Surgery for Anomalous Aortic Origin of Coronary Arteries: Technical Safeguards and Pitfalls

Abstract

Anomalous aortic origin of a coronary artery (AAOCA) is reported as the second leading cause of sudden cardiac death in otherwise healthy young individuals. Several surgical studies have reported a shallow operative risk, describing repair as safe and effective with short or medium-term follow-up. However, surgical repair can also be associated with a high risk of complications. Numerous repair techniques have been described in the literature, but each technique's indications and limitations are often not well-understood or understated. Since explicit technical knowledge of the most appropriate surgical technique is highly desirable, we sought to thoroughly and clearly outline the safeguards and pitfalls of the most common surgical techniques used to repair AAOCA.

Keywords: anomalous coronary arteries; outcomes; pitfalls; surgery; techniques.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Padalino, Jegatheeswaran, Blitzer, Ricciardi and Guariento.

Figures

Figure 1

Diagram showing cross section aortic view : (A) Normal coronary artery anatomy: the left main coronary artery (LMCA) gives origin to the Left anterior descending (LAD) and circumflex (CX) coronary artery, which arise from a common stem from the left aortic sinus; the right coronary artery (RCA) arises from the right aortic sinus; (B) the most common type, i.e., anomalous aortic origin of the RCA from the left sinus (AAORCA), with an intramural segment; (C) the most lethal type, i.e., anomalous aortic origin of the LCA from the left sinus (AAOLCA), with an intramural segment.

Figure 2

Following a cardioplegic arrest of the heart, a transverse aortotomy is made above the sinotubular junction. The aortotomy is then extended parallel to the annulus of the aortic valve, directed to the left inter-coronary commissure. Additional care must be paid in case of high intramural course of proximal tract of the coronary, to avoid accidental lesions to the anomalous coronary.

Figure 3

Unroofing technique. (A) The orifice of the anomalous coronary artery origin is gently explored with a coronary probe to determine the extent of any intramural segment and its relationship to the correct sinus. (B) Diagram showing a small right-angle clamp which is gently placed into the anomalously located coronary ostium to determine its intramural course and evaluate the overlying common wall of the coronary artery and aorta. (C) Diagram showing a small right-angle clamp inserted into the anomalously located coronary ostium, and gently pushed inside the intramural course, to reveal the overlying common wall of the coronary artery and aorta which is incised with a blade and unroofed.

Figure 4

Unroofing technique. The composite figures show a case of AAOLCA in which the intramural portion of the coronary goes from one aortic sinus into the next one by traversing the commissural plane (A). The commissure is gently detached with a blade or fine scissor to expose the intramural portion of the coronary artery (B). Then, the intramural portion of the anomalous coronary is unroofed, by cutting with fine scissors along its course until the take-off of the coronary from the aortic wall. Lastly, the entire intramural course is unroofed and the intima tacked around the new coronary ostium (C).

Figure 5

(A) The diagram shows that the previously detached commissure is then resuspended with pledgeted sutures in order to create a neo-commissure, and preserve aortic valve integrity. (B) The diagram shows a surgical alternative when the intramural coronary segment is located below the commissure. In such a case, a “neo-ostium” can be created in the aortic wall of the correct sinus, opposite to the point where the coronary artery emerges from the aortic wall. (C) Interrupted tacking stitches are placed circumferentially around the ostium, securing the coronary intima to the aortic wall with the aim of preventing intimal dissection at the neo-orifice.

Figure 6

Ostioplasty technique. (A) The diagram shows that the aortic and pulmonary roots are separated from each other down to the annular level, to expose the epicardial course of the anomalous coronary artery. (B) The normal epicardial course of the left coronary artery is identified and exposed by removing all surrounding connective tissue. The aorta is transected above the sinotubular junction. (C) The proximal epicardial course of the anomalous left coronary artery is incised longitudinally. (D) The ascending aorta is incised vertically in the left coronary sinus toward the coronary incision, beginning from the cut edge of the aorta. The two incisions, aortic and coronary, are joined at the point where the coronary artery leaves its intramural course to become epicardial.

Figure 7

Reimplantation technique. (A) The aberrant coronary artery is identified, dissected free along its course, and mobilized by means of low cautery. (B) A button of tissue around the ostium of the coronary artery is excised. Attention must be paid to avoid damage to the other coronary ostium, which may be very close. (C) A corresponding portion of the correct sinus is then incised with an aortic punch.

Figure 8

Reimplantation technique. (A) Alternatively, a corresponding portion of the correct sinus is incised through a medial trap-door technique. (B) The coronary button is sutured to the aorta in its new position. (C) The original location of the ostium is usually closed with a small prosthetic patch to reconstruct the aortic wall.

Figure 9

Pulmonary artery translocation technique. (A) The perivascular soft tissue between the aorta and the pulmonary artery is debulked. The distal main pulmonary artery is carefully transected at the bifurcation. (B) The left pulmonary artery (PA) is incised toward the left hilum. (C) A prosthetic material (pulmonary homograft or heterologous pericardium) is then fashioned to widely patch the opening in the PA confluence so as to avoid right PA stenosis. (D) The main PA is then re-anastomosed toward the left hilum, resulting in a widely patent PA and pulmonary branches.

Figure 10

Coronary artery bypass graft. The standard technique can be used, especially in older patients, utilizing the mammary artery as graft to the coronary. In such a case, it is imperative to ligate the coronary artery tract proximal to the insertion of the graft, so as to avoid competitive blood flow which may cause graft.