Anomalous Aortic Origin of the Right Coronary Artery: Translocation and Reimplantation Technique

Anomalous aortic origin of the coronary artery (AAOCA) is a condition that represents between 0.1–1 percent of malformations (1). It has been found with a prevalence of 0.44 percent in the young population (2). It is most frequently asymptomatic but can also be related to sudden death (3).

AAOCA can present in different forms, such as the right coronary artery emerging from the left Valsalva sinus within the same or separate ostium from the left coronary artery. It can also be present with an anomaly that may be intraarterial (between the aorta and the pulmonary artery) or intraarterial (a segment is intramural). Less frequent but also identified is the left coronary artery arising from the right Valsalva sinus (4). The preferred imaging technique to reach the diagnosis and evaluate the anatomy of the coronaries is multislice computer tomography angiography (4). Surgery is recommended in patients with typical angina symptoms who present with evidence of stress-induced myocardial ischemia in a matching territory or high-risk anatomy. 

This video presents the case of a fifty-year-old woman who was admitted to the hospital for a presentation of INOCA. She reported episodes of syncope, functional class two dyspnea, and angina. She had a sedentary lifestyle and dyslipidemia. Her father died suddenly at the age of fifty-nine, as did her paternal grandfather. She had no history of coronary artery disease or diabetes mellitus. She mentioned being under observation due to a diagnosis of anomalous origin of the right coronary artery (RCA). She was examined with a multislice computer tomography angiography, which reported AAORCA from the left sinus that was very small in caliber and difficult to assess. It coursed between the aorta and the pulmonary artery before following its usual path and was dominant. The patient’s coronary arteries were without significant lesions. It was decided to proceed with surgical intervention.

First, through median sternotomy, an RA and ascending aortic cannulation were performed. Once on cardiopulmonary bypass, with the assistance of an octopus-type stabilizer to support the RV, surgeons aimed to dissect the RCA along its entire proximal portion, reaching its origin in the left Valsalva sinus of the aorta. It was important to identify the small collaterals of this artery and ligate them to prevent potential bleeding.

The next step was to mark the dorsal part of the RCA to prevent twisting during the reimplantation. Surgeons then proceeded to ligate and section the RCA right at its origin, which was later reinforced with stitches using pledgets. The team then proceeded to measure the correct site for the reimplantation of the RCA into the aorta, leaving sufficient space for the RV to determine the position of the anastomosis and avoid kinking of the artery. Proximal anastomosis of the artery was performed with 5-0 Prolene continuous sutures.

The patient’s CPB weaning and hemostasis control was satisfactory and she was discharged on the fourth postoperative day without complications. During the one-month follow up, a CT scan revealed the respected new course of the RCA.

References

1. Thierry Carrell MD; Surgical Treatment of Anomalous Aortic Origin of Coronary Arteries: The Reimplantation Technique and Its Modifications. Oper Tech Thorac Cardiovasc Surg. Vol 1 issue 3 p 178-201.
2. P. Angelini, B.Y. Cheong, V.V. Lenge De Rosen, et al. Magnetic resonance imaging-based screening study in a general population of adolescents. J Am Coll Cardiol, 71 (2018), pp. 579-580.
3. Gherardo Finocchiaro, Elijah R. Behr, Gaia Tanzarella, Michael Papadakis, Aneil Malhotra, Harshil Dhutia, Chris Miles, Igor Diemberger, Sanjay Sharma, Mary N. Sheppard. Anomalous Coronary Artery Origin and Sudden Cardiac Death: Clinical and Pathological Insights From a National Pathology Registry. JACC: Clinical Electrophysiology, Volume 5, Issue 4- 2019,Pages 516-522.
4. Helmut Baumgartner, Julie De Backer, Sonya V Babu-Narayan, Werner Budts, Massimo Chessa, Gerhard-Paul Diller, Bernard lung, Jolanda Kluin, Irene M Lang, Folkert Meijboom, Philip Moons, Barbara J M Mulder, Erwin Oechslin, Jolien W Roos-Hesselink, Markus Schwerzmann, Lars Sondergaard, Katja Zeppenfeld, ESC Scientific Document Group , 2020 ESC Guidelines for the management of adult congenital heart disease: The Task Force for the management of adult congenital heart disease of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Adult Congenital Heart Disease (ISACHD), European Heart Journal, Volume 42, Issue 6, 7 February 2021, Pages 563–645.

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