In this video, the authors present a case of anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) repaired via right axillary thoracotomy. A 5-month-old, 6 kg child with no prior medical history was admitted after an accidental echocardiography finding showed ARCAPA. Angiography was performed to assess the position and geometry of the right coronary artery draining into the pulmonary trunk. The patient had good biventricular function with no signs of ischemia and extensive collateralization between the left and right coronary systems.
The surgical approach chosen was a right lateral axillary thoracotomy (VRAT). The chest was entered through the fourth intercostal space. The initial steps included evaluating the coronary anatomy and dissection of the right coronary artery (RCA) adjacent to the pulmonary artery trunk. The origin of the RCA was just above the sinotubular junction.
The initial dissection was performed using diathermy with a fine-tip needle blade and blunt dissection with a right-angle clamp to develop the plane between the RCA and pulmonary trunk. Before initiating cardiopulmonary bypass (CPB), the surgeons attempted to fully mobilize part of the RCA that did not have an epicardial course. After mobilizing the initial part of the RCA, the ductus arteriosus was dissected and mobilized, triple-clipped, and divided. The authors’ general tendency is to double-clip the aortic side and single-clip the pulmonary artery side and divide it in between.
The site of the aortic purse-string was chosen at the most cranial area for aortic annulation to preserve the site for RCA reimplantation at the ascending aorta. CPB was established via direct aortic and bicaval cannulation. Before initiating bypass, the RCA was occluded, and the electrocardiogram (ECG) was evaluated for possible signs of ischemia. The superior vena cava (SVC) was cannulated with a right-angled, metal-tipped cannula, and the inferior vena cava (IVC) was cannulated with a straight cannula.
The area of cardioplegia cannula was carefully chosen to avoid interfering with the potential site of RCA reimplantation. Before administering cardioplegia, the RCA was occluded with a temporary clip to avoid cardioplegic solution run off into the pulmonary artery (PA). The PA was not cannulated separately because of the extensive collaterals between the left and right coronary systems.
The aorta was cross-clamped, and the heart was vented through the interatrial septum. The aorta was retracted dorsally with a stay suture, and harvesting of the coronary button was initiated with the incision using a fine ophthalmic blade at the most cranial part of the RCA ostium. It is important to initially incise the pulmonary artery wall and then visualize the osteal rim of the RCA to perform the consequent harvesting under direct visual control.
After excision of the RCA button, the RCA trunk was further mobilized from the pulmonary artery wall using precise sharp dissection with micro-scissors. Care was taken because there was no fatty or loose areolar tissue along the RCA course, and the plane between the RCA and the pulmonary artery wall was very intimate.
Upon reaching the epicardial course, great attention was paid to the minor coronary epicardial branches. These were divided with electrocautery to prevent further bleeding after reimplantation.
The zone of reimplantation of the coronary artery on the ascending aorta was carefully chosen in accordance with the coronary artery length and its geometry. Special attention was given to the beginning of the epicardial course because it is the site where potential kinking was mostly anticipated. The incision of the aortic wall was initiated with a fine ophthalmic blade and continued with micro-scissors. The coronary implantation was carried out with the running suture in a usual fashion. During the anastomosis, the coronary artery was occluded with the temporary vascular clip because the RCA backflow was expected to be copious. The pulmonary artery wall defect was reconstructed with the autologous pericardial patch. One can encounter copious blood return from the pulmonary artery, and considering the limited surgical field in the minimally invasive procedure, it is advised to occlude both pulmonary artery branches with the snares to facilitate reconstruction. The right atrium was closed in a standard fashion with a single-layer running suture.
The patient was successfully weaned from CPB and was extubated the following day. Postoperative echocardiography showed good biventricular function with no evidence of ischemia and a good flow through the reimplanted coronary artery. The cosmetic result was satisfactory.
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