Unroofing of Anomalous Right Coronary Artery

A sixty-year-old woman with angina. A coronary angiography showed an anomalous origin of the right coronary artery from the left coronary cusp. This was confirmed on s gated coronary CT, which showed it arising from the left sinus of Valsalva with a slitlike orifice and a significant intramural course. She was scheduled for repair by unroofing of the anomaly.  

Median sternotomy was performed and routine cannulation done for cardiopulmonary bypass. Dissection began between the great arteries to identify the right coronary artery (RCA) as it exited from the aorta. Cardioplegic arrest was then achieved, and the RCA was isolated at the point of exit from the aorta by placing a silastic loop around it. 

An aortotomy was then performed just superior to the sinotubular junction, extending it to the left somewhat superiorly. The orifice of the RCA was identified, a metal probe was inserted, and it was clear that in this case the track ran superior to the commissure between the left and right coronary sinuses. 

Careful assessment was then performed to assess the length of the intramural segment. An unroofing with the probe as a guide then began. The importance of establishing the length of the intramural segment is to avoid being overly aggressive with the unroofing, which would lead to bleeding externally. 

The roof of the tunnel was excised as the unroofing proceeded, and stay sutures helped in providing the necessary traction for this. Once this has been done, the intima of the aorta and the coronary artery were tacked together using 6-0 Prolene sutures. This avoided the risk of dissection when the aortic root was pressurized. About six to eight of these tacking sutures will usually suffice. 

The final probe confirmed that the orifice was widely patent. The aortotomy was then closed in the usual way. The cross-clamp was released, and the RCA was immediately inspected as it exited the aorta to make sure that there was no bleeding, which would have occurred if the unroofing had been overly aggressive. 

Transit time flow measurements were then performed, confirming that there was excellent flow in the RCA. The patient was then weaned from cardiopulmonary bypass and decannulated, and routine closure was performed. The patient was discharged on postoperative day four, and a coronary CTA performed six weeks later confirmed that the anomaly had been corrected. 

The advantage of unroofing is that it relocates the functional orifice to the appropriate sinus and enlarges the orifice considerably. Also, it eliminates the intramural portion of the anomalous artery and eliminates the segment that lies between the great arteries. Some pitfalls include aortic incompetence from damage to the commissure, dissection if the layers are not tacked, and overaggressive unroofing that leads to external bleeding. 

References

1. Bibevski S, Ruzmetov M, Turner II, Scholl FG. ANOMALOUS AORTIC ORIGIN OF RIGHT CORONARY ARTERY: OUTCOMES OF SURGICAL AND NON-SURGICAL TREATMENT. Ann Thorac Surg. 2021 Dec 7:S0003-4975(21)02024-5. doi: 10.1016/j.athoracsur.2021.11.008. Epub ahead of print. PMID: 34890570.
2. Gharibeh L, Rahmouni K, Hong SJ, Crean AM, Grau JB. Surgical Techniques for the Treatment of Anomalous Origin of Right Coronary Artery From the Left Sinus: A Comparative Review. J Am Heart Assoc. 2021 Nov 16;10(22):e022377. doi: 10.1161/JAHA.121.022377. Epub 2021 Nov 2. PMID: 34726074; PMCID: PMC8751967.

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