Management of Anomalous Aortic Origin of the Right Coronary Artery During the Ross Procedure

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Clinical Vignette 
 
A 41-year-old male with a unicuspid aortic valve since childhood and an ascending aortic aneurysm was referred after developing worsening fatigue with exercise and occasional palpitations. The echocardiogram showed an ejection fraction of 50 to 55 percent, severe aortic regurgitation with an eccentric jet directed toward the mitral valve, and moderate aortic stenosis with a mean gradient of 25 mmHg and an aortic valve area of 1.3 cm2. A computed tomography angiogram (CTA) of the chest revealed that the mid-ascending aorta measured 5.0 cm. The proximal left main artery (LM) was visualized, but the origin of the right coronary artery (RCA) was not well seen. The coronary angiogram revealed a left dominant system. The RCA appeared to have a downward and anterior takeoff, and the LM was partially visualized when the RCA was engaged. 
 
Surgical Technique 

After transecting the aorta above the sinotubular junction, the patient was found to have an anomalous RCA ostium just above the raphae of the fused right and left cusps, adjacent to the ostium of the LM. The RCA had a short intramural course followed by an interarterial trajectory. 

To determine the feasibility of the Ross procedure, the pulmonary valve was then examined. To assess the pulmonary root and leaflets, the aorto-pulmonary window and ligament were dissected with meticulous care to avoid injuring the anomalous RCA. The pulmonary valve was a trileaflet valve with no fenestrations was, therefore suitable as an autograft. 
 
Since autograft harvesting is made easier with an open aortic root, the coronary arteries were first mobilized. There was just enough room between the ostia of the LM and the RCA to allow for the mobilization of both arteries as two separate buttons. The LM was mobilized in the usual fashion with two straight lines. Aortic tissue was dissected off the LM to preserve as much supportive surrounding tissue around the artery as possible, which helped avoid kinking and stretching during reimplantation. The same technique was employed for the RCA. The right ventricle (RV) was circumferentially dissected off the aortic root to help in mobilizing the RCA. A right angle was passed two mm below the RCA origin to dissect the aortic wall off the artery prior to completing the button. 
 
The autograft was then harvested in the usual fashion. The conal branch of the RCA was ligated as it crossed the autograft. Afterwards, the RCA was further dissected from the aortic root and the base of the RV to respect its anomalous spatial origin during reimplantation. The RCA ostium was then unroofed over a distance of 5 mm. Tacking sutures with 6-0 Prolene were then placed, and both edges of the unroofed portion of the artery were marsupialized to maintain its wide opening. 
 
The autograft was implanted using a total root technique. The ostium of the LM was implanted within the middle of the left coronary sinus. Next, a 29 mm pulmonary homograft was implanted, and the ascending aorta was replaced with a 28 mm Dacron graft. Once completed, both the RV and aorta were pressurized to provide a better sense of where the anomalous RCA would lie most naturally while avoiding any tension, torsion, or kinking. As such, it was implanted in the Dacron graft distal to the sinotubular junction anastomosis and directed toward the pulmonary homograft from the midline. 
 
Cardiopulmonary bypass was successfully weaned. The patient spontaneously regained sinus rhythm with normal biventricular function. On intraoperative monitoring, the RCA had excellent follow with no resistance. The echocardiogram showed that the autograft had a mean gradient of 6 mmHg with trace central insufficiency. The patient was extubated upon arrival in the intensive care unit (ICU). His postoperative course was unremarkable, and he was discharged home on postoperative day four. On discharge CTA of the chest, both coronary arteries were completely patent. 

References

1. El-Hamamsy I, Eryigit Z, Stevens L-M, Sarang Z, George R, Clark L, et al: Long-term outcomes after autograft versus homograft aortic root replacement in adults with aortic valve disease: a randomised controlled trial. The Lancet 2010;376:524–53
2. David TE, David C, Woo A, Manlhiot C: The Ross procedure: Outcomes at 20 years. The Journal of Thoracic and Cardiovascular Surgery 2014;147: 85–94
3. Chauvette V, Lefebvre L, Chamberland M-È, Williams EE, El-Hamamsy I: Contemporary Review of the Ross Procedure. Structural Heart 2021;5: 11–23
4. El-Hamamsy I, Toyoda N, Itagaki S, Stelzer P, Varghese R, Williams EE, et al: Propensity-Matched Comparison of the Ross Procedure and Prosthetic Aortic Valve Replacement in Adults. Journal of the American College of Cardiology 2022;79:805–815]
5. Notenboom ML, Melina G, Veen KM, De Robertis F, Coppola G, De Siena P, et al: Long-Term Clinical and Echocardiographic Outcomes Following the Ross Procedure: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Cardiol 2024;9:6–14
6. Williams EE, El-Hamamsy I: The Ross Procedure. Operative Techniques in Thoracic and Cardiovascular Surgery 2021;26:189–20
7. Pawale A, Yanagawa B, Varghese R, Stelzer P. Ross procedure in the setting of anomalous aortic origin of a coronary artery. J Thorac Cardiovasc Surg. 2015; 150(4):1000-1002

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