Anomalous Right Coronary Artery Management: An Exploration With Sameh Said and Vince Gaudiani

Very thorough video, and I really enjoyed the discussion. I was taught both the re-implant and unroofing approaches in my training. But the simplest seemed to have been CABG with RIMA. It was the preferred method by our adult congenital surgeon Dr Mike Dewar at Yale. There is concern of competitive flow. He always taught that was not his experience. Nevertheless, I do dissect out the prox RCA as it comes out between aorta and PA and ligate it there. Any thoughts on CABG off or on pump with the RIMA to the right plus or minus ligation of prox RCA?

Thank you, Sasha for your insightful comment and glad you liked the discussion. Your question is quite important as it actually comes up very often. I personally don't like ligating the proximal coronary artery which you will have to do when you decide to do CABG to avoid competitive flow and to ensure your graft stays patent and matures. I have seen problems with bypass in these settings and immaturity of the graft due to competitive flow from the native "normal" coronary artery is a real issue that can happen. So, I believe it is an unnecessary risk especially most of these patients are young and healthy with no native coronary artery diseases and you have re-implantation or unroofing as good valid option with long-term excellent results. I wrote that commentary a while back in the Annals of Thoracic Surgery in response to an article in which the authors performed CABG to anomalous coronary arteries and they did measure the flow intraoperatively etc. but i felt a commentary is needed. Said SM. Coronary Artery Bypass for Anomalous Coronary Arteries: Something I Will Not Do. Ann Thorac Surg. 2021 Jan;111(1):377

I agree w Sameh. RCA bypass is unattractive because the RCA has a dynamic not a fixed lesion. For we adult surgeons, what is easier than a right proximal? Good luck! Vince