techniques. Journal of ExtraCorporeal Technology. 2026;58:295–300. doi:10.1051/ject/2026013.
