Anomalous Aortic Origin of the Left Coronary Artery—Anatomical Repair

This article is part of CTSNet’s Guest Editor Series, Coronary Arterial Anomalies—Pediatric and Adult Congenital. CTSNet Senior Editor Dr. Sameh Said invited both pediatric and adult cardiac surgeons from around the world to contribute clinical videos on various coronary arterial anomalies and different surgical techniques that are used to manage them.   

Anomalous aortic origin of coronary arteries (AAOCA) is a rare condition in which a coronary artery arises from the wrong aortic sinus. AAOCA is a recognized cause of sudden death, being the second leading cause of sudden death in children and teenagers. This anomalous origin is sometimes accompanied by other anatomical conditions that may contribute to ischemic events. 

These anatomical variations include hypoplasia of the initial segment of the artery, interatrial course with compression between both great arteries, and other ostial abnormalities such as intramural course and slit-like orifice. The estimated incidence of this pathology ranges from 0.3 percent to 1 percent (1). 

The indications for surgery remain a matter of debate (2); however, surgical correction should be strongly considered in situations involving any type of symptomatology, such as angina, electrocardiogram changes, syncope, and obviously sudden death, as well as dangerous anatomical variations like left AAOCA, interarterial course, and intramural segment. 

Anatomical correction was first described in 2014 (3). This approach creates a new ostium in the correct sinus, away from any external compression. The initial segment of the native artery remains intact, creating a new orifice covered with pericardium. 

This technique could be used in many anatomical substrates, being especially useful in multilevel stenosis. 

The surgical correction began with the establishment of full cardiopulmonary bypass. Once the heart was arrested, both great arteries were transected to improve visualization. 

Once the coronary anatomy was inspected, two corresponding incisions were made: one in the correct aortic sinus and another in the left main coronary artery. 

Next, both arteries were anastomosed using 7-0 polypropylene suture in a running fashion. 

The creation of the coronary orifice was completed using a piece of fresh autologous pericardium. The aorta and pulmonary arteries were then reanastomosed, the heart was reperfused, and cardiopulmonary bypass was discontinued. 

Thus far, the authors have performed this procedure on 10 patients using this technique. None of the patients suffered any adverse events during the follow-up period. The one-year follow-up CT coronary angiogram showed perfect patency of the neo-ostium in all the patients. 

Although good midterm results were achieved, long-term results should be carefully examined. 

References

1. Engel HJ, Torres C, Page HL Jr. Major variations in anatomical origin of the coronary arteries: angiographic observations in 4,250 patients with-out associated congenital heart disease. Cathet Cardiovasc Diagn 1975;1: 157–69.
2. Brothers J, Frommelt M, Jaquiss RDB, Myerburg RJ, Fraser CD, Tweddell JS. Congenital: AATS expert consensus guidelines: anomalous coronary artery. J Thorac Cardiovasc Surg 2017;153:1440–57.
3. Gaudin R, Raisky O, Vouhe´ PR. Anomalous aortic origin of coronary arteries: ‘anatomical’ surgical repair. Multimed Man Cardiothorac Surg 2014;2014:mmt022.

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