Transection and Re-implantation of an Anomalous Aortic Origin of the Right Coronary Artery: How I Do It

A 14-year old boy was referred to the coronary artery anomalies program after an incidental echocardiographic finding of a right coronary artery (RCA) arising from the left coronary sinus. The patient was evaluated and managed following a standardized approach: anatomy was determined by computed tomography angiography (CTA) and myocardial perfusion by stress cardiac magnetic resonance (sCMR). Patients with evidence of myocardial ischemia are offered surgical repair.

The patient did not report symptoms of ischemia. Preoperative CTA showed an RCA arising from the left coronary sinus with a 6 mm intramural course and a slit-like orifice. Preoperative sCMR showed an inducible subendocardial perfusion defect in the septum. Based on the findings of ischemia, the patient was offered surgical repair. During surgery, it was determined that coronary unroofing was not feasible as the coronary passes behind the inter-coronary pillar which supports the aortic valve. The decision was made to rei-mplant the RCA into the right coronary sinus without attempting unroofing the intramural segment. The anomalous RCA was transected as it exited the aortic root and the coronary stump was then closed. The transected coronary was sutured into an appropriate site within the right coronary sinus. After three months, the patient remained asymptomatic and postoperative CTA showed an RCA arising from a round, patent ostium within the right coronary sinus. Postoperative sCMR at six months showed normal perfusion with no inducible defects.

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