Anomalous Origin of the RCA—Tailoring the Operative Strategy in Complex Aortic Pathology

This video submission is from the 2025 CTSNet Instructional Video Competition. Watch all entries from the competition, including the winning videos.  

The anomalous origin of the right coronary artery (RCA) from the left sinus has an incidence of 0.33 percent. More cases are being identified as a result of increasing imaging screening. When intervention is required, the morbidity from this is nontrivial, including recurrent ischemia and symptoms. Recurrent ischemia is often something that can be avoided with appropriate decision-making and surgical technique. In patients with concomitant aortic root pathology (for example, those undergoing valve-sparing root replacement), further complexity arises due to longer clamp times, potential myocardial protection issues if the RCA ostia is very small, risks of thrombosis with small vessel anastomosis to Dacron, risks of thrombosis with the use of blood products and factors, and challenging aortic root geometries that increase the risk of kinking at the RCA proximal anastomosis. 
 
In this video, the authors present their tailored approach to the management of an interarterial anomalous RCA originating from the left coronary sinus in patients with complex aortic root pathologies. High-quality videos were presented, demonstrating that surgeons need to be versatile in their approach and highlighting the specific situations when one must pivot from unroofing to reimplantation, or reimplantation with a conduit extension, with or without coronary artery bypass grafting (CABG). 

References

1. 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.
2. Gaudino M, Di Franco A, Arbustini E, Bacha E, Bates ER, Cameron DE, Cao D, David TE, De Paulis R, El-Hamamsy I, Farooqi KM, Girardi LN, Gräni C, Kochav JD, Molossi S, Puskas JD, Rao SV, Sandner S, Tatoulis J, Truong QA, Weinsaft JW, Zimpfer D, Mery CM. Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review. Ann Thorac Surg. 2023 Dec;116(6):1124-1141.
3. Stephens EH, Jegatheeswaran A, Brothers JA, Ghobrial J, Karamlou T, Francois CJ, Krishnamurthy R, Dearani JA, Binsalamah Z, Molossi S, Mery CM. Anomalous Aortic Origin of a Coronary Artery. Ann Thorac Surg. 2024 Jun;117(6):1074-1086.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.