Original Cardiovascular
Anomalous Origin of Right Coronary Artery from Left Coronary Sinus: Surgical Management and Clinical Result Sang-Ho Cho1,2
Hyun-Chel Joo3
Kyung-Jong Yoo3
1 Department of Thoracic and Cardiovascular Surgery, Kyung Hee
University Hospital at Gangdong, Seoul, Republic of Korea 2 Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, Chungbuk National University, Seoul, Republic of Korea 3 Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
Young-Nam Youn3 Address for correspondence Young-Nam Youn, MD, PhD, Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea (e-mail: [email protected]).
Thorac Cardiovasc Surg 2015;63:360–366.
Abstract
Keywords
► coronary anomalies ► cardiac stress test ► coronary artery bypass ► off-pump
Background Anomalous aortic origin of coronary artery is a rare congenital condition in which the coronary artery arises from the opposite sinus of Valsalva. Although many patients are asymptomatic at the time of presentation or diagnosis, surgical correction is recommended due to the risk of ischemic sudden death. We describe seven cases of right coronary artery (RCA) arising from the left sinus of Valsalva, causing the hypoperfusion through RCA. Patients and Methods All patients underwent preoperative coronary angiography, echocardiography, and cardiac stress test (treadmill test [TMT], n ¼ 4; technetium-99m sestamibi [MIBI], n ¼ 3). In four patients, coronary computed tomography (CT) was performed. On the basis of preoperative test results, unroofing of the coronary artery (n ¼ 3) or off-pump coronary artery bypass (OPCAB; n ¼ 4; patients with coronary arterial occlusive disease) was performed. In two patients, intraoperative flow meter was performed and showed the improvement of flow rate through RCA. Results Postoperative CT angiography after OPCAB confirmed good graft patency (n ¼ 4); CT angiography after unroofing demonstrated widely patent neo-orifice (n ¼ 3). All patients underwent postoperative cardiac stress tests including TMT and MIBI, which revealed no evidence of ischemia. All patients were asymptomatic and returned to normal activities (mean follow-up, 41 months; 32–49 months). Conclusion The appropriate surgical procedure based on specific anatomical details, perioperative evaluation, and follow-up by focusing on the ischemia may lead to successful surgical outcomes of this coronary anomaly.
Introduction Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital anomaly in which the left coronary artery
received November 17, 2013 accepted after revision March 4, 2014 published online June 9, 2014
(LCA) arises from the right sinus of Valsalva or the right coronary artery (RCA) arises from the left sinus of Valsalva.1–3 Angelini reported a global incidence of 5.64% for congenital coronary artery anomaly, with an incidence of
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1376256. ISSN 0171-6425.
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Table 1 Preoperative characteristics of study patients Patient no.
Age
Sex
Symptoms
Stress test
Coronary angiography (LN %)
1
74
M
Exertional chest pain
TMT (þ) in II, III, AVF
mRCA—50%, LN 30%
2
46
F
Exertional chest pain
TMT (þ) in II, III, AVF
3
66
M
Exertional chest pain
MIBI—reversible defect of inferior wall
4
40
M
Exertional chest pain
MIBI—reversible defect of inferior wall
5
62
F
Palpitation
TMT (þ) in V4–6 and II, III, AVF Holter—NL c PVCs
mRCA—50%
6
65
M
Exertional chest pain
MIBI—NL
mRCA—50%
7
23
M
Postexertional syncope
TMT (þ) in II, III, AVF
pRCA—50%
Abbreviations: LN, luminal narrowing; MIBI, technetium sestamibi nuclear study; pRCA, proximal RCA; mRCA, mid-RCA; TMT, treadmill test.
experience with AAOCA and outlines current management strategy.
Patients and Methods We included seven patients (men, n ¼ 5; women, n ¼ 2; mean age, 48.5 35 years) who underwent surgical repair of AAOCA at the Severance Cardiovascular Hospital of Yonsei University Health System in Korea from 2008 to 2010. This study was approved by the Institutional Review Board of Yonsei University College of Medicine. Preoperative characteristics are shown in ►Table 1. Symptoms were present in all patients (exertional chest pain, n ¼ 5; palpitation, n ¼ 1; syncope, n ¼ 1). All patients underwent preoperative coronary angiography, echocardiography, and cardiac stress test (treadmill test [TMT], n ¼ 4; technetium-99m sestamibi [MIBI], n ¼ 3). Preoperative coronary computed tomography (CT) was performed for identification of anatomic characteristics (n ¼ 4). In all patients, the RCA originated from the left sinus of Valsalva. The intramural course of the RCA was identified and traveled between the aorta and pulmonary artery (►Fig. 1). In four patients, the concomitant obstructive atherosclerotic coronary artery disease was identified by preoperative coronary angiography.
Fig. 1 Coronary computed tomography. (A) Axial cross-sectional image, (B) three-dimensional reconstruction. The images show interarterial course and luminal narrowing of anomalous RCA. Ao, aorta; LCA, left coronary artery; LCS, left coronary sinus; PA, pulmonary artery; RCA, right coronary artery. Thoracic and Cardiovascular Surgeon
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1.07% for AAOCA (RCA originating from the left sinus, 0.92%; LCA originating from the right sinus, 0.15%).1 AAOCA can lead to ischemic sudden death in young asymptomatic patients, particularly when the artery is associated with an intramural course, slit-like ostia, marked coronary artery angulation, and compression from the pulmonary artery.2–7 AAOCA can also cause angina, palpitation, syncope, and dyspnea, which are typically experienced in exercise.2–4,7–9 Although many patients are asymptomatic at the time of presentation or diagnosis, surgical correction is generally recommended due to the risk of ischemic sudden death.2–4,7–9 Several surgical techniques for AAOCA have been described, including coronary artery bypass graft (CABG), reimplantation of the coronary ostia, and unroofing of the coronary artery.2–4,9–13 Ultimately, to attempt an effective surgical treatment of this condition, it is crucial to understand its pathophysiology. Previous studies have reported both the advantages and the disadvantages of each surgical option. For example, there are some debates about the efficacy of CABG regarding the potential for graft failure. In this study, we describe seven cases of RCA arising from the left sinus of Valsalva treated with different surgical techniques including unroofing and CABG. The following section summarizes a retrospective review of our
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Fig. 2 Coronary unroofing. (A) RCA from left coronary sinus; (B) unroofing without taking down the intercoronary commissure; (C) operative finding of unroofing. Unroofing procedure performed on three of the seven patients.
Operative Techniques
Results
The surgical technique, unroofing or off-pump coronary artery bypass (OPCAB), was determined preoperatively based on the results of the CT scan, coronary angiography, or both. The type of repair was determined by the location of the anomalous coronary artery with respect to the aortic valve commissures, the intramural course of anomalous artery, and the presence or absence of coronary arterial occlusive disease (CAOD). Unroofing was first considered whenever the anomalous RCA had an intramural course. But in case of significant stenosis of RCA (defined as > 50% luminal narrowing), OPCAB was selected (►Table 1). Cardiopulmonary bypass with mild hypothermia was used for all unroofing cases. The RCA arising from the left sinus of Valsalva was dissected and mobilized over a few centimeters up to the takeoff of the conal branch. The aorta was then cross-clamped, and antegrade cardioplegia was given. A transverse aortotomy was performed to gain access to the anomalous intramural portion of the RCA, and the locations of the aortic valve commissure and the right sinus of Valsalva were identified. A probe was placed into the coronary artery, and the intra-aortic roof of the proximal portion of the RCA and its ostium was sharply opened. Excess tissue was removed and the remaining edges were tacked down with fine sutures (►Fig. 2). Following confirmation of aortic valve competency, the aortotomy was closed, and the operation was completed in the usual manner. OPCAB surgery was performed through a full sternotomy incision. The right internal mammary artery (RIMA) was harvested in a semi-skeletonized fashion. After stabilization of the target coronary artery, the anastomosis to mid or distal RCA was constructed using an intracoronary shunt. When the size and flow of the RIMA were insufficient for the graft, the radial artery was harvested from the nondominant forearm instead of the RIMA. The ascending aorta was usually partially clamped, and a bypass anastomosis from the aorta to the RCA was constructed with the radial artery (►Fig. 3).
Statistical Analyses Continuous variables are expressed as mean standard deviation. SPSS for Windows, Release 15.0 (SPSS Inc., Chicago, Illinois, United States), was used for statistical analysis. Thoracic and Cardiovascular Surgeon
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Of the total of seven patients in the study, three patients underwent the unroofing procedure, and four underwent OPCAB (►Table 2). There was no operative mortality or early morbidity. Cardiopulmonary bypass in the unroofing procedure was used in three out of the seven patients (mean cardiopulmonary bypass time, 89.0 7.2 min; mean aortic cross-clamp time, 66 4.3 min). The operative finding in unroofing, after aortotomy, showed a tight, “slit-like” ostium of the anomalous coronary artery that was able to accommodate only a 1or 2-mm probe. After unroofing, we confirmed widening the orifice of the origin, which reduced the compression of the intramural segment. The detachment and resuspension of aortic valve was performed on one of the three patients, and aortic insufficiency did not occurred. In four patients, preoperative coronary angiography showed 50% or greater stenotic lesion in proximal or midRCA. Mean age of these patients was 66.8 5.1 years. These elderly patients with coronary arterial occlusive disease underwent OPCAB. A bypass anastomosis was constructed to mid or distal RCA with the RIMA (n ¼ 2) or the radial artery (n ¼ 2). In two cases, intraoperative coronary blood flow through the distal RCA was determined by transit-time flow
Fig. 3 Off-pump coronary artery bypass (OPCAB). The bypass anastomosis was constructed with radial artery from ascending aorta to mid-RCA. Ao, aorta; RV, right ventricle; RCA, right coronary artery; RA, radial artery.
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Table 2 Postoperative follow-up data Patient no.
Symptom F/U (mo)
Symptom
Preoperative stress test
MIBI (1 wk after surgery)
TMT
TMT F/U (mo)
Normal
7
Coronary CT
1
OPCAB
38
Free
Ischemia
Normal
2
Unroofing
42
Free
Ischemia
Normal
Patent RIMA graft
3
OPCAB
45
Free
Ischemia
Normal
4
Unroofing
49
Free
Ischemia
Normal
5
OPCAB
32
Free
Ischemia
Normal
6
OPCAB
44
Free
Normal
Normal
Normal
6
Patent RIMA graft
7
Unroofing
38
Free
Ischemia
Normal
Normal
3
Patent of neo-orifice
Patent of neo-orifice Patent RA graft from aorta
Normal
24
Patent of neo-orifice Patent RA graft from aorta
measurement (TTFM); the flow rates were 53 and 210 mL/ min with improved diastolic flow after surgery. ►Fig. 4 shows the improved RCA flow after OPCAB and unroofing procedures. ►Table 2 shows postoperative clinical characteristics of the patients and the surgical outcomes. Electrocardiograms (ECGs) were normal in all seven patients. All patients underwent stress tests, including TMT and MIBI, revealing no evidence of ischemia. The three patients in the unroofing group showed improvement in the stress test early after the operation. In the OPCAB group, three patients who had exhibited preoperative ischemia underwent postoperative stress tests, which showed no evidence of ischemia (one patient showed normal result in preoperative MIBI). Postoperative CT was performed within 7 days after the operation in the OPCAB group and at 1, 3, and 10 months, respectively, after the operation in the unroofing group. A widely patent
neo-orifice after unroofing and a good graft patency after OPCAB were confirmed by CT images. An echocardiogram within 7 days after the operation demonstrated normal left and right ventricular motion and no aortic regurgitation. Mean follow-up time was 41 months (range, 32–49 months). All patients were asymptomatic and returned to their normal activities.
Discussion A coronary artery arising from the wrong coronary sinus is a rare congenital anomaly.1–3 Certain of its variants carry a high risk of mortality, with sudden death often occurring without any preceding symptoms.2,3,5,6 The morphologic spectrum of this entity encompasses the following: anomalous artery from left or right coronary sinus; single ostium versus separate ostium; intramural course within the wall of the aorta
Fig. 4 Flow meter on distal RCA. Intraoperative coronary blood flow through the distal RCA was determined by transit-time flow meter. (A) Improved right coronary arterial flow after OPCAB and unroofing procedures; (B) operative finding measuring RCA flow by transit-time flow meter. OPCAB, off-pump coronary artery bypass; RCA, right coronary artery. Thoracic and Cardiovascular Surgeon
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Abbreviations: MIBI, technetium sestamibi nuclear study; OPCAB, off-pump coronary artery bypass; RIMA, right internal mammary artery; RA, radial artery; TMT, treadmill test.
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versus nonintramural course; interarterial course between the aorta and pulmonary artery versus non-interarterial course; and degrees of ostial compromise including slit-like ostium or angulation.9 In the present study, we focused on the anomalous origin of the RCA from an ostium in the left sinus. Proposed pathophysiological mechanisms for myocardial ischemia and sudden death were as follows: ostial obstruction due to slit-like coronary orifice; compression of RCA between aorta and pulmonary artery; stretching of the RCA with aortic/pulmonary artery; coronary angulation with aortic/pulmonary artery; and coronary arterial spasm.2–7 Presentations vary from no symptoms to angina pectoris, myocardial infarction, syncope, and arrhythmias secondary to minor ischemic insults.2–4,7–9
Preoperative, Intraoperative, and Postoperative Evaluation Commonly used diagnostic techniques, such as coronary angiography and, to a smaller extent, transesophageal echocardiography, are invasive. Improvements in noninvasive diagnostic techniques, such as transthoracic echocardiography and coronary CT, have increased the ability to easily and safely screen the condition12,13; thus, its diagnosis is on the rise. In our institution, all patients underwent a coronary artery assessment by coronary angiography and transthoracic echocardiography. Four patients underwent coronary CT to determine the information on the specific anatomic and morphologic details. As described earlier, this anomaly may cause ischemic insult related to sudden death and other symptoms, so all patients underwent a spectrum of additional testing including 24-hour Holter monitoring, TMT, and MIBI perfusion scan as functional assessment after diagnosis. Although resting ECG was normal for most patients in the present study, stress test developed ST segment abnormalities or symptoms suggestive of myocardial ischemia. Stress tests might detect compromised coronary artery blood flow and contribute to decision making about the appropriate surgical intervention.1,14 In the present study, all patients underwent stress tests preoperatively and, in all cases except one, showed evidence of ischemia. In the postoperative periods, these tests also are used for future comparisons after surgery. In addition, we performed coronary CT evaluation in all patients after CABG or unroofing. Recently, CT has emerged as an important diagnostic tool for the evaluation of coronary surgery in both the early ( 1 month) and late (> 1 month) postoperative settings. It has assumed an integral role in the characterization of surgical failure after coronary surgery manifested as dyspnea or chest pain while allowing the investigation of alternative postoperative complications mimicking recurrent angina.15 Thus, we suggest that early and late postoperative coronary CT evaluation may be helpful in the evaluation of the prognosis, as well as in the confirmation of the graft patency after CABG and the adequacy of coronary unroofing. We recently performed intraoperative TTFM in two patients. TTFM usually has been used to assess graft patency intraoperatively during CABG, because the hemodynamics of a patent coronary graft is similar to those physiologically Thoracic and Cardiovascular Surgeon
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observed in the coronary circulation.16 To correctly interpret TTFM, flow curves, pulsatility index (PI), and mean flow values should be evaluated simultaneously. In a patent coronary circulation, blood flow should be mainly diastolic with minimal systolic peaks. Mean blood flow of around 15 mL/ min or less and PI of approximately 3 or higher were proposed as the cut-off criteria to predict a higher incidence of early graft failure after CABG.17 In our study, TTFM performed in the native coronary artery (RCA) showed that blood flow rates after unroofing and OPCAB increased with improved diastolic flow (71 vs. 210 mL/min, 19 vs. 53 mL/min, respectively) and PIs were in the optimal range (1.7 and 2.7, respectively). Although there is currently no research to support the efficacy of TTMF in the surgery of AAOCA, we cautiously suggest that the intraoperative TTFM could be used to assess the postoperative functional recovery of coronary flow impairment.
Surgical Intervention Surgical correction is commonly recommended when AAOCA is diagnosed, regardless of whether symptoms are present.2,9 CABG, reimplantation of the coronary ostia, and unroofing of the coronary artery have been advocated. The specific morphologic details are considered when determining the appropriate surgical repair. Although its value has been debated, CABG is one of the surgical options for AAOCA.2 However, previous studies reported early graft failure as a result of competitive flow7,12; Tavaf and colleagues7 reported that two bypass procedures had early failure (3 and 6 months, respectively), and two procedures designed to establish normal coronary anatomy were successful. Fedoruk and colleagues12 reported four patients who underwent unroofing procedures and one patient who underwent a reimplantation with good results. Two of the patients in this series had previously undergone bypass surgeries that had resulted in early graft failure (5 and 7 months, respectively). Reul and colleagues18 reported a patient with graft occlusion who had undergone CABG a month before at another institution. The association with early graft failure may be related to the dynamic nature of the obstructive process and the concomitant competitive flow. The native artery can be ligated to avoid competitive flow; however, this ligation creates an irreversible iatrogenic occlusion and makes the circulation completely dependent on a graft and anastomosis, which have uncertain durability and growth potential.12 Thus, some researchers12,18 suggested that CABG may not be appropriate for the treatment of AAOCA, regardless of the proximal ligation. However, Tavaf and colleagues7 suggested that CABG might be reserved for the patients with concomitant obstructive atherosclerotic coronary artery disease unless ligating the proximal RCA is planned. As shown by Sabik and colleagues, the effect of competitive flow on coronary bypass graft patency is mild in case of bypassing coronary arteries with moderate to severe degrees of stenosis.19 To address these concerns, we performed CABG in elderly patients (about over 60 years old) with concomitant atherosclerotic stenosis of RCA detected by preoperative angiography (luminal narrowing > 50%).
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perioperative evaluations, and follow-up by focusing on the ischemia may improve the surgical outcomes of this coronary anomaly.
References 1 Angelini P. Coronary artery anomalies: an entity in search of an
identity. Circulation 2007;115(10):1296–1305 2 Davies JE, Burkhart HM, Dearani JA, et al. Surgical management of
3
4
5
6 7
8
9
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11
12
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14
15
Conclusion Anomalous origin of RCA from left coronary sinus is a rare, potentially lethal cardiac anomaly, which requires surgical repair. Based on our experiences and previous studies, we believe that if the anatomy permits (e.g., intramural course and appropriate location relative to the aortic valve), unroofing with creation of a neo-ostium is more durable approach to repair this defect basically, producing excellent results. However, in selected patients, CABG using the internal mammary artery or the radial artery may be feasible with low surgical risk and good early and midterm results. The appropriate surgical procedure based on specific anatomical details,
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17
18
anomalous aortic origin of a coronary artery. Ann Thorac Surg 2009;88(3):844–847, discussion 847–848 García-Rinaldi R, Sosa J, Olmeda S, Cruz H, Carballido J, Quintana C. Surgical treatment of right coronary arteries with anomalous origin and slit ostium. Ann Thorac Surg 2004;77(5):1525–1529 Hamzeh G, Crespo A, Estarán R, Rodríguez MA, Voces R, Aramendi JI. Anomalous origin of right coronary artery from left coronary sinus. Asian Cardiovasc Thorac Ann 2008;16(4):305–308 Eckart RE, Jones SO IV, Shry EA, Garrett PD, Scoville SL. Sudden death associated with anomalous coronary origin and obstructive coronary disease in the young. Cardiol Rev 2006;14(4):161–163 Maron BJ. Sudden death in young athletes. N Engl J Med 2003; 349(11):1064–1075 Tavaf-Motamen H, Bannister SP, Corcoran PC, Stewart RW, Mulligan CR, DeVries WC. Repair of anomalous origin of right coronary artery from the left sinus of Valsalva. Ann Thorac Surg 2008;85(6): 2135–2136 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(4): 309–312 Gulati R, Reddy VM, Culbertson C, et al. Surgical management of coronary artery arising from the wrong coronary sinus, using standard and novel approaches. J Thorac Cardiovasc Surg 2007; 134(5):1171–1178 Furukawa K, Itoh T. Direct coronary reimplantation for repair of anomalous aortic origin of left or right coronary artery. Ann Thorac Surg 2005;79(1):389–390, author reply 390 Adachi I, Kagisaki K, Yagihara T, et al. Unroofing aortic intramural left coronary artery arising from right pulmonary artery. Ann Thorac Surg 2008;85(2):675–677 Fedoruk LM, Kern JA, Peeler BB, Kron IL. Anomalous origin of the right coronary artery: right internal thoracic artery to right coronary artery bypass is not the answer. J Thorac Cardiovasc Surg 2007;133(2):456–460 Rogers SO Jr, Leacche M, Mihaljevic T, Rawn JD, Byrne JG. Surgery for anomalous origin of the right coronary artery from the left aortic sinus. Ann Thorac Surg 2004;78(5):1829–1831 Angelini P. Coronary artery anomalies—current clinical issues: definitions, classification, incidence, clinical relevance, and treatment guidelines. Tex Heart Inst J 2002;29(4):271–278 Frazier AA, Qureshi F, Read KM, Gilkeson RC, Poston RS, White CS. Coronary artery bypass grafts: assessment with multidetector CT in the early and late postoperative settings. Radiographics 2005; 25(4):881–896 Cerrito PB, Koenig SC, VanHimbergen DJ, Jaber SF, Ewert DL, Spence PA. Neural network pattern recognition analysis of graft flow characteristics improves intra-operative anastomotic error detection in minimally invasive CABG. Eur J Cardiothorac Surg 1999; 16(1):88–93 Tokuda Y, Song MH, Oshima H, Usui A, Ueda Y. Predicting midterm coronary artery bypass graft failure by intraoperative transit time flow measurement. Ann Thorac Surg 2008;86(2): 532–536 Reul RM, Cooley DA, Hallman GL, Reul GJ. Surgical treatment of coronary artery anomalies: report of a 37 1/2-year experience at the Texas Heart Institute. Tex Heart Inst J 2002;29(4):299–307 Thoracic and Cardiovascular Surgeon
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Moreover, to minimize systemic inflammation and the associated adverse postoperative outcomes of cardiopulmonary bypass, such as renal, pulmonary, neurologic, and coagulopathic complications, we performed off-pump CABG. In our OPCAB patient group, early graft failure did not occur, although the proximal RCA was not ligated, and all patients in this group were asymptomatic after a mean follow-up time of 41 months. Follow-up studies are needed to assess the longterm benefits of CABG for AAOCA. Mustafa and associates described “unroofing” of the intramural coronary artery that creates a new coronary ostium in the correct sinus.20 The ostium is enlarged, the angulation is corrected, and the arterial path is removed from passing between the great vessels and from its intramural course within the aortic wall. Fedoruk and colleagues12 describe that, if the anatomy permits, this is the most reliable and safe approach to correct this anomaly. However, involvement of the aortic valve commissure that may cause aortic insufficiency often requires detachment and resuspension of the corresponding commissure. Therefore, the coronary ostium and course of the anomalous coronary artery should be determined by careful examination of the preoperative images.2,3,9,12,21 If the position of the coronary ostia relative to the aortic valve commissures is a concern, reimplantation of the coronary ostia through a separate punch hole in the right sinus of Valsalva is recommended.4,12,13 In addition, it should be noted that some anomalous coronary arteries are not intramural but rather distinct arteries.12 However, obtaining a significant length of RCA for coronary translocation and reimplantation requires an extensive dissection and manipulation of the artery, increasing the potential for neo-ostial obstruction, kinking, and flow disruption.7,12 Thus, concerns have been raised regarding the increased complexity of reimplantation as a primary technique for AAOCA. Our current operative strategy is that procedures designed to establish normal coronary anatomy are preferred to bypass surgery. In our institution, unroofing was first considered whenever the anomalous RCA had an intramural course. We recommend reimplantation only in cases when the inspection indicates that unroofing the RCA will undermine the aortic valve. In addition, in case of a significant atherosclerotic stenosis of RCA, CABG could be an option for the treatment of this anomaly.
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19 Sabik JF III, Lytle BW, Blackstone EH, Khan M, Houghtaling PL,
Cosgrove DM. Does competitive flow reduce internal thoracic artery graft patency? Ann Thorac Surg 2003;76(5):1490–1496, discussion 1497 20 Mustafa I, Gula G, Radley-Smith R, Durrer S, Yacoub M. Anomalous origin of the left coronary artery from the anterior aortic sinus: a
potential cause of sudden death. Anatomic characterization and surgical treatment. J Thorac Cardiovasc Surg 1981;82(2):297–300 21 Romp RL, Herlong JR, Landolfo CK, et al. Outcome of unroofing procedure for repair of anomalous aortic origin of left or right coronary artery. Ann Thorac Surg 2003;76(2):589–595, discussion 595–596
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Anomalous Origin of Right Coronary Artery from Left Coronary Sinus: Surgical Management and Clinical Result Sang-Ho Cho1,2
Hyun-Chel Joo3
Kyung-Jong Yoo3
1 Department of Thoracic and Cardiovascular Surgery, Kyung Hee
University Hospital at Gangdong, Seoul, Republic of Korea 2 Department of Thoracic and Cardiovascular Surgery, Graduate School of Medicine, Chungbuk National University, Seoul, Republic of Korea 3 Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
Young-Nam Youn3 Address for correspondence Young-Nam Youn, MD, PhD, Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea (e-mail: [email protected]).
Thorac Cardiovasc Surg 2015;63:360–366.
Abstract
Keywords
► coronary anomalies ► cardiac stress test ► coronary artery bypass ► off-pump
Background Anomalous aortic origin of coronary artery is a rare congenital condition in which the coronary artery arises from the opposite sinus of Valsalva. Although many patients are asymptomatic at the time of presentation or diagnosis, surgical correction is recommended due to the risk of ischemic sudden death. We describe seven cases of right coronary artery (RCA) arising from the left sinus of Valsalva, causing the hypoperfusion through RCA. Patients and Methods All patients underwent preoperative coronary angiography, echocardiography, and cardiac stress test (treadmill test [TMT], n ¼ 4; technetium-99m sestamibi [MIBI], n ¼ 3). In four patients, coronary computed tomography (CT) was performed. On the basis of preoperative test results, unroofing of the coronary artery (n ¼ 3) or off-pump coronary artery bypass (OPCAB; n ¼ 4; patients with coronary arterial occlusive disease) was performed. In two patients, intraoperative flow meter was performed and showed the improvement of flow rate through RCA. Results Postoperative CT angiography after OPCAB confirmed good graft patency (n ¼ 4); CT angiography after unroofing demonstrated widely patent neo-orifice (n ¼ 3). All patients underwent postoperative cardiac stress tests including TMT and MIBI, which revealed no evidence of ischemia. All patients were asymptomatic and returned to normal activities (mean follow-up, 41 months; 32–49 months). Conclusion The appropriate surgical procedure based on specific anatomical details, perioperative evaluation, and follow-up by focusing on the ischemia may lead to successful surgical outcomes of this coronary anomaly.
Introduction Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital anomaly in which the left coronary artery
received November 17, 2013 accepted after revision March 4, 2014 published online June 9, 2014
(LCA) arises from the right sinus of Valsalva or the right coronary artery (RCA) arises from the left sinus of Valsalva.1–3 Angelini reported a global incidence of 5.64% for congenital coronary artery anomaly, with an incidence of
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1376256. ISSN 0171-6425.
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Table 1 Preoperative characteristics of study patients Patient no.
Age
Sex
Symptoms
Stress test
Coronary angiography (LN %)
1
74
M
Exertional chest pain
TMT (þ) in II, III, AVF
mRCA—50%, LN 30%
2
46
F
Exertional chest pain
TMT (þ) in II, III, AVF
3
66
M
Exertional chest pain
MIBI—reversible defect of inferior wall
4
40
M
Exertional chest pain
MIBI—reversible defect of inferior wall
5
62
F
Palpitation
TMT (þ) in V4–6 and II, III, AVF Holter—NL c PVCs
mRCA—50%
6
65
M
Exertional chest pain
MIBI—NL
mRCA—50%
7
23
M
Postexertional syncope
TMT (þ) in II, III, AVF
pRCA—50%
Abbreviations: LN, luminal narrowing; MIBI, technetium sestamibi nuclear study; pRCA, proximal RCA; mRCA, mid-RCA; TMT, treadmill test.
experience with AAOCA and outlines current management strategy.
Patients and Methods We included seven patients (men, n ¼ 5; women, n ¼ 2; mean age, 48.5 35 years) who underwent surgical repair of AAOCA at the Severance Cardiovascular Hospital of Yonsei University Health System in Korea from 2008 to 2010. This study was approved by the Institutional Review Board of Yonsei University College of Medicine. Preoperative characteristics are shown in ►Table 1. Symptoms were present in all patients (exertional chest pain, n ¼ 5; palpitation, n ¼ 1; syncope, n ¼ 1). All patients underwent preoperative coronary angiography, echocardiography, and cardiac stress test (treadmill test [TMT], n ¼ 4; technetium-99m sestamibi [MIBI], n ¼ 3). Preoperative coronary computed tomography (CT) was performed for identification of anatomic characteristics (n ¼ 4). In all patients, the RCA originated from the left sinus of Valsalva. The intramural course of the RCA was identified and traveled between the aorta and pulmonary artery (►Fig. 1). In four patients, the concomitant obstructive atherosclerotic coronary artery disease was identified by preoperative coronary angiography.
Fig. 1 Coronary computed tomography. (A) Axial cross-sectional image, (B) three-dimensional reconstruction. The images show interarterial course and luminal narrowing of anomalous RCA. Ao, aorta; LCA, left coronary artery; LCS, left coronary sinus; PA, pulmonary artery; RCA, right coronary artery. Thoracic and Cardiovascular Surgeon
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1.07% for AAOCA (RCA originating from the left sinus, 0.92%; LCA originating from the right sinus, 0.15%).1 AAOCA can lead to ischemic sudden death in young asymptomatic patients, particularly when the artery is associated with an intramural course, slit-like ostia, marked coronary artery angulation, and compression from the pulmonary artery.2–7 AAOCA can also cause angina, palpitation, syncope, and dyspnea, which are typically experienced in exercise.2–4,7–9 Although many patients are asymptomatic at the time of presentation or diagnosis, surgical correction is generally recommended due to the risk of ischemic sudden death.2–4,7–9 Several surgical techniques for AAOCA have been described, including coronary artery bypass graft (CABG), reimplantation of the coronary ostia, and unroofing of the coronary artery.2–4,9–13 Ultimately, to attempt an effective surgical treatment of this condition, it is crucial to understand its pathophysiology. Previous studies have reported both the advantages and the disadvantages of each surgical option. For example, there are some debates about the efficacy of CABG regarding the potential for graft failure. In this study, we describe seven cases of RCA arising from the left sinus of Valsalva treated with different surgical techniques including unroofing and CABG. The following section summarizes a retrospective review of our
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Fig. 2 Coronary unroofing. (A) RCA from left coronary sinus; (B) unroofing without taking down the intercoronary commissure; (C) operative finding of unroofing. Unroofing procedure performed on three of the seven patients.
Operative Techniques
Results
The surgical technique, unroofing or off-pump coronary artery bypass (OPCAB), was determined preoperatively based on the results of the CT scan, coronary angiography, or both. The type of repair was determined by the location of the anomalous coronary artery with respect to the aortic valve commissures, the intramural course of anomalous artery, and the presence or absence of coronary arterial occlusive disease (CAOD). Unroofing was first considered whenever the anomalous RCA had an intramural course. But in case of significant stenosis of RCA (defined as > 50% luminal narrowing), OPCAB was selected (►Table 1). Cardiopulmonary bypass with mild hypothermia was used for all unroofing cases. The RCA arising from the left sinus of Valsalva was dissected and mobilized over a few centimeters up to the takeoff of the conal branch. The aorta was then cross-clamped, and antegrade cardioplegia was given. A transverse aortotomy was performed to gain access to the anomalous intramural portion of the RCA, and the locations of the aortic valve commissure and the right sinus of Valsalva were identified. A probe was placed into the coronary artery, and the intra-aortic roof of the proximal portion of the RCA and its ostium was sharply opened. Excess tissue was removed and the remaining edges were tacked down with fine sutures (►Fig. 2). Following confirmation of aortic valve competency, the aortotomy was closed, and the operation was completed in the usual manner. OPCAB surgery was performed through a full sternotomy incision. The right internal mammary artery (RIMA) was harvested in a semi-skeletonized fashion. After stabilization of the target coronary artery, the anastomosis to mid or distal RCA was constructed using an intracoronary shunt. When the size and flow of the RIMA were insufficient for the graft, the radial artery was harvested from the nondominant forearm instead of the RIMA. The ascending aorta was usually partially clamped, and a bypass anastomosis from the aorta to the RCA was constructed with the radial artery (►Fig. 3).
Statistical Analyses Continuous variables are expressed as mean standard deviation. SPSS for Windows, Release 15.0 (SPSS Inc., Chicago, Illinois, United States), was used for statistical analysis. Thoracic and Cardiovascular Surgeon
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Of the total of seven patients in the study, three patients underwent the unroofing procedure, and four underwent OPCAB (►Table 2). There was no operative mortality or early morbidity. Cardiopulmonary bypass in the unroofing procedure was used in three out of the seven patients (mean cardiopulmonary bypass time, 89.0 7.2 min; mean aortic cross-clamp time, 66 4.3 min). The operative finding in unroofing, after aortotomy, showed a tight, “slit-like” ostium of the anomalous coronary artery that was able to accommodate only a 1or 2-mm probe. After unroofing, we confirmed widening the orifice of the origin, which reduced the compression of the intramural segment. The detachment and resuspension of aortic valve was performed on one of the three patients, and aortic insufficiency did not occurred. In four patients, preoperative coronary angiography showed 50% or greater stenotic lesion in proximal or midRCA. Mean age of these patients was 66.8 5.1 years. These elderly patients with coronary arterial occlusive disease underwent OPCAB. A bypass anastomosis was constructed to mid or distal RCA with the RIMA (n ¼ 2) or the radial artery (n ¼ 2). In two cases, intraoperative coronary blood flow through the distal RCA was determined by transit-time flow
Fig. 3 Off-pump coronary artery bypass (OPCAB). The bypass anastomosis was constructed with radial artery from ascending aorta to mid-RCA. Ao, aorta; RV, right ventricle; RCA, right coronary artery; RA, radial artery.
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Table 2 Postoperative follow-up data Patient no.
Symptom F/U (mo)
Symptom
Preoperative stress test
MIBI (1 wk after surgery)
TMT
TMT F/U (mo)
Normal
7
Coronary CT
1
OPCAB
38
Free
Ischemia
Normal
2
Unroofing
42
Free
Ischemia
Normal
Patent RIMA graft
3
OPCAB
45
Free
Ischemia
Normal
4
Unroofing
49
Free
Ischemia
Normal
5
OPCAB
32
Free
Ischemia
Normal
6
OPCAB
44
Free
Normal
Normal
Normal
6
Patent RIMA graft
7
Unroofing
38
Free
Ischemia
Normal
Normal
3
Patent of neo-orifice
Patent of neo-orifice Patent RA graft from aorta
Normal
24
Patent of neo-orifice Patent RA graft from aorta
measurement (TTFM); the flow rates were 53 and 210 mL/ min with improved diastolic flow after surgery. ►Fig. 4 shows the improved RCA flow after OPCAB and unroofing procedures. ►Table 2 shows postoperative clinical characteristics of the patients and the surgical outcomes. Electrocardiograms (ECGs) were normal in all seven patients. All patients underwent stress tests, including TMT and MIBI, revealing no evidence of ischemia. The three patients in the unroofing group showed improvement in the stress test early after the operation. In the OPCAB group, three patients who had exhibited preoperative ischemia underwent postoperative stress tests, which showed no evidence of ischemia (one patient showed normal result in preoperative MIBI). Postoperative CT was performed within 7 days after the operation in the OPCAB group and at 1, 3, and 10 months, respectively, after the operation in the unroofing group. A widely patent
neo-orifice after unroofing and a good graft patency after OPCAB were confirmed by CT images. An echocardiogram within 7 days after the operation demonstrated normal left and right ventricular motion and no aortic regurgitation. Mean follow-up time was 41 months (range, 32–49 months). All patients were asymptomatic and returned to their normal activities.
Discussion A coronary artery arising from the wrong coronary sinus is a rare congenital anomaly.1–3 Certain of its variants carry a high risk of mortality, with sudden death often occurring without any preceding symptoms.2,3,5,6 The morphologic spectrum of this entity encompasses the following: anomalous artery from left or right coronary sinus; single ostium versus separate ostium; intramural course within the wall of the aorta
Fig. 4 Flow meter on distal RCA. Intraoperative coronary blood flow through the distal RCA was determined by transit-time flow meter. (A) Improved right coronary arterial flow after OPCAB and unroofing procedures; (B) operative finding measuring RCA flow by transit-time flow meter. OPCAB, off-pump coronary artery bypass; RCA, right coronary artery. Thoracic and Cardiovascular Surgeon
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Abbreviations: MIBI, technetium sestamibi nuclear study; OPCAB, off-pump coronary artery bypass; RIMA, right internal mammary artery; RA, radial artery; TMT, treadmill test.
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versus nonintramural course; interarterial course between the aorta and pulmonary artery versus non-interarterial course; and degrees of ostial compromise including slit-like ostium or angulation.9 In the present study, we focused on the anomalous origin of the RCA from an ostium in the left sinus. Proposed pathophysiological mechanisms for myocardial ischemia and sudden death were as follows: ostial obstruction due to slit-like coronary orifice; compression of RCA between aorta and pulmonary artery; stretching of the RCA with aortic/pulmonary artery; coronary angulation with aortic/pulmonary artery; and coronary arterial spasm.2–7 Presentations vary from no symptoms to angina pectoris, myocardial infarction, syncope, and arrhythmias secondary to minor ischemic insults.2–4,7–9
Preoperative, Intraoperative, and Postoperative Evaluation Commonly used diagnostic techniques, such as coronary angiography and, to a smaller extent, transesophageal echocardiography, are invasive. Improvements in noninvasive diagnostic techniques, such as transthoracic echocardiography and coronary CT, have increased the ability to easily and safely screen the condition12,13; thus, its diagnosis is on the rise. In our institution, all patients underwent a coronary artery assessment by coronary angiography and transthoracic echocardiography. Four patients underwent coronary CT to determine the information on the specific anatomic and morphologic details. As described earlier, this anomaly may cause ischemic insult related to sudden death and other symptoms, so all patients underwent a spectrum of additional testing including 24-hour Holter monitoring, TMT, and MIBI perfusion scan as functional assessment after diagnosis. Although resting ECG was normal for most patients in the present study, stress test developed ST segment abnormalities or symptoms suggestive of myocardial ischemia. Stress tests might detect compromised coronary artery blood flow and contribute to decision making about the appropriate surgical intervention.1,14 In the present study, all patients underwent stress tests preoperatively and, in all cases except one, showed evidence of ischemia. In the postoperative periods, these tests also are used for future comparisons after surgery. In addition, we performed coronary CT evaluation in all patients after CABG or unroofing. Recently, CT has emerged as an important diagnostic tool for the evaluation of coronary surgery in both the early ( 1 month) and late (> 1 month) postoperative settings. It has assumed an integral role in the characterization of surgical failure after coronary surgery manifested as dyspnea or chest pain while allowing the investigation of alternative postoperative complications mimicking recurrent angina.15 Thus, we suggest that early and late postoperative coronary CT evaluation may be helpful in the evaluation of the prognosis, as well as in the confirmation of the graft patency after CABG and the adequacy of coronary unroofing. We recently performed intraoperative TTFM in two patients. TTFM usually has been used to assess graft patency intraoperatively during CABG, because the hemodynamics of a patent coronary graft is similar to those physiologically Thoracic and Cardiovascular Surgeon
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observed in the coronary circulation.16 To correctly interpret TTFM, flow curves, pulsatility index (PI), and mean flow values should be evaluated simultaneously. In a patent coronary circulation, blood flow should be mainly diastolic with minimal systolic peaks. Mean blood flow of around 15 mL/ min or less and PI of approximately 3 or higher were proposed as the cut-off criteria to predict a higher incidence of early graft failure after CABG.17 In our study, TTFM performed in the native coronary artery (RCA) showed that blood flow rates after unroofing and OPCAB increased with improved diastolic flow (71 vs. 210 mL/min, 19 vs. 53 mL/min, respectively) and PIs were in the optimal range (1.7 and 2.7, respectively). Although there is currently no research to support the efficacy of TTMF in the surgery of AAOCA, we cautiously suggest that the intraoperative TTFM could be used to assess the postoperative functional recovery of coronary flow impairment.
Surgical Intervention Surgical correction is commonly recommended when AAOCA is diagnosed, regardless of whether symptoms are present.2,9 CABG, reimplantation of the coronary ostia, and unroofing of the coronary artery have been advocated. The specific morphologic details are considered when determining the appropriate surgical repair. Although its value has been debated, CABG is one of the surgical options for AAOCA.2 However, previous studies reported early graft failure as a result of competitive flow7,12; Tavaf and colleagues7 reported that two bypass procedures had early failure (3 and 6 months, respectively), and two procedures designed to establish normal coronary anatomy were successful. Fedoruk and colleagues12 reported four patients who underwent unroofing procedures and one patient who underwent a reimplantation with good results. Two of the patients in this series had previously undergone bypass surgeries that had resulted in early graft failure (5 and 7 months, respectively). Reul and colleagues18 reported a patient with graft occlusion who had undergone CABG a month before at another institution. The association with early graft failure may be related to the dynamic nature of the obstructive process and the concomitant competitive flow. The native artery can be ligated to avoid competitive flow; however, this ligation creates an irreversible iatrogenic occlusion and makes the circulation completely dependent on a graft and anastomosis, which have uncertain durability and growth potential.12 Thus, some researchers12,18 suggested that CABG may not be appropriate for the treatment of AAOCA, regardless of the proximal ligation. However, Tavaf and colleagues7 suggested that CABG might be reserved for the patients with concomitant obstructive atherosclerotic coronary artery disease unless ligating the proximal RCA is planned. As shown by Sabik and colleagues, the effect of competitive flow on coronary bypass graft patency is mild in case of bypassing coronary arteries with moderate to severe degrees of stenosis.19 To address these concerns, we performed CABG in elderly patients (about over 60 years old) with concomitant atherosclerotic stenosis of RCA detected by preoperative angiography (luminal narrowing > 50%).
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perioperative evaluations, and follow-up by focusing on the ischemia may improve the surgical outcomes of this coronary anomaly.
References 1 Angelini P. Coronary artery anomalies: an entity in search of an
identity. Circulation 2007;115(10):1296–1305 2 Davies JE, Burkhart HM, Dearani JA, et al. Surgical management of
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Conclusion Anomalous origin of RCA from left coronary sinus is a rare, potentially lethal cardiac anomaly, which requires surgical repair. Based on our experiences and previous studies, we believe that if the anatomy permits (e.g., intramural course and appropriate location relative to the aortic valve), unroofing with creation of a neo-ostium is more durable approach to repair this defect basically, producing excellent results. However, in selected patients, CABG using the internal mammary artery or the radial artery may be feasible with low surgical risk and good early and midterm results. The appropriate surgical procedure based on specific anatomical details,
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anomalous aortic origin of a coronary artery. Ann Thorac Surg 2009;88(3):844–847, discussion 847–848 García-Rinaldi R, Sosa J, Olmeda S, Cruz H, Carballido J, Quintana C. Surgical treatment of right coronary arteries with anomalous origin and slit ostium. Ann Thorac Surg 2004;77(5):1525–1529 Hamzeh G, Crespo A, Estarán R, Rodríguez MA, Voces R, Aramendi JI. Anomalous origin of right coronary artery from left coronary sinus. Asian Cardiovasc Thorac Ann 2008;16(4):305–308 Eckart RE, Jones SO IV, Shry EA, Garrett PD, Scoville SL. Sudden death associated with anomalous coronary origin and obstructive coronary disease in the young. Cardiol Rev 2006;14(4):161–163 Maron BJ. Sudden death in young athletes. N Engl J Med 2003; 349(11):1064–1075 Tavaf-Motamen H, Bannister SP, Corcoran PC, Stewart RW, Mulligan CR, DeVries WC. Repair of anomalous origin of right coronary artery from the left sinus of Valsalva. Ann Thorac Surg 2008;85(6): 2135–2136 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(4): 309–312 Gulati R, Reddy VM, Culbertson C, et al. Surgical management of coronary artery arising from the wrong coronary sinus, using standard and novel approaches. J Thorac Cardiovasc Surg 2007; 134(5):1171–1178 Furukawa K, Itoh T. Direct coronary reimplantation for repair of anomalous aortic origin of left or right coronary artery. Ann Thorac Surg 2005;79(1):389–390, author reply 390 Adachi I, Kagisaki K, Yagihara T, et al. Unroofing aortic intramural left coronary artery arising from right pulmonary artery. Ann Thorac Surg 2008;85(2):675–677 Fedoruk LM, Kern JA, Peeler BB, Kron IL. Anomalous origin of the right coronary artery: right internal thoracic artery to right coronary artery bypass is not the answer. J Thorac Cardiovasc Surg 2007;133(2):456–460 Rogers SO Jr, Leacche M, Mihaljevic T, Rawn JD, Byrne JG. Surgery for anomalous origin of the right coronary artery from the left aortic sinus. Ann Thorac Surg 2004;78(5):1829–1831 Angelini P. Coronary artery anomalies—current clinical issues: definitions, classification, incidence, clinical relevance, and treatment guidelines. Tex Heart Inst J 2002;29(4):271–278 Frazier AA, Qureshi F, Read KM, Gilkeson RC, Poston RS, White CS. Coronary artery bypass grafts: assessment with multidetector CT in the early and late postoperative settings. Radiographics 2005; 25(4):881–896 Cerrito PB, Koenig SC, VanHimbergen DJ, Jaber SF, Ewert DL, Spence PA. Neural network pattern recognition analysis of graft flow characteristics improves intra-operative anastomotic error detection in minimally invasive CABG. Eur J Cardiothorac Surg 1999; 16(1):88–93 Tokuda Y, Song MH, Oshima H, Usui A, Ueda Y. Predicting midterm coronary artery bypass graft failure by intraoperative transit time flow measurement. Ann Thorac Surg 2008;86(2): 532–536 Reul RM, Cooley DA, Hallman GL, Reul GJ. Surgical treatment of coronary artery anomalies: report of a 37 1/2-year experience at the Texas Heart Institute. Tex Heart Inst J 2002;29(4):299–307 Thoracic and Cardiovascular Surgeon
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Moreover, to minimize systemic inflammation and the associated adverse postoperative outcomes of cardiopulmonary bypass, such as renal, pulmonary, neurologic, and coagulopathic complications, we performed off-pump CABG. In our OPCAB patient group, early graft failure did not occur, although the proximal RCA was not ligated, and all patients in this group were asymptomatic after a mean follow-up time of 41 months. Follow-up studies are needed to assess the longterm benefits of CABG for AAOCA. Mustafa and associates described “unroofing” of the intramural coronary artery that creates a new coronary ostium in the correct sinus.20 The ostium is enlarged, the angulation is corrected, and the arterial path is removed from passing between the great vessels and from its intramural course within the aortic wall. Fedoruk and colleagues12 describe that, if the anatomy permits, this is the most reliable and safe approach to correct this anomaly. However, involvement of the aortic valve commissure that may cause aortic insufficiency often requires detachment and resuspension of the corresponding commissure. Therefore, the coronary ostium and course of the anomalous coronary artery should be determined by careful examination of the preoperative images.2,3,9,12,21 If the position of the coronary ostia relative to the aortic valve commissures is a concern, reimplantation of the coronary ostia through a separate punch hole in the right sinus of Valsalva is recommended.4,12,13 In addition, it should be noted that some anomalous coronary arteries are not intramural but rather distinct arteries.12 However, obtaining a significant length of RCA for coronary translocation and reimplantation requires an extensive dissection and manipulation of the artery, increasing the potential for neo-ostial obstruction, kinking, and flow disruption.7,12 Thus, concerns have been raised regarding the increased complexity of reimplantation as a primary technique for AAOCA. Our current operative strategy is that procedures designed to establish normal coronary anatomy are preferred to bypass surgery. In our institution, unroofing was first considered whenever the anomalous RCA had an intramural course. We recommend reimplantation only in cases when the inspection indicates that unroofing the RCA will undermine the aortic valve. In addition, in case of a significant atherosclerotic stenosis of RCA, CABG could be an option for the treatment of this anomaly.
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19 Sabik JF III, Lytle BW, Blackstone EH, Khan M, Houghtaling PL,
Cosgrove DM. Does competitive flow reduce internal thoracic artery graft patency? Ann Thorac Surg 2003;76(5):1490–1496, discussion 1497 20 Mustafa I, Gula G, Radley-Smith R, Durrer S, Yacoub M. Anomalous origin of the left coronary artery from the anterior aortic sinus: a
potential cause of sudden death. Anatomic characterization and surgical treatment. J Thorac Cardiovasc Surg 1981;82(2):297–300 21 Romp RL, Herlong JR, Landolfo CK, et al. Outcome of unroofing procedure for repair of anomalous aortic origin of left or right coronary artery. Ann Thorac Surg 2003;76(2):589–595, discussion 595–596
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