Minimally Invasive RCA Reimplantation for Anomalous Aortic Origin of the Right Coronary Artery

Among the various procedures introduced for the repair of the anomalous aortic origin of the right coronary artery from the left sinus (AAORCA), the reimplantation technique is the closest to anatomical correction (1). This technique avoids any manipulation of the aortic valve and eliminates all mechanisms of ischemia in AAORCA patients, including slit-like orifice, intramural and interarterial compression, and acute angle take off.

Over the last five years, the authors have been using the minimally invasive technique for RCA reimplantation, and now this approach is their technique of choice for this operation. Nineteen patients have been operated on using this approach with excellent results. This is, to the authors’ knowledge, the first report of a minimally invasive approach for RCA reimplantation.

The patient presented in this video is a forty-year-old male with typical ischemic symptoms during exertion. The coronary angiography was suspicious of the abnormal origin of the RCA, and the CT angiogram confirmed that the right coronary artery was arising from the left sinus near the left coronary ostium. There was a 6 mm intramural course with significant narrowing of the proximal RCA.

This minimally invasive approach for RCA translocation uses the upper ministernotomy, which is identical to the technique employed for aortic valve replacement (AVR), or the Bentall operation. The upper sternotomy incision was cut to the right at the third or fourth intercostal space, and a small- or medium-sized chest retractor was placed.

The cardiovascular pulmonary bypass was then started through femoro-femoral cannulation, and the aorta was clamped as high as possible. Cardioplegia was infused into the aortic root and then the cardioplegic cannula was removed. Traction sutures play an important role in exposing the working area in this approach. Two traction sutures were placed in the epicardial fat pad to pull it up and slightly to the left and another traction suture was placed in the aortic adventitia to pull it to the right. The entire basal part of the aorta was exposed in this manner.

Meticulous dissection of the adventitia and fat pad by electrocautery started between the pulmonary artery and the aorta continued to expose the RCA at its emerging point on the aorta. Further fine dissection was continued to expose and reveal the proximal 2 cm of RCA and its first branches. With the heart filled and the traction sutures loosened, the ideal point of reimplantation of the RCA on the anterior aorta was marked. The direction of the RCA anastomosis should be the same as how it normally lays on the aorta at this position.

Next, the RCA was clipped and/or sutured at its emerging point, followed by a cut of 1-2 mm distally. Depending on the anatomy, small branches of the proximal RCA were preserved and left either on the aortic side before the occlusion point or on the RCA side. A hole of approximately 3–4 mm was created at the designated implantation site. This point should not necessarily be in the right sinus, but the best place that the RCA can lay without angulation or kinking. Anastomosis was then performed using 6-0 Prolene sutures.

A small aortotomy was then made to make sure the aortic leaflets wouldn’t be damaged during punching and to pass a delicate right-angle clamp to check the anastomotic patency after it was finished. The aorta was then declamped, and the RCA's position and the hemostasis of the reimplantation site were assessed.

The authors concluded that this minimally invasive approach can be used for RCA reimplantation in AAORCA safely. In this case, no conversion to sternotomy was needed and no related complications occurred.

References

1. Law T, Dunne B, Stamp N, Ho KM, Andrews D. Surgical results and outcomes after reimplantation for the management of anomalous aortic origin of the right coronary artery. The Annals of Thoracic Surgery. 2016 Jul 1;102(1):192-8.

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