Anatomic Rerouting of Anomalous Left Coronary Artery From Right Coronary Sinus Christoph Haller, MD, David Schibilsky, MD, Frank Al-Shajlawi, MD, Karl K. Haase, MD, and Christian Schlensak, MD Department of Thoracic and Cardiovascular Surgery, University Hospital Tuebingen, Tuebingen; and Department of Cardiology, Klinikum am Steinenberg, Reutlingen, Germany
We herein present a new surgical technique in the treatment of an anomalous left coronary artery from the right coronary sinus in an 18-year-old patient
with an intramural course of the left main coronary artery. (Ann Thorac Surg 2015;99:2234–6) Ó 2015 by The Society of Thoracic Surgeons
D FEATURE ARTICLES
ue to the unique anatomic characteristics in this case, a standard unroofing procedure could not be performed. A new technique combined the creation of a neo-ostium with patch augmentation of the coronary. This technique avoids the need for a coronary artery bypass in a young patient and eliminates the underlying pathology of the intramural segment.
Technique The patient presented as an emergency after strenuous exercise in a soccer game. During the game he suddenly passed out, initially recovering without intervention by first aiders. The on-site electrocardiogram showed ST-depressions in anterior and ST-elevations in inferior leads. On admission the patient was hemodynamically stable and had a normal electrocardiogram, but further workup revealed slightly elevated troponin values of 0.14 ng/mL on admission, peaking at 1.34 ng/mL (normal value < 0.1 ng/mL). Echocardiography confirmed good biventricular function. Stress echocardiography neither revealed any symptoms nor elicited any electrocardiographic changes or regional wall motion abnormalities. Coronary angiography was performed and anomalous left coronary artery from right coronary sinus (ALRCS) with a separate origin of the left and right coronary artery, respectively diagnosed (Fig 1A). Magnetic resonance imaging (MRI)-angiography showed an intramural course of the anomalous artery (Fig 1B). For definitive treatment, the patient was referred to cardiac surgery. Intraoperative inspection confirmed the anomalous origin as well as the intramural course. An unroofing procedure of the coronary artery could not be performed because the proximal extramural segment was Accepted for publication Jan 16, 2015. Address correspondence to Dr Haller, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
directly adjacent to the respective commissure. Dissection and direct reimplantation was not feasible as well, due to the artery’s course, the impossibility of adequate mobilization, and the risk of kinking. After initiation of extracorporeal circulation and antegrade cardioplegia, we transected the aorta at the sinotubular junction. A longitudinal incision of the left coronary sinus with due regard to the commissure was performed down to the level of the anomalous coronary. The proximal extramural segment of the coronary was incised longitudinally and partially anastomosed to the aortic incision (Fig 2A). A wide, tapered autologous pericardial patch augmented the side-to-side anastomosis, leaving the artery in its native undistorted position and creating an unimpeded inflow (Fig 2B). The aortotomy was closed with some tailoring to compensate for the slightly increased diameter of the proximal circumference due to the pericardial patch. The patient’s postoperative course was uneventful. Acetylsalicylic acid therapy was initiated to facilitate initial healing processes and re-endothelialization. Postoperative follow-up showed no pathologic results on electrocardiogram, echocardiography, and stress testing. The patient mentioned no further episodes of fainting or other symptoms of coronary malperfusion. The MRI repeated 6 months postoperatively showed an unobstructed wide neo-ostium, laminar flow, and no signs of restrictive or aneurysmatic changes of the patched segment (Fig 1C).
Comment Anomalous origins of the coronary arteries are usually asymptomatic but may present with ischemia, myocardial infarction, or even sudden cardiac death. Especially in young competitive athletes, coronary anomalies may cause more than 15% off sudden cardiac deaths [1]. Among the various anomalies, an origin of the left coronary artery from the right coronary sinus carries a 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.069
Ann Thorac Surg 2015;99:2234–6
HOW TO DO IT HALLER ET AL SURGICAL REPAIR OF ANOMALOUS CORONARY
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Fig 2. (A) Partial anastomosis of an anomalous coronary artery to longitudinally incised aortic root. (B) Patch augmentation of longitudinal incision and initial segment of coronary artery. Asterisk indicates commissure between the right and left coronary sinus; solid arrow indicates the location directly opposite to the commissure where the coronary course starts to direct away from the aortic wall; and dotted arrow indicates original ostium of the left coronary artery in close proximity to the right coronary ostium. FEATURE ARTICLES
Fig 1. (A) Aortic root fluoroscopy showing origin of both coronary arteries from the right coronary sinus (black circle ¼ right coronary artery origin; dotted circle ¼ left coronary artery origin). (B) Magnetic resonance imaging (MRI) delineating the interarterial course of the left coronary artery (arrows ¼ left coronary artery). (C) Postoperative MRI follow-up showing an unobstructed wide coronary neo-ostium (arrow ¼ left coronary artery).
higher risk of death than other variants [2, 3]. Up to 82% of sudden deaths of patients with ALRCS are related to its anatomic course between the aorta and the pulmonary trunk [2]. Several underlying causes have been discussed, taking into account the mechanical stress between the 2 vessels and within the aortic wall, as well as angulations in the artery’s course or the hypoplastic and abnormal morphologic aspect of the intramural segment [4]. Many operative technical approaches have been described. Among these are coronary artery bypass grafting (CABG), unroofing or patching procedures, reinsertion of the artery, or even translocation of the pulmonary artery. All of these options had to be discarded in the case presented. Pulmonary artery translocation, although technically feasible, is a rarely used technique and inappropriately aggressive, if other options exist. Unroofing of ALRCS could not be performed as the neo-ostium would have been located underneath the commissure. The same anatomic reasons prohibited division, mobilization, and reinsertion. Technically CABG could have been performed, but due to the patient’s age and the controversially discussed limitations of CABG in ALRCS, such as competitive flow or steal phenomena, made us prefer this new approach. Various other authors have already described patching techniques in ALRCS [5, 6]. Nevertheless our technique is a new approach if there are no options for adequate mobilization and an unfavorable course of the artery. The technique takes the pathologic intramural and interarterial segment into account, creates a wide neo-
2236
HOW TO DO IT HALLER ET AL SURGICAL REPAIR OF ANOMALOUS CORONARY
ostium, is technically not challenging, and allows for unimpaired coronary perfusion.
References
FEATURE ARTICLES
1. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation 2009;119:1085–92. 2. Taylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol 1992;20:640–7.
Ann Thorac Surg 2015;99:2234–6
3. Eckart RE, Scoville S, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med 2004;141:829–34. 4. Angelini P. Coronary artery anomalies: an entity in search of an identity. Circulation 2007;115:1296–305. 5. Lee MK, Choi JB, Kim KH, Kim KS. Surgery for anomalous origin of the left main coronary artery from the right sinus of Valsalva, in association with left main stenosis. Tex Heart Inst J 2009;36:309–12. 6. Li J, Lai H, Zheng J, Guo C, Gu J, Wang C. Patch repair of anomalous origin of the left main coronary artery from the anterior aortic sinus. Ann Thorac Surg 2014;97: e59–61.
We herein present a new surgical technique in the treatment of an anomalous left coronary artery from the right coronary sinus in an 18-year-old patient
with an intramural course of the left main coronary artery. (Ann Thorac Surg 2015;99:2234–6) Ó 2015 by The Society of Thoracic Surgeons
D FEATURE ARTICLES
ue to the unique anatomic characteristics in this case, a standard unroofing procedure could not be performed. A new technique combined the creation of a neo-ostium with patch augmentation of the coronary. This technique avoids the need for a coronary artery bypass in a young patient and eliminates the underlying pathology of the intramural segment.
Technique The patient presented as an emergency after strenuous exercise in a soccer game. During the game he suddenly passed out, initially recovering without intervention by first aiders. The on-site electrocardiogram showed ST-depressions in anterior and ST-elevations in inferior leads. On admission the patient was hemodynamically stable and had a normal electrocardiogram, but further workup revealed slightly elevated troponin values of 0.14 ng/mL on admission, peaking at 1.34 ng/mL (normal value < 0.1 ng/mL). Echocardiography confirmed good biventricular function. Stress echocardiography neither revealed any symptoms nor elicited any electrocardiographic changes or regional wall motion abnormalities. Coronary angiography was performed and anomalous left coronary artery from right coronary sinus (ALRCS) with a separate origin of the left and right coronary artery, respectively diagnosed (Fig 1A). Magnetic resonance imaging (MRI)-angiography showed an intramural course of the anomalous artery (Fig 1B). For definitive treatment, the patient was referred to cardiac surgery. Intraoperative inspection confirmed the anomalous origin as well as the intramural course. An unroofing procedure of the coronary artery could not be performed because the proximal extramural segment was Accepted for publication Jan 16, 2015. Address correspondence to Dr Haller, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
directly adjacent to the respective commissure. Dissection and direct reimplantation was not feasible as well, due to the artery’s course, the impossibility of adequate mobilization, and the risk of kinking. After initiation of extracorporeal circulation and antegrade cardioplegia, we transected the aorta at the sinotubular junction. A longitudinal incision of the left coronary sinus with due regard to the commissure was performed down to the level of the anomalous coronary. The proximal extramural segment of the coronary was incised longitudinally and partially anastomosed to the aortic incision (Fig 2A). A wide, tapered autologous pericardial patch augmented the side-to-side anastomosis, leaving the artery in its native undistorted position and creating an unimpeded inflow (Fig 2B). The aortotomy was closed with some tailoring to compensate for the slightly increased diameter of the proximal circumference due to the pericardial patch. The patient’s postoperative course was uneventful. Acetylsalicylic acid therapy was initiated to facilitate initial healing processes and re-endothelialization. Postoperative follow-up showed no pathologic results on electrocardiogram, echocardiography, and stress testing. The patient mentioned no further episodes of fainting or other symptoms of coronary malperfusion. The MRI repeated 6 months postoperatively showed an unobstructed wide neo-ostium, laminar flow, and no signs of restrictive or aneurysmatic changes of the patched segment (Fig 1C).
Comment Anomalous origins of the coronary arteries are usually asymptomatic but may present with ischemia, myocardial infarction, or even sudden cardiac death. Especially in young competitive athletes, coronary anomalies may cause more than 15% off sudden cardiac deaths [1]. Among the various anomalies, an origin of the left coronary artery from the right coronary sinus carries a 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.069
Ann Thorac Surg 2015;99:2234–6
HOW TO DO IT HALLER ET AL SURGICAL REPAIR OF ANOMALOUS CORONARY
2235
Fig 2. (A) Partial anastomosis of an anomalous coronary artery to longitudinally incised aortic root. (B) Patch augmentation of longitudinal incision and initial segment of coronary artery. Asterisk indicates commissure between the right and left coronary sinus; solid arrow indicates the location directly opposite to the commissure where the coronary course starts to direct away from the aortic wall; and dotted arrow indicates original ostium of the left coronary artery in close proximity to the right coronary ostium. FEATURE ARTICLES
Fig 1. (A) Aortic root fluoroscopy showing origin of both coronary arteries from the right coronary sinus (black circle ¼ right coronary artery origin; dotted circle ¼ left coronary artery origin). (B) Magnetic resonance imaging (MRI) delineating the interarterial course of the left coronary artery (arrows ¼ left coronary artery). (C) Postoperative MRI follow-up showing an unobstructed wide coronary neo-ostium (arrow ¼ left coronary artery).
higher risk of death than other variants [2, 3]. Up to 82% of sudden deaths of patients with ALRCS are related to its anatomic course between the aorta and the pulmonary trunk [2]. Several underlying causes have been discussed, taking into account the mechanical stress between the 2 vessels and within the aortic wall, as well as angulations in the artery’s course or the hypoplastic and abnormal morphologic aspect of the intramural segment [4]. Many operative technical approaches have been described. Among these are coronary artery bypass grafting (CABG), unroofing or patching procedures, reinsertion of the artery, or even translocation of the pulmonary artery. All of these options had to be discarded in the case presented. Pulmonary artery translocation, although technically feasible, is a rarely used technique and inappropriately aggressive, if other options exist. Unroofing of ALRCS could not be performed as the neo-ostium would have been located underneath the commissure. The same anatomic reasons prohibited division, mobilization, and reinsertion. Technically CABG could have been performed, but due to the patient’s age and the controversially discussed limitations of CABG in ALRCS, such as competitive flow or steal phenomena, made us prefer this new approach. Various other authors have already described patching techniques in ALRCS [5, 6]. Nevertheless our technique is a new approach if there are no options for adequate mobilization and an unfavorable course of the artery. The technique takes the pathologic intramural and interarterial segment into account, creates a wide neo-
2236
HOW TO DO IT HALLER ET AL SURGICAL REPAIR OF ANOMALOUS CORONARY
ostium, is technically not challenging, and allows for unimpaired coronary perfusion.
References
FEATURE ARTICLES
1. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation 2009;119:1085–92. 2. Taylor AJ, Rogan KM, Virmani R. Sudden cardiac death associated with isolated congenital coronary artery anomalies. J Am Coll Cardiol 1992;20:640–7.
Ann Thorac Surg 2015;99:2234–6
3. Eckart RE, Scoville S, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med 2004;141:829–34. 4. Angelini P. Coronary artery anomalies: an entity in search of an identity. Circulation 2007;115:1296–305. 5. Lee MK, Choi JB, Kim KH, Kim KS. Surgery for anomalous origin of the left main coronary artery from the right sinus of Valsalva, in association with left main stenosis. Tex Heart Inst J 2009;36:309–12. 6. Li J, Lai H, Zheng J, Guo C, Gu J, Wang C. Patch repair of anomalous origin of the left main coronary artery from the anterior aortic sinus. Ann Thorac Surg 2014;97: e59–61.
