Anomalous Aortic Origin of the Right Coronary Artery from the Wrong Sinus of Valsalva (AAORCA): Two Surgical Strategies

Anomalous aortic origin of the right coronary artery (AAORCA) is frequently diagnosed, and decision-making regarding surgical intervention remain sometimes controversial in asymptomatic patients. This video presents two cases with AAORCA in two symptomatic patients who were treated with two different surgical techniques because of differences in their anatomy.

First Patient

The first patient is a fifteen-year-old who presented with chest pain and had a positive exercise test. A preoperative CTA showed AAORCA with an intramural course. The decision was made to proceed with surgical unroofing. The procedure was performed though median sternotomy and normothermic cardiopulmonary bypass (CPB) with aortic and single venous cannulation. An oblique aortotomy was performed in a hockey-stick fashion and the intramural segment was identified and unroofed. The edges of the unroofed segment were trimmed, and multiple interrupted 7-0 polypropylene sutures were used to keep the edges everted. The right coronary artery (RCA) ostium was then transferred from the left sinus of Valsalva to the right one, where it normally originates. The aortotomy was then closed in two layers, the heart was deaired, the aortic cross-clamp was removed, and the patient was weaned off CPB in the standard fashion. A post-bypass transesophageal echocardiogram (TEE) showed good flow in the RCA and good biventricular functions. The rest of the procedure was then completed in the standard fashion and the patient was extubated in the operating room. The aortic cross-clamp time and CPB time were fifty and sixty-two minutes respectively. The postoperative course uneventful and the patient was discharged three days later.

Second Patient

The second patient is a thirty-seven-year-old man who was morbidly obese and presented with chest pain and a positive stress test. A CTA showed high take off the RCA with interarterial course between the aorta and the main pulmonary artery and no intramural course. Because of his symptoms and a positive stress test, the decision was made to proceed with repair via translocation of the anomalous RCA.

The procedure was performed in a similar manner to the first case. Through a median sternotomy and normothermic cardiopulmonary bypass, antegrade cardioplegic arrest was achieved and an oblique high aortotomy was performed. The anomalous RCA ostium was identified, and it was harvested with a large button from the aorta. The RCA native location was reconstructed with an appropriately sized bovine pericardial patch. The RCA was then translocated to a new, higher location on the ascending aorta anteriorly. The aortotomy was then closed in two-layer fashion. The heart was then deaired, and the aortic cross-clamp was removed. The patient was ventilated and weaned off CPB without difficulty. Intraoperative fluorescent angiography with indocyanine green was performed, as well as the RCA flow with ultrasound, all of which confirmed good flow. The rest of the procedure was then completed in the standard fashion.

The aortic cross-clamp and CPB times were forty-three and seventy minutes respectively. Predischarge CTA showed widely patent RCA ostium in its new location. The patient was discharged seven days later.

Both patients reported improvement in their symptoms during the follow-up period.

References

1. Said SM, Dearani JA, Burkhart HM, Schaff HV. Surgical management of congenital coronary arterial anomalies in adults. Cardiol Young. 2010 Dec;20 Suppl 3:68-85
2. Said SM. Coronary Artery Bypass for Anomalous Coronary Arteries: Something I Will Not Do. Ann Thorac Surg. 2021 Jan;111(1):377

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